Methylprednisolone reduces pain, emesis, and fatigue after breast augmentation surgery: a single-dose, randomized, parallel-group study with methylprednisolone 125 mg, parecoxib 40 mg, and placebo

Hyperesthesia one year after breast augmentation surgery increases the odds for persisting pain at four years A prospective four-year follow-up study

In this long-term follow-up study of 175 women, we investigated the prevalence of and factors associated with persisting pain and sensory changes four years after augmentation mammoplasty. Previously the women had participated in an acute postoperative pain study, and follow-up investigations at 6 weeks and 1 year after surgery. In the present study, the women were mailed questionnaires about pain, sensory changes, and affection of daily life, quality of life and pain catastrophizing 4 years after surgery.

One hundred and sixteen women answered the questionnaire. The fraction of women reporting evoked- and/or spontaneous pain during the last 24 h had declined from 20% at 1 year to 14% at 4 years. Hyperesthesia had declined from 46% at 1 year to 32% at 4 years, while the change in hypoesthesia was small, 47% at 1 year to 51% at 4 years. Methylprednisolone and parecoxib given pre incisionally reduced acute postoperative pain and reduced the prevalence of hyperesthesia after 6 weeks/1 year, but after 4 years we found no significant differences between the test drug groups. Those having concomitant pain and hyperesthesia at 6 weeks and 1 year had high odds for persisting pain at 4 years (OR 7.8, 95% CI 2.1–29.8, P = 0.003; OR 13.2, 95% CI 2.5–71.3, P = 0.003). In patients without pain but with hyperesthesia at 1 year, the hyperesthesia increased the odds for pain at 4 years (OR 2.6 95% CI 1.1–6.1, P = 0.03). Hypoesthesia at 6 weeks or at 1 year did not affect the odds for pain at 4 years. A good general health condition (mental and physical) was associated with reduced odds for pain at 4 years (OR = 0.56, 95% CI 0.35–0.88, P = 0.01). However, using the Short Form health survey, SF-12, the Mental Component Summary Score seemed to affect the odds for chronic pain more than the Physical Component Summary Score.

To conclude, the prevalence of pain and hyperesthesia after breast augmentation declined from 1 to 4 years. Nevertheless, the most striking finding in the current trial was that pain coinciding with hyperesthesia at 6 weeks and 1 year resulted in highly increased odds for persistent postoperative pain. Even hyperesthesia alone, without pain, increased the odds for chronic postsurgical pain. Thus, the present study suggests hyperesthesia as an independent risk factor for chronic postsurgical pain.

Dexamethasone before total laparoscopic hysterectomy: a randomized controlled dose-response study

PURPOSE

A prospective, randomized, double blind, placebo-controlled study was undertaken to evaluate the efficacy of a single preoperative dose of dexamethasone, in different dosages, in providing postoperative analgesia in patients undergoing total laparoscopic hysterectomy (TLH).

METHOD

The study included 55 patients randomly divided into three groups. Patients in Groups P, D4, and D8 received saline, 4, and 8 mg dexamethasone, respectively, intravenously, 2 h before induction.

RESULTS

The time to first analgesic requirement was significantly delayed in patients in the D8 group compared with the D4 group (P = 0.01) and placebo (P = 0.01). Total postoperative fentanyl consumption was significantly less in patients in the D8 group compared with the D4 group (P = 0.01) and placebo (P = 0.01). Use of 8 mg dexamethasone resulted in a 99.3 mcg decrease in total 24-h fentanyl consumption. Postoperative nausea and vomiting (PONV) was significantly less in the D8 group with a complete response rate (no emetic episodes and no rescue medication for 24 h) of 36.8% compared with the placebo group in which all the patients had PONV. No adverse effects were observed in any group.

CONCLUSION

Dexamethasone at a dose of 8 mg given intravenously 2 h before induction, delays patient request for analgesia and reduces total fentanyl consumption and PONV in patients undergoing TLH.

A systematic review of comparative studies indicates that paravertebral block is neither superior nor safer than epidural analgesia for pain after thoracotomy

Background

The “gold standard” for pain relief after thoracotomy has been thoracic epidural analgesia (TEA). The studies comparing TEA with paravertebral block (PVB) and recent reviews recommend PVB as a novel, safer method than TEA.

