Preoperative versus intraoperative antiemetic strategies in patients undergoing laparoscopic cholecystectomy: A randomised double-blind study.

BACKGROUND: Previous studies have determined ondansetron's efficacy in preventing and treating postoperative nausea and vomiting (PONV). However, evidence regarding the timing of drug administration in relation to the surgical procedure remains vague. OBJECTIVE: To compare the preoperative and intraoperative administration of ondansetron on the incidence of PONV. DESIGN: Single-centred, randomised, double-blind trial. Patients were recruited between November 2018 and April 2021. Follow-up for PONV and retching was up to 24 h. SETTING: Aretaieio University Hospital, Greece. PATIENTS: A total of 121 patients undergoing elective laparoscopic cholecystectomy gave written consent. INTERVENTIONS: Patients were randomly allocated to the preoperative or the intraoperative group. The preoperative group received 4 mg of ondansetron dissolved in 100 ml of 0.9% saline 1 hour before induction of anaesthesia and 100 ml of 0.9% saline 30 min before end of surgery. The intraoperative group received 100 ml of 0.9% saline 1 h before induction of anaesthesia and 4 mg of ondansetron dissolved in 100 ml of 0.9% saline 30 min before end of surgery. MAIN OUTCOME MEASURES: The primary outcome was the incidence of nausea and/or vomiting combined at 24 h. RESULTS: No difference was found between the two groups regarding either the incidence of nausea and vomiting at 24 h (1.7% for the preoperative group versus 5.3% for the intraoperative group, P  = 0.31) or the incidence of nausea, vomiting and retching combined (5.3% for the preoperative group versus 10.5% for the intraoperative group, P  = 0.30). There was no difference between the groups in the pain intensity at rest or with coughing in the post anaesthesia care unit, at 4, 8 and 24 h postoperatively ( P  = 0.961, 0.929, 0.748 and 0.883 at rest, and 0.974, 0.220, 0.235 and 0.317 with coughing, respectively). CONCLUSION: Under the current study design, we found no difference in the incidence of PONV between the administration of ondansetron 1 h before induction of anaesthesia and the intraoperative administration of ondansetron 30 min before the end of surgery. TRIAL REGISTRATION: ClinicalTrials.gov NCT03023306.

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.

Differences in Pain Perception Between Men and Women of Reproductive Age: A Laser-Evoked Potentials Study.

Objective: We investigated differences in pain perception between men and women of reproductive age by using Laser-Evoked Potentials (LEPs). Design, Setting, Subjects: Forty-four right-handed healthy volunteers (19 males/25 females), aged 30­40 years were studied. A CO2 laser generated three series of 10 thermal pulses (4.5 W) on the radial aspect of the dorsum of the left hand. A recording montage for late LEPs was used, and the potentials of each series of stimuli were averaged to calculate mean latency and amplitude for each subject. Volunteers scored verbally pain intensity (Numerical rating scale [NRS]; 0­10). Three series of 10 numbers were averaged for calculation of mean NRS score. Methods: LEP peak-to-peak amplitude, latency, and NRS scoring were compared between genders, and correlations between LEP amplitude/latency and NRS scores were assessed. Results: Data from 44 subjects were analyzed. LEP amplitudes differed significantly (P < 0.001) between men (24.2 ± 6.0 µV) and women (38.9 ± 15.28 µV), while no difference was found for latency (156.5 ± 8.6 versus 160.4 ± 19.8 ms, P = 0.42) or NRS score (2.6 ± 1.5 versus 2.4 ± 1.4, P = 0.63), respectively. Menstrual cycle phase did not influence LEP parameters (P = 0.59 for amplitude and P = 0.69 for latency) or NRS score (P = 0.95). No significant correlation was found between latency or amplitude and NRS score (P = 0.43 and P = 0.90, respectively). Conclusions: Our results demonstrate a significant gender-related difference in LEP amplitudes with lower mean values in men, while no difference was found in LEP latencies or in subjective pain ratings. Further research is required to clarify the clinical significance of the above experimental findings.

Sugammadex at both high and low doses does not affect the depth of anesthesia or hemodynamics: a randomized double blind trial.

