Anesthesia and analgesia
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Anesthesia and analgesia · Apr 2004
Randomized Controlled Trial Clinical TrialThe efficacy of continuous fascia iliaca compartment block for pain management in burn patients undergoing skin grafting procedures.
Postoperative pain from split skin donor sites is often more intense than the pain at the grafted site. In this prospective, randomized, double-blind study we assessed the efficacy of a continuous fascia iliaca compartment block (FICB) in reducing the pain at the thigh donor site. Twenty patients, with a total burn surface area of 16% +/- 13% (mean +/- SD) were randomized 1:1 to receive either ropivacaine 0.2% or saline 0.9%. All patients received a general anesthesic followed by preincision continuous FICB with 40 mL of the randomized solution, then an infusion of 10 mL/h of either ropivacaine or saline until the first dressing change (72 h later). Postoperative analgesia consisted of propacetamol 2g/6h, IV patient-controlled analgesia of morphine chlorhydrate (2 mg/mL), and morphine hydrochlorate 0.5 mg/kg PO once 60 min before first dressing change. The visual analog scale (VAS) scores were compared using the Mann-Whitney U-test preoperatively, 24 and 48 h postoperatively, and during the first dressing change. The cumulative morphine consumption was compared with repeated-measures analysis of variance followed by Scheffé's method if indicated. Patients with continuous FICB had significantly reduced postoperative morphine consumption at all time points (23 +/- 20 versus 88 +/- 29 mg after 72 h, study versus control groups, respectively; P < 0.05). In both groups, VAS scores remained low but were only significantly lower for patients with continuous FICB during the first dressing change (3 [1] versus 7 [3]; median [interquartile range]; P < 0.05). We conclude that continuous FICB is an efficient method for diminishing pain at the thigh donor site. (250 words) ⋯ Postoperative pain at the split skin donor sites is often more intense than the pain at the grafted site. This prospective, randomized, double-blind study assessed the efficacy of a continuous fascia iliaca compartment block in reducing the pain at the thigh donor site.
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Anesthesia and analgesia · Apr 2004
Randomized Controlled Trial Clinical TrialPerioperative rofecoxib improves early recovery after outpatient herniorrhaphy.
Non-opioid analgesics have become increasingly popular as part of a multimodal regimen for pain management in the ambulatory setting. We designed this randomized, double-blind, placebo-controlled study to evaluate the effect of perioperative administration of the cyclooxygenase-2 inhibitor rofecoxib on patient outcome after inguinal herniorrhaphy procedures. Sixty consenting outpatients undergoing elective hernia repair surgery were randomly assigned to one of two treatment groups: control (vitamin C, 500 mg) or rofecoxib (rofecoxib, 50 mg). The first oral dose of the study medication was administered 30-40 min before entering the operating room, and a second dose of the same medication was given on the morning of the first postoperative day. Recovery times, postoperative pain scores, the need for "rescue" analgesics, and side effects were recorded at 1- to 10-min intervals before discharge from the recovery room. Follow-up evaluations were performed at 36 h, 7 days, and 14 days after surgery to assess postdischarge pain, analgesic requirements, resumption of normal activities, as well as patient satisfaction with their postoperative pain management. Rofecoxib significantly decreased the early recovery times, leading to an earlier discharge home after surgery (88 +/- 30 vs 126 +/- 44 min, P < 0.05). When compared with the control group, the patients' median [range] quality of recovery score was also significantly higher in the rofecoxib group (18 [14-18] vs 16 [13-18], P < 0.05). In the predischarge period, a significantly larger percentage of patients required rescue pain medications in the control group (67% vs 37% in the rofecoxib group, P < 0.05). At the 36-h follow-up assessment, rofecoxib-treated patients reported significantly reduced oral analgesic requirements (0 [0-20] vs 9 [1-33] pills, P < 0.05) and lower maximal pain scores, resulting in improved patient satisfaction with their postoperative pain management (3 [1-4] vs 2 [0-3], P < 0.05). However, there were no differences in the times required to resume their activities of daily living. In conclusion, perioperative rofecoxib, 50 mg per os, significantly decreased postoperative pain and the need for analgesic rescue medication, leading to a faster and improved quality of recovery after outpatient hernia surgery. However, perioperative use of rofecoxib failed to improve recovery end points in the postdischarge period. ⋯ Rofecoxib (50 mg per os), given before and after surgery, was effective in improving postoperative pain management, as well as the speed and quality of recovery after outpatient inguinal herniorrhaphy. However, it failed to accelerate the postdischarge resumption of normal activities of daily living.
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Anesthesia and analgesia · Apr 2004
Randomized Controlled Trial Clinical TrialPreoperative ketamine improves postoperative analgesia after gynecologic laparoscopic surgery.