Methods

A systematic search of the Cochrane and PubMed databases for prospective, randomized trials (RCTs) comparing TEA and PVB for post-thoracotomy analgesia was done. We assessed how TEA and PVB were performed, methods of randomization, assessment of pain relief, and complications. Abstracts only were excluded.

Results

Ten studies were included, comprising 224 patients randomized to TEA, 243 to PVB. The studies were heterogeneous. Therefore, a systematic narrative review with our evaluations is presented.

Only 3/10 trials reported the method of randomization. Pain during coughing was reported in only 5/10, pain assessment not specified in 5/10. Only 1/10 trials found PVB superior to TEA, but placed TEA catheters too low (<T7). TEA was superior to PVB in 1/10, during first 1.5 days. PVB and TEA were equally effective in 8/10. 5/10 trials found PVB had less hypotension or urinary retention. None of the studies used appropriate and optimal TEA: TEA was started after end of surgery in half, catheters placed too low (2/10), too high (1/10), not reported in (1/10). 7/10 infused local anaesthetic only, 2/10 added fentanyl, 1/10 added morphine, and none added adrenaline. PVB infusions had higher concentration of bupivacaine (5 mg/ml) in 2/10, 1/10 added fentanyl, 1/10 added ornipressin. Loading doses were higher in 5/10, and with more concentrated solutions in 5/10 of PVB than in the TEA group.

Conclusions

10 heterogeneous, mostly small, studies comparing TEA and PVB for post-thoracotomy analgesia do not allow conclusions on which method has superior analgesic efficacy and safety. The main methodological problem was that none of the studies use optimal thoracic epidural analgesia, with siting of catheters inappropriate in some and the epidural infusion containing too concentrated local anaesthetic because opioid and adrenaline were not added. Anatomical considerations (the paravertebral space comprises parts of the epidural space and contains spinal cord arteries) and personally experienced complications with PVB (paraplegia) convince us that PVB must have higher risk of, infrequent but serious, spinal cord complications than TEA. Percutaneous PVB may puncture pleura and lung.

Some surgeons expressed satisfaction with PVB because the method omits costly acute pain services for monitoring on surgical wards and saves time in the operating room. They are, however, bound to experience serious complications from PVB, sooner or later.

To our knowledge, optimally conducted epidural analgesia has not been compared with PVB. Current literature and our experience with both techniques for up to four decades, indicate that PVB may be an alternative for post-thoracotomy pain when TEA is infeasible for various patient-related reasons (Breivik et al., 2009). Severely disturbed haemostasis is a contraindication for PVB and TEA. Higher concentrations of local anaesthetics are needed to obtain intercostal nerve blocks and epidural analgesia with PVB, risking local anaesthetic intoxication. Robust monitoring regimen for effects and adverse effects is as important for PVB as for TEA.

The effective analgesic dose of dexamethasone after laparoscopic hysterectomy

BACKGROUND

Apart from being antiemetic, glucocorticoids have an analgesic property. The optimal dose of dexamethasone in the management of pain after surgery has not been established. In this placebo-controlled, dose-finding study, we evaluated the analgesic effect of three doses of dexamethasone after laparoscopic hysterectomy.

METHODS

We randomized 129 women scheduled for laparoscopic hysterectomy to receive placebo, dexamethasone 5 mg (D5), 10 mg (D10), or 15 mg (D15) IV before the induction of anesthesia. The patients were anesthetized with propofol and remifentanil in a standardized manner. Until the first postoperative morning, postoperative pain was managed with IV oxycodone using patient-controlled analgesia. The visual analog scale scores for pain and side effects, and the amounts of the analgesics were recorded for 3 days after surgery.