Previous studies have shown that sugammadex decreases the anesthetic depth when administered to reverse the neuromuscular blockade produced by rocuronium/vecuronium. The aim of the present study was to investigate the effect of sugammadex alone on anesthetic depth and hemodynamics. Sixty patients scheduled for abdominal surgery participated in the study. Anesthesia was induced with thiopental/fentanyl and maintained with N2O/oxygen and sevoflurane concentrations adjusted to maintain Entropy and Bispectral Index (BIS) values between 40 and 50. Cis-atracurium 0.2 mg/kg was administered for neuromuscular blockade which was monitored with a TOF-Watch® SX acceleromyograph. State entropy (SE), response entropy (RE), Bispectral Index (BIS), systolic (SAP) and diastolic blood pressure (DAP), heart rate (HR), SpO2, end-tidal CO2 and sevoflurane concentrations were recorded every 3 min intraoperatively. Sugammadex 2 mg/kg (Group-2), 4 mg/kg (Group-4) or 16 mg/kg (Group-16) was given intravenously when a count of two responses of the train-of-four (TOF) or a post-tetanic count (PTC) 1-3 appeared or when no response at all (PTC = 0) was observed, respectively. The overall SE values, thus the primary outcome of the study, were 44 ± 11, 43 ± 10 and 43 ± 11 for Group-2, Group-4 and Group-16, respectively (p = 0.812). Also, the secondary endpoints, namely RE, BIS, SAP and DAP, HR and SpO2 did not differ between the three groups. Comparisons between Group-2 versus Group-4, Group-2 versus Group-16 and Group-4 versus Group-16 showed no differences (p > 0.05) for all the studied variables. Sugammadex alone at low, medium or high clinical doses has no effect on anesthetic depth as assessed by Entropy and BIS or on hemodynamics.

Ropivacaine, Interleukin-6 and Tumor Necrosis Factor Alpha Plasma Levels during Intermittent Epidural and Continuous Wound Infusion of Ropivacaine for Analgesia after Hysterectomy or Myomectomy: An Observational Study.

BACKGROUND/AIMS: The concentration-time profile of the long-acting local anesthetic ropivacaine after epidural (EP) administration at fixed time intervals or continuous subcutaneous (SC) infusion has not been fully evaluated. The objective of this work was to determine total plasma concentrations of ropivacaine and changes in cytokine interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-α) levels during EP and SC. METHODS: In this prospective randomized controlled trial, 18 patients undergoing abdominal hysterectomy or myomectomy were randomly selected to receive ropivacaine either every 6 h via an EP catheter or by continuous wound infusion along the skin incision, after a bolus dose, for 48 h. Total plasma ropivacaine concentrations were measured before the bolus and 2, 4, 8, 24, 48, and 50 h after the bolus using high-performance liquid chromatography-UV and IL-6 and TNF-α levels were measured at 0, 8 and 24 h with ELISA and analyzed statistically. RESULTS: During EP, mean ± SD ropivacaine concentrations were relatively stable up to 50 h postoperatively, that is, 239 ± 89 ng/ml, while during SC, initial concentrations between 2 and 8 h were comparatively lower (101.5 ± 42.9 ng/ml) than 24-50 h concentrations (437.1 ± 206 ng/ml). An increase in IL-6 levels was noted between 0 and 24 h during EP and SC, but TNF-α levels increased slightly, between 0 and 24 h, only during EP. CONCLUSION: Ropivacaine plasma concentrations with both EP and SC were found to be safe throughout the administration time interval. IL-6 levels increased during the same time interval, while TNF levels varied only slightly.

Deep sedation for endoscopic cholangiopancreatography with or without pre or intraprocedural opioids: A double-blind randomised controlled trial.

BACKGROUND: Propofol alone or combined with opioids is considered the drug of choice for sedation during endoscopic retrograde cholangiopancreatography (ERCP). OBJECTIVE: To investigate the effect of pre or intraprocedural opioids on propofol requirement during deep sedation for ERCP, and on recovery, pain and cognitive function postoperatively. DESIGN: Three-arm, double-blinded randomised controlled trial. SETTING: Aretaieio University Hospital, February 2011 to July 2013. PATIENTS: One hundred and eighty adults aged between 45 and 75 years. INTERVENTIONS: Deep sedation with propofol (target bispectral index 40 to 70) was performed. In the remifentanil group (R), patients received intranasal placebo before ERCP, and remifentanil 0.1 ml kg(-1) h(-1) (concentration 10 µg ml(-1)) during ERCP. In the fentanyl group (F), patients received intranasal fentanyl 200 µg before ERCP and placebo during ERCP. In the placebo group (P), patients received intranasal placebo before ERCP and placebo during ERCP. MAIN OUTCOME MEASURES: The primary outcome was total propofol requirement. Secondary outcomes were recovery [assessed using the Ramsay Sedation Scale score and Observer's Assessment of Alertness/Sedation Score (OAAS)] at 30 min; postoperative pain [assessed using a visual analogue pain scale (VAS; 0 to 100 mm)]; and cognitive function [assessed using a MiniMental state test (max. 25 points) 30 min before and 30 min after ERCP]. RESULTS: Fifty-seven patients were included in group R, 59 in group F and 57 in group P. Propofol requirements for deep sedation were similar in all groups (13 mg kg(-1); P = 0.97). Ramsay Sedation Scale scores and OAAS scores were similar in all groups (P = 0.18 and P = 0.55, respectively). Postoperative median pain VAS differed among the groups (P = 0.007): 10 in group R, 0 in group F, five in group P. Cognitive function was high pre and postprocedure (median MiniMental state test 23 to 24) and not different among the groups. CONCLUSION: The addition of pre or intraprocedural opioids had no effect on propofol requirement for deep sedation, but patients who received fentanyl had less minor pain. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01304342.