In this study, we evaluated the preemptive effect of a small dose of ketamine on postoperative wound pain. In a randomized, double-blinded, controlled trial, we compared the analgesic requirement in patients receiving preincision ketamine with ketamine after skin closure or placebo after gynecologic laparoscopic surgery. One-hundred-thirty-five patients were randomly assigned to receive preincision or postoperative ketamine 0.15 mg/kg or saline IV. Anesthetic technique was standardized. Patients were interviewed regularly up to 4 wk after surgery. Pain score, morphine consumption, side effects, and quality of recovery score were recorded. Patients receiving preincision ketamine had a lower pain score in the first 6 h after operation compared with the postoperative (P = 0.001) or placebo groups (P < 0.001). The mean (95% confidence intervals) time to first request for analgesia in the preincision group, 1.8 h (1.4-2.1), was longer than the postoperative group, 1.2 h (0.9-1.5; P < 0.001), or the placebo group, 0.7 h (0.4-0.9; P < 0.001). The mean +/- SD morphine consumption in the preincision group, 1.5 +/- 2.0 mg, was less than that in the postoperative group, 2.9 +/- 3.1 mg (P = 0.04) and the placebo group, 3.4 +/- 2.7 mg (P = 0.003). There was no significant difference among groups with respect to hemodynamic variables or side effects. No patient complained of hallucinations or nightmares. We conclude that a small dose of ketamine is not only safe, but it also provides preemptive analgesia in patients undergoing gynecologic laparoscopic surgery. ⋯ In women undergoing laparoscopic gynecologic surgery, a small preoperative dose of ketamine (0.15 mg/kg) produced preemptive analgesia. There were no significant hemodynamic and psychological side effects with this dose.
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Anesthesia and analgesia · Apr 2004
Randomized Controlled Trial Comparative Study Clinical TrialBispectral index values at sevoflurane concentrations of 1% and 1.5% in lower segment cesarean delivery.
Inadequate hypnosis in the absence of opioid analgesia may account for the increased incidence of awareness in cesarean delivery. An end-tidal concentration of 0.5 MAC isoflurane in 50% nitrous oxide (N(2)O) during cesarean delivery resulted in bispectral index (BIS) values >60, the threshold below which consciousness is unlikely. Our aim was to determine the BIS values achieved with the equivalent end-tidal concentration of sevoflurane and to determine if a larger concentration would consistently maintain BIS values <60. Twenty ASA physical status I-II parturients were randomized to receive an end-tidal concentration of either 1% sevoflurane or 1.5% sevoflurane delivered in 50% N(2)O throughout surgery. Thiopental 4 mg/kg was used for anesthetic induction. Morphine 0.1-0.15 mg/kg was administered only after delivery. Mean BIS values in the period between skin incision and neonatal delivery were 61 (95% confidence interval, 57-64) in the 1% sevoflurane group, versus 42 (95% confidence interval, 37-47) in the 1.5% sevoflurane group. BIS values were significantly different between groups at skin incision, uterine incision, delivery, and 10 min after delivery, but not thereafter. Indices of maternal and neonatal outcome were similar between groups. ⋯ Bispectral index (BIS) values <60 are consistent with a high probability of unconsciousness. An end-tidal concentration of 1.5% sevoflurane maintained BIS values <60 during cesarean delivery, whereas 1% did not. Adverse effects were not seen with the use of larger concentrations of sevoflurane.
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Anesthesia and analgesia · Apr 2004
Randomized Controlled Trial Clinical TrialSkin sensitivity to rocuronium and vecuronium: a randomized controlled prick-testing study in healthy volunteers.
Prick tests are frequently used for the authentication of neuromuscular blocking drugs (NMBDs) as causative drugs for anaphylactic reactions during anesthesia. Unfortunately, the actual threshold concentration for skin testing remains debatable for most NMBDs. We studied the flare and wheal responses to prick tests with rocuronium and vecuronium. Thirty healthy, nonatopic, anesthesia-naive male and female volunteers (14 men and 16 women) from 18 to 40 yr of age were assigned randomly to receive a total of 10 prick tests-4 ascending dilutions (1:1000, 1:100, 1:10, and 1) of rocuronium and vecuronium and 2 controls-on both forearms. An assessor blinded to the assignment monitored systemic and skin responses to NMBDs and measured wheal and flare surfaces immediately after and 15 min after prick tests. None of the volunteers experienced any immediate systemic or cutaneous responses to rocuronium or vecuronium. Although a dilution of 1:1000 of both NMBDs failed to promote any skin response at 15 min, 50% and 40% of the subjects had a positive skin reaction to undiluted rocuronium and vecuronium, respectively. We demonstrated a sex effect related to smaller threshold concentration-induced cutaneous reactions in female volunteers to both muscle relaxants. Our observation questions the reliability of prick testing with undiluted solutions of rocuronium and vecuronium for the diagnosis of allergy. ⋯ Building concentration-skin response curves to prick tests with rocuronium and vecuronium in healthy, nonatopic, anesthesia-naive male and female volunteers demonstrated that the nonreactive concentration for both muscle relaxants is the 1:1000 dilution of the stock solutions. Our observation calls into question the past practice of prick-testing skin for sensitivity to neuromuscular blocking drugs by using undiluted solutions.