RESULTS

The total dose of oxycodone (0-24 h after surgery) was smaller in the D15 (0.34 mg/kg [0.11-0.87]) group than in the placebo group (0.55 mg/kg [0.19-1.13]) (P = 0.003). The doses of oxycodone during Hours 0-2 after surgery were smaller in the D10 (0.17 mg/kg [0.03-0.36]) and D15 (0.17 mg/kg [0.03-0.35]) groups than in the placebo (0.26 mg/kg [0.10-0.48]) (P = 0.001, D10 versus placebo; P < 0.001, D15 versus placebo) group. During Hours 2-24 after surgery, however, the doses of oxycodone were equal in the placebo, D5, D10, and D15 groups (0.31 mg/kg [0.03-0.78], 0.22 mg/kg [0.03-0.92], 0.24 mg/kg [0.05-0.87], and 0.20 mg/kg [0-0.65], respectively). The visual analog scale scores for pain at rest, in motion, or at cough did not differ in the study groups. The incidence of dizziness was lower in the D15 group than in the placebo group (P = 0.001), the D5 group (P = 0.006), and the D10 group (P = 0.030) during the first 24 h after surgery. During the later course of recovery, the incidence of dizziness did not differ among the four study groups.

CONCLUSIONS

IV dexamethasone 15 mg before induction of anesthesia decreases the oxycodone consumption during the first 24 h after laparoscopic hysterectomy. During first 2 h after surgery, dexamethasone 10 mg reduces the oxycodone consumption as effectively as the 15 mg dose.

Marcaine: A Dependable Local Anesthetic for Breast Augmentation

Background:

Many investigators have evaluated the utility of local anesthetic use before, during, and after augmentation mammoplasty. Routes used include subcutaneous injections, intercostal nerve blocks, pump infusions, drain infusions, and “splashing” into the submuscular pocket. Although many of these techniques yield statistically significant results, they can add time to the operation and can cause additional complications. In particular, local anesthetic pump infusions add significant cost and require a foreign body to be in contact with the skin in a pocket with a sterile implant. We sought to find an affordable solution that would decrease postoperative recovery time, reduce narcotic requirements, and decrease pain in the early postoperative period without adding significant cost or risk to the procedure.

Objective:

To determine whether Marcaine placement into the breast pocket during breast augmentation actually improves patient pain in the early postoperative period, and to determine whether this therapy has any detrimental effects.

Methods:

This double-blind, randomized study was undertaken to compare the effects of placing 10 mL 0.25% Marcaine with epinephrine into 1 or both breast pockets of each patient undergoing bilateral breast augmentation. We sought to evaluate whether this therapy improved postoperative pain and to assess the safety of using Marcaine for this purpose.

Results:

A total of 26 patients voluntarily enrolled in and completed our study. Of these, 25 received Marcaine in 1 or both breast pockets. In all, 24 patients reported less pain on the Marcaine-infused side, and 1 believed that her pain was equal in the 2 breasts. Among 4 patients who received Marcaine in both pockets, no narcotics were required in the recovery suite. No negative reactions to Marcaine were reported in any patient, nor were any infections or hematomas noted.

Conclusions:

Placing 10 mL of 0.25% Marcaine with epinephrine into each breast pocket during breast augmentation is a safe and effective form of early postoperative analgesia.

[New substances and applications for postoperative pain therapy]

The onset of postoperative pain is the result of various pathophysiological mechanisms and depends on the type of surgery performed. Therefore, any adequate postoperative pain treatment requires multimodal and procedure-specific analgesia. In addition to reducing perioperative complications and improving patient comfort, optimal postoperative pain management also represents an important quality characteristic which can influence the patient in their choice of hospital. In the past 1-2 years, known groups of substances have been rediscovered for postoperative pain therapy (e.g., Gabapentin and Pregabalin, i.v. Lidocaine, Ketamine or glucocorticoids), while new substances (coxibe, oral oxycodone+naloxone) and applications have been developed. The present overview article discusses the advantages and disadvantages of these substances and analgesic methods, as well as their specific areas of application.

Sevoflurane requirement during elective ankle day surgery: the effects of etirocoxib premedication, a prospective randomised study

BACKGROUND

Anti-inflammatory drugs, NSAIDs, have become an important part of the pain management in day surgery. The aim of the present study was to evaluate the effect of Coxib premedication on the intra-operative anaesthetic requirements in patients undergoing elective ankle surgery in general anaesthesia.

TYPE OF STUDY

Prospective, randomized study of the intra-operative anaesthetic-sparing effects of etoricoxib premedication as compared to no NSAID preoperatively.