Pretreatment with nitrous oxide enhances induction of anesthesia with sevoflurane: A randomized controlled trial.

BACKGROUND AND AIMS: Inhalation anesthesia with sevoflurane may be enhanced by several drugs or techniques. The aim of the present study was to investigate the effect of nitrous oxide (N2O) pretreatment on the speed of anesthesia induction with sevoflurane. MATERIAL AND METHODS: Eighty patients scheduled for hysteroscopy under general anesthesia were randomly assigned to inhale for 10 min before induction 50% N2O in oxygen or air via a facemask. Anesthesia was induced with 7-8% sevoflurane in oxygen via a facemask. Bispectral index (BIS), end-tidal carbon dioxide (EtCO2) tidal volume, respiratory rate, oxygen saturation (SpO2), and heart rate were recorded every minute during the 10 min pretreatment periods and every 30 s during the first 300 s of induction with sevoflurane. During induction of anesthesia inspired and end-tidal sevoflurane concentrations were also recorded. RESULTS: During the 10 min of inspired 50% N2O or air BIS, EtCO2, tidal volume, respiratory rate and heart rate values did not differ between the two groups except for the SpO2, which was higher in the N2O group (P < 0.001). During induction of anesthesia the N2O group exhibited lower BIS values (P = 0.001), being significant at 60-150 s (P < 0.001, P < 0.001, P = 0.002, P = 0.014) as well as at 270 s (P = 0.004). EtCO2 and tidal volume were consistently lower in the N2O group (P = 0.001, P = 0.041 respectively) and respiratory rate was higher (P = 0.007). CONCLUSION: Our results show that pretreatment of the patients with 50% N2O for 10 min enhances the speed of induction with sevoflurane as assessed by the BIS monitoring.

Intermittent epidural vs continuous wound infusion of ropivacaine for acute and chronic pain control after hysterectomy or myomectomy: a randomized controlled trial.

OBJECTIVE: Adequate postoperative analgesia may enhance recovery. The efficacy of continuous wound infusion vs intermittent epidural ropivacaine for postoperative analgesia was investigated. DESIGN: Prospective randomized, observer blind trial. SETTING: Aretaieio University Hospital. SUBJECTS: Patients scheduled for open abdominal hysterectomy or myomectomy. METHODS: Patients received 10 mL of 0.75% ropivacaine along the skin incision before skin closure, followed by wound infusion 2 mL/hour of 0.375% ropivacaine or epidurally 10 mL of 0.75% ropivacaine in the beginning of surgery followed by 10 mL of 0.2% ropivacaine 6 hourly. The epidural injections or the wound infusion of ropivacaine lasted 48 hours. Rescue analgesia consisted of patient-controlled analgesia morphine up to 48 hours and acetaminophen/codeine tablets the next 24 hours. Analgesic consumption and visual analog scale pain at rest and during cough were assessed 2, 4, 8, 24, 48, and 72 hours postoperatively. One and three months later, patients were interviewed by phone for analgesic consumption at home and presence of pain. RESULTS: The subcutaneous group consumed more morphine during the first 2, 4, and 8 hours postoperatively (P < 0.001, P < 0.001, and P < 0.001, respectively). Subsequent morphine and acetaminophen/codeine requirements did not differ between the two groups. Pain intensity during cough was higher only 2 hours after surgery in the subcutaneous group (P = 0.002). Three months postoperatively, the two groups did not differ in the analgesic requirements and presence of persisting and/or burning pain. CONCLUSION: Based on our results, there is no clinical significant difference between the epidural ropivacaine and the subcutaneous ropivacaine group or a clear superiority to one management strategy.

Propofol or sevoflurane anaesthesia does not affect hepatic integrity as assessed by the M30 & M65 cell death markers & liver enzymes.

BACKGROUND & OBJECTIVES: General anaesthetics may induce apoptosis. The pro-apoptotic/necrotic markers M30 (caspase-cleaved cytokeratin-18) and M65 (intact cytokeratin-18) have been used to identify early apoptosis in liver disease. The aim of this study was to detect the effect of propofol and sevoflurane anaesthesia on these markers and blood transaminase levels in female patients undergoing elective surgery. METHODS: Sixty-seven women undergoing mastectomy or thyroidectomy under general anaesthesia were randomly allocated to the propofol or sevoflurane groups. Venous blood samples for measuring the apoptotic and necrotic markers M30 and M65 as well as for measuring the alanine aminotransferase (ALT) and the aspartate aminotransferase (AST) liver enzymes were collected before induction of anaesthesia, immediately after completion of surgery, and 24 and 48 h postoperatively. RESULTS: The M30 values preoperatively and 0, 24 and 48 h postoperatively were 280±229, 300±244, 267±198 and 254±189 U/l in the propofol group and 237±95, 242±109, 231±94 and 234±127 U/l in the sevoflurane group, respectively. The M30 values did not differ within or between the groups. The M65 levels at the same time intervals were 470±262, 478±271, 456±339 and 485±273 in the propofol group and 427±226, 481±227, 389±158 and 404±144 U/l in the sevoflurane group, respectively. No significant changes were found in the M65 either within or between the propofol and the sevoflurane groups. The ALT and AST levels did not change at these time intervals. INTERPRETATION & CONCLUSIONS: Under the present study design propofol or sevoflurane anaesthesia did not induce apoptosis or affected the liver function as assessed by the M30, M65 markers and liver enzymes in patients undergoing mastectomy or thyroidectomy under general anaesthesia.

Postoperative pain after major abdominal surgery: is it gender related? An observational prospective study.

OBJECTIVES: Gender may be associated with postoperative pain. This study aimed to assess pain intensity and postoperative analgesic requirements in female and male patients scheduled for major abdominal surgery. METHODS: Sixty-five patients, 31 men and 34 women, scheduled for major abdominal surgery were recruited. Anesthesia and intraoperative analgesics were standardized in all patients. Postoperatively, all patients had access to a 60 mL PCA pump containing 1 mg/mL morphine and 50 µg/mL droperidol. Morphine consumption and VAS scores at rest and after cough were recorded 2, 4, 8, 24, and 48 hours postoperatively. RESULTS: Of the 65 patients recruited for the study, 30 women and 30 men aged 65 ± 8.9 and 66 ± 9.0 years, respectively, were included in the analysis. Morphine consumption was examined 2, 4, 8, 24, and 48 hours after surgery and did not differ in women vs. men (mean ± standard deviation, 4.4 ± 3.2 vs. 5 ± 4.8, 7.2 ± 4.8 vs. 8.7 ± 6.9, 10.4 ± 7.1, vs. 12.5 ± 8.5, 22.9 ± 11.6 vs. 25.6 ± 14.5, and 36.2 ± 15.7 vs. 39.7 ± 21.7 mg, P = 0.384). Cumulative morphine consumption was not significantly different in women vs. men when normalized for body mass index (mean ± standard deviation, 0.17 ± 0.13, 0.28 ± 0.20, 0.40 ± 0.30, 0.88 ± 0.46, and 1.38 ± 0.59 mg/kg(/) m(2) in women and 0.18 ± 0.18, 0.31 ± 0.25, 0.46 ± 0.32, 0.95 ± 0.54, and 1.47 ± 0.81 mg/kg/m(2) in men at 2, 4, 8, 24, and 48 hours postoperatively (P = 0.567). Both genders exhibited similar VAS pain scores (mm) at rest and after cough (P = 0.476, P = 0.378, respectively). CONCLUSIONS: Postoperative morphine requirements did not differ between female and male patients undergoing major abdominal surgery. Pain intensity reported at rest and after cough did not differ between the 2 groups.

The impact of 30 ml/kg hydroxyethyl starch 130/0.4 vs hydroxyethyl starch 130/0.42 on coagulation in patients undergoing abdominal surgery.