METHODS

The intra-operative requirement of sevoflurane was studied in forty-four ASA 1-2 patients undergoing elective ankle day surgical in balanced general anaesthesia. Primary study endpoint was end-tidal sevoflurane concentration to maintain Cerebral State Index of 40-50 during surgery.

RESULTS

All anaesthesia and surgery was uneventful, no complications or adverse events were noticed. The mean end-tidal sevoflurane concentration intra-operatively was 1.25 (SD 0.2) and 0.91 (SD 0.2) for the pre and post-operative administered group of patients respectively (p < 0.0001). No other intra-operative differences could be noted. Emergence and recovery was rapid and no difference was noticed in time to discharge-eligible mean 52 minutes in both groups studied. In all 6 patients, 5 in the group receiving etoricoxib post-operatively, after surgery, and one in the pre-operative group required rescue analgesia before discharge from hospital. No difference was seen in pain or need for rescue analgesia, nausea or patients satisfaction during the first 24 postoperative hours.

CONCLUSION

Coxib premedication before elective day surgery has an anaesthetic sparing potential.

Increased susceptibility of annexin-A1 null mice to nociceptive pain is indicative of a spinal antinociceptive action of annexin-A1

BACKGROUND AND PURPOSE

Annexin-A1 (ANXA1), a glucocorticoid-regulated protein, mediates several of the anti-inflammatory actions of the glucocorticoids. Previous studies demonstrated that ANXA1 is involved in pain modulation. The current study, using ANXA1 knockout mice (ANXA1-/-), is aimed at addressing the site and mechanism of the modulatory action of ANXA1 as well as possible involvement of ANXA1 in mediating the analgesic action of glucocorticoids.

EXPERIMENTAL APPROACH

The acetic acid-induced writhing response was performed in ANXA1-/- and wild-type (ANXA1+/+) mice with spinal and brain levels of prostaglandin E2 (PGE2) examined in both genotypes. The effect of the ANXA1 peptomimetic Ac2-26 as well as methylprednisolone on the writhing response and on spinal cord PGE2 of ANXA1+/+ and ANXA1-/- was compared. The expression of proteins involved in PGE2 synthesis, cytosolic phospholipase A2 (cPLA2) and cyclooxygenases (COXs), in the spinal cord of ANXA1+/+ and ANXA1-/- was also compared.

KEY RESULTS

ANXA1-/- mice exhibited a significantly greater writhing response and increased spinal cord levels of PGE2 compared with ANXA1+/+ mice. Ac2-26 produced analgesia and reduced spinal PGE2 levels in ANXA1+/+ and ANXA1-/- mice, whereas methylprednisolone reduced the writhing response and spinal PGE2 levels in ANXA1+/+, but not in ANXA1-/- mice. The expression of cPLA2, COX-1, COX-2 and COX-3 in spinal cord tissues was upregulated in ANXA1-/-compared with ANXA1+/+.

CONCLUSIONS AND IMPLICATIONS

We conclude that ANXA1 protein modulates nociceptive processing at the spinal level, by reducing synthesis of PGE2 by modulating cPLA2 and/or COX activity. The analgesic activity of methylprednisolone is mediated by spinal ANXA1.

Fast-track anesthetic techniques for ambulatory surgery

PURPOSE OF REVIEW

Improving perioperative efficiency and throughput has become increasingly important in facilitating the fast-track recovery process following ambulatory surgery. This review focuses on the important role played by the anesthesiologist as a perioperative physician in fast-track ambulatory surgery.

RECENT FINDINGS

A literature review of more than 200 peer-reviewed publications was used to develop evidence-based recommendations for optimizing recovery following ambulatory anesthesia. The choice of anesthetic technique should be tailored to the needs of the patient as well as the type of surgical procedure being performed in the ambulatory setting. The anesthetic decisions made by the anesthesiologist, as a key perioperative physician, are of critical importance in developing a successful fast-track ambulatory surgery program.

SUMMARY

The pivotal role played by the anesthesiologist as the key perioperative physician in facilitating the recovery process has assumed increased importance in the current outpatient fast-track recovery environment. The choice of premedication, anesthetic, analgesic and antiemetic drugs, as well as cardiovascular, hormonal and fluid therapies, can all influence the ability to fast-track outpatients after ambulatory surgery.