BACKGROUND & OBJECTIVES: Hydroxyethyl starches (HES) 130/0.4 (Voluven;) and 130/0.42 (Venofundin;) impair coagulation less than older HES solutions with higher molecular weight and molar substitution. Thus, these may be used in high doses up to 50 ml/kg/day. The aim of this study was to investigate and compare the effects of HES 130/0.4 versus HES 130/0.42 on coagulation after the intraoperative infusion of 30 ml/kg in patients undergoing major abdominal surgery. METHODS: Fifty two patients scheduled for elective major abdominal surgery were randomized to receive 30 ml/kg of HES 130/0.4 or HES 130/0.42 intraoperatively. Coagulation variables were assessed before and after infusion of the colloid solution using thrombelastography. RESULTS: Data from 49 patients, 25 patients in the HES 130/0.4 and 24 in the HES 130/0.42 group, were analyzed. Measurements of reaction time, kinetic time, α-angle, maximum amplitude and coagulation index before and after colloid infusion did not differ between the groups. Within each group, after colloid infusion, reaction time did not change significantly, while α-angle, maximum amplitude and coagulation index values were significantly decreased (P <0.01, P<0.001 and P<0.001, respectively in HES 130/0.4 group and P<0.01, P<0.001 and P<0.01, respectively in HES 130/0.42 group). Kinetic time was significantly increased (P<0.001) in both the groups. In both groups, all thrombelastographic measurements after colloid infusion were found within normal limits. INTERPRETATION & CONCLUSIONS: HES 130/0.4 and HES 130/0.42 showed similar, not clinically significant effects on coagulation, as assessed by thrombelastography, when a dose of 30 ml/kg was administered in patients undergoing major abdominal surgery.

Sciatic lateral popliteal block with clonidine alone or clonidine plus 0.2% ropivacaine: effect on the intra-and postoperative analgesia for lower extremity surgery in children: a randomized prospective controlled study.

BACKGROUND: The effect of adding clonidine to local anesthetics for nerve or plexus blocks remains unclear. Most of the studies in adults have demonstrated the positive effects of clonidine on intra- and postoperative analgesia when used as an adjunctive agent or in some cases as a single to regional techniques. In the pediatric population, there are only few trials involving clonidine as an adjunct to regional anesthesia, and the analgesic benefits are not definite in this group of patients. The evidence concerning perineural administration of clonidine is so far inconclusive in children, as different types and volume of local anesthetic agents have been used in these studies. Moreover, the efficacy of regional anesthesia is largely affected by the operator's technique, accuracy and severity of operation. METHODS: The use of clonidine alone or combined with 0.2% ropivacaine for effective analgesia after mild to moderate painful foot surgery was assessed in 66 children, after combined sciatic lateral popliteal block (SLPB) plus femoral block. The patients were randomly assigned into three groups to receive placebo, clonidine, and clonidine plus ropivacaine. Time to first analgesic request in the groups was analyzed by using Kaplan-Meier and the log-rank test (mean time, median time, 95% CI). RESULTS: In our study, clonidine administered alone in the SLPB seems promising, maintaining intraoperatively the hemodynamic parameters SAP, DAP, HR to the lower normal values so that no patient needed nalbuphine under 0.6 MAC sevoflurane anesthesia, and postoperatively without analgesic request for a median time of 6 hours. In addition, clonidine administered as adjuvant enhances ropivacaine's analgesic effect for the first postoperative day in the majority of children (p = 0.001). Clonidine and clonidine plus ropivacaine groups also didn't demonstrate PONV, motor blockade, and moreover, the parents of children expressed their satisfaction with the excellent perioperative management of their children, with satisfaction score 9.74 ± 0.45 and 9.73 ± 0.70 respectively. On the contrary all the patients in the control group required rescue nalbuphine in the recovery room, and postoperatively, along with high incidence of PONV, and the parents of children reported a low satisfaction score (7.50 ± 0.70). CONCLUSIONS: Clonidine appears promising more as an adjuvant in 0.2% ropivacaine and less than alone in the SLPB plus femoral block in children undergoing mild to moderate painful foot surgery, with no side effects. TRIAL REGISTRATION: ClinicalTrials.gov, ISRCTN90832436, (ref: CCT-NAPN-20886).

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.

An assessment of subarachnoid block: a survey of 175 articles and recommendations for improvement.