Multi-modal-analgesia for pain management after Hallux Valgus surgery: a prospective randomised study on the effect of ankle block

BACKGROUND

Pain and emesis are the two major complaints after day case surgery. Local anaesthesia has become an important part of optimizing intra and post-operative pain treatment, but is sometimes not entirely sufficient. The aim of the present study was to study the effect of adding an ankle block to a multi-modal analgesic approach on the first 24-hour-need for rescue analgesia in patients undergoing elective Hallux Valgus surgery.

TYPE OF STUDY

Prospective, randomized patient-blind study comparing ankle block with levo-bupivacaine, lidocaine and Saline placebo control.

METHODS

Ninety patients were studied comparing ankle block (15 cc) using levo-bupivacaine 2.5 mg/ml, lidocaine 10 mg/ml or placebo (saline) on day-case elective Hallux Valgus surgery, supported by general anaesthesia in all cases. Primary study endpoint was number of patient's requiring oral analgesics during the first 24 post-operative hours.

RESULTS

Ankle block had no effect on need for rescue analgesia and pain ratings during the 1st 24 postoperative hours, there was no difference seen between placebo and any of the two active local anaesthesia studied. The only differences seen was that both lidocaine and levo-bupivacaine reduced the intra-operative need for anaesthetic (sevoflurane) and that levo-bupivacaine patients had a lower need as compared to the lidocaine patients for oral analgesics during the afternoon of surgery.

CONCLUSION

Adding a single shot ankle block to a multi-modal pain management strategy reduces the need for intra-operative anaesthesia but has no major impact of need of rescue analgesics or pain during the first 24-hour after surgery.

The Prolonged Postoperative Analgesic Effect When Dexamethasone Is Added to a Nonsteroidal Antiinflammatory Drug (Rofecoxib) Before Breast Surgery

BACKGROUND

Glucocorticoids provide analgesia. In this study, we evaluated the effects of adding dexamethasone to a multimodal postoperative analgesic regimen, including a long-acting nonsteroidal antiinflammatory drug.

METHODS

One-hundred patients admitted for ambulatory breast cancer surgery were studied. They received paracetamol 2 g and rofecoxib 50 mg orally 1 h before start of general anesthesia with propofol and remifentanil. The patients were then randomized to receive, in a double-blind manner, either dexamethasone 16 mg IV or placebo. Both groups received fentanyl 1 mug/kg IV and 20-40 mL bupivacaine 2.5 mg/mL wound infiltration before the end of surgery.

RESULTS

There was no difference in pain scores or rescue medication between the groups during the first 4 h after surgery. After discharge, the median pain score during coughing or shoulder movement was 3 on a 0-10 scale in patients receiving placebo, and 1 in the patients receiving dexamethasone, which did not reach statistical significance (P = 0.06). From 24 to 72 h, the median pain with coughing or shoulder movement in patients receiving placebo was 2, and 1 in patients receiving dexamethasone, which did reach statistical significance (P < 0.05). Forty percent of patients receiving dexamethasone were pain free from 4 to 24 h, compared with 24% of patients receiving placebo, a difference that did not reach statistical significance (P = 0.09). Similarly, 46% of patients receiving dexamethasone were pain free from 24 to 72 h, compared with 28% of patients receiving placebo (P = 0.06). More patients had slept poorly on the first night in the dexamethasone group than in the control group, 68% vs 44%, (P < 0.05).

CONCLUSIONS

Dexamethasone 16 mg provides prolonged postoperative analgesia from 24 to 72 h after surgery when added to a multimodal regimen including nonsteroidal antiinflammatory drug (rofecoxib).

The Role of the Anesthesiologist in Fast-Track Surgery: From Multimodal Analgesia to Perioperative Medical Care

BACKGROUND

Improving perioperative efficiency and throughput has become increasingly important in the modern practice of anesthesiology. Fast-track surgery represents a multidisciplinary approach to improving perioperative efficiency by facilitating recovery after both minor (i.e., outpatient) and major (inpatient) surgery procedures. In this article we focus on the expanding role of the anesthesiologist in fast-track surgery.

METHODS

A multidisciplinary group of clinical investigators met at McGill University in the Fall of 2005 to discuss current anesthetic and surgical practices directed at improving the postoperative recovery process. A subgroup of the attendees at this conference was assigned the task of reviewing the peer-reviewed literature on this topic as it related to the role of the anesthesiologist as a perioperative physician.

RESULTS

Anesthesiologists as perioperative physicians play a key role in fast-track surgery through their choice of preoperative medication, anesthetics and techniques, use of prophylactic drugs to minimize side effects (e.g., pain, nausea and vomiting, dizziness), as well as the administration of adjunctive drugs to maintain major organ system function during and after surgery.

CONCLUSION

The decisions of the anesthesiologist as a key perioperative physician are of critical importance to the surgical care team in developing a successful fast-track surgery program.

Premedication with controlled-release oxycodone does not improve management of postoperative pain after day-case gynaecological laparoscopic surgery

BACKGROUND

Controlled-release (CR) oxycodone provides an option for the prevention of postoperative pain. We designed this randomized double-blinded placebo controlled study to evaluate the control of pain after premedication with CR oxycodone 15 mg in addition to ibuprofen 800 mg orally in day-case gynaecological laparoscopic surgery.

METHODS

Sixty consenting patients were anaesthetized in a standardized fashion. Postoperative analgesia was provided by ibuprofen 800 mg twice a day in combination with fentanyl i.v. in the recovery room and normal-release (NR) oxycodone orally after the recovery room. The visual analogue scale (VAS) scores for pain and side-effects, and the amounts of postoperative analgesics were recorded for 24 h after discharge from the hospital. After a statistical analysis of the original study, we extended the study to investigate another 10 patients, who received CR oxycodone 15 mg orally in an open-labelled fashion 60 min before surgery. The plasma concentrations of oxycodone were measured from samples drawn before and 2, 4, 6 and 8 h after premedication.

RESULTS

The amounts of fentanyl [100 microg (0-330) in the CR oxycodone group; 125 microg (0-330) in the placebo group], NR oxycodone, or the VAS scores for pain during the first 24 h after the discharge from the hospital did not differ after the premedication with CR oxycodone or placebo. In the extension study group, the peak plasma concentration (C(max)) of oxycodone was 10.0 (4.6-14.7) ng ml(-1), indicating possibly a sub-therapeutic level.

CONCLUSION

Oral premedication with CR oxycodone did not improve management of postoperative pain after day-case gynaecological laparoscopic surgery.

Chronic pain and sensory changes after augmentation mammoplasty: Long term effects of preincisional administration of methylprednisolone

We studied the prevalence of chronic pain and long term sensory changes after cosmetic augmentation mammoplasty and the effects of a single i.v. preoperative dose of methylprednisolone 125 mg (n=74), parecoxib 40 mg (n=71), or placebo (n=74). A questionnaire was mailed 6 weeks and 1 year after surgery. Response rate after 1 year was 80%. At 1 year non-evoked pain was present in 13%, and evoked pain was present in 20% with no statistically significant differences between the groups. Methylprednisolone was associated with reduced odds for hyperesthesia at 1 year (OR 0.3, 95% CI 0.1-0.6), and significantly reduced the prevalence of hyperesthesia (30%) compared with placebo (56%, P<0.01) and parecoxib (51%, P<0.04). Factors associated with increased odds for pain at 1 year were intensity of pain during the first 6 days after surgery (OR 1.3, 95% CI 1.1-1.6), pain at 6 weeks (OR 18.4, 95% CI 6.9-49.3), hyperesthesia at 6 weeks (OR 2.3, 95% CI 1.1-5.1) and present hyperesthesia (OR 3.1, 95% CI 1.4-6.7). We conclude that persistent pain and sensory changes are common after augmentation mammoplasty, and that patients having pain at 6 weeks most likely will have pain also at 1 year. Acute postoperative pain, hyperesthesia at 6 weeks, and the presence of hyperesthesia increased the odds for pain at 1 year. Preoperative methylprednisolone resulted in significantly less hyperesthesia compared with both parecoxib and placebo, but did not significantly reduce the prevalence of persistent spontaneous or evoked pain.