BACKGROUND: Assessment of subarachnoid block, particularly the sensory component, may be incomplete and influence the conclusions of studies involving subarachnoid anesthesia, as well as their application in routine clinical practice. METHODS: We manually searched 175 articles concerning subarachnoid block published from 2006 to 2009 in 8 anesthesia journals to determine the components of the subarachnoid anesthetic procedure recorded as well as the extent of sympathetic and motor block. RESULTS: The level of subarachnoid injection was reported in 86% of the articles, baricity in 84%, concentration of local anesthetic in 77%, patient's position in 75%, needle size in 77%, and needle type in 71%. The stimulus used for assessing sensory block was reported in 69% of the articles; 17% described the block as unilateral or bilateral, and 11% described the lines along which the stimulus was applied. Motor and sympathetic block were assessed in 40% and 18% of studies, respectively. CONCLUSIONS: These results suggest incomplete description of tools and assessment of sensory block in studies involving subarachnoid anesthesia. We propose a checklist to facilitate a more standardized evaluation of the extent of subarachnoid anesthesia.

Impact of Altmetrics in evaluation of scientific journals, research outputs and scientists' careers: Views of editors of high impact anaesthesia, critical care and pain medicine journals.

BACKGROUND AND AIMS: Altmetrics represent the attention of an article drawn from social and mainstream media. The aim of this survey was to investigate the views of editors of high-impact journals on the Altmetric Attention Score (AAS), the number derived from an automated algorithm including a weighted count of mainstream news and social media sources. METHODS: A questionnaire related to the AAS was sent to the editors of high-impact journals, namely Anaesthesia, Critical Care Medicine (CCM) and Pain Medicine (PM). Eleven questions were related to the possible benefits and flaws of Altmetrics. RESULTS: Of the 1,381 editors asked, 126 answered. The overall answers showed that 76% of the editors were familiar with Altmetrics, 28% knew how AAS is calculated, 12% believed that AAS should replace traditional bibliometrics, 34% favoured AAS for journal ranking, 40% believed that AAS should be used to assess an article, 44% felt that AAS should be included in researchers' curriculum vitae and 22% felt that it should be considered for grants. Sixty-two percent of editors believed that AAS is vulnerable to manipulations, 60% proposed improvement and 16% abandonment. Positive answers were similar across the fields, except for journal ranking. Fifty-four percent of editors of the CCM journals favoured journal ranking using AAS versus 28% and 26% editors of anaesthesia and PM journals (P = 0.025 and P = 0.006, respectively). CONCLUSION: A high percentage of editors believed that AAS should be used to assess scholarly output and that it should be included in the researchers' curriculum vitae. Sixty percent of responders supported the improvement of AAS.

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.

Pharmacology of sedation agents and reversal agents.

Sedation for gastrointestinal endoscopies is obtained by opioids, benzodiazepines, propofol, ketamine and/or droperidol. The pharmacokinetic profile of some sedatives/anesthetics renders them advantageous over others. Opioids, mainly pethidine and fentanyl, are the most popular. Though newer opioids provide a faster recovery, fentanyl is safe and advantageous due to its lower cost. Remifentanil, due to its pharmacokinetic profile (elimination half-life: 9 min), is advantageous for ambulatory patients, though it is not known whether the high cost compensates the benefits. Midazolam is the benzodiazepine of choice as it has a shorter duration of action and a better pharmacokinetic profile than diazepam. Propofol, an intravenous anesthetic, has become very popular for gastrointestinal endoscopies in sedative doses. The opioid and benzodiazepine antagonists, naloxone and flumazenil, are indicated only in particular circumstances, like deep sedation with threatening respiratory depression. Ketamine and droperidol are not popular agents for sedation in the modern endoscopic practice.

Emergencies and treatment of complications.

Sedation for gastrointestinal endoscopy may induce central respiratory depression and/or airway obstruction. Early diagnosis and treatment of these complications is mandatory as the resulting hypoxia may cause irreversible damage, particularly to vital organs, or death. Sedatives and centrally acting analgesics depress respiration in a dose-dependent manner. However, significant untoward events are preventable by titrating the doses for sedation and by monitoring patient oxygenation and respiration. Cardiovascular adverse events may also occur during gastrointestinal endoscopy, and can be major or minor. Hypotension needs treatment as well as severe hypertension. Cardiac dysrhythmias may occur due to stress, pain and/or hypercarbia, which may accompany endoscopies. The anesthesia provider must be able to diagnose, assess the risk and treat all the adverse events during gastrointestinal endoscopy. The resuscitation equipment, including the defibrillator, must be readily accessible.