Preoperative dexamethasone improves surgical outcome after laparoscopic cholecystectomy: a randomized double-blind placebo-controlled trial

The effect of dexamethasone on postoperative vomiting and oral intake after adenotonsillectomy

OBJECTIVE

Vomiting is one of the most important postoperative complications of adenotonsillectomy. This study was designed to determine the effectiveness of preoperative intravenous dexamethasone on postoperative emesis.

METHODS

In a double-blind, placebo-controlled clinical trial, 100 patients aged 5-15 years, ASA classes I and II were randomly selected to receive either 0.5 mg/kg IV dexamethasone (n=50), as study group or an equivalent volume of saline preoperatively, as control group. The anesthetic regimen and surgical procedures were standardized for all patients. The incidence of early and late vomiting, the time to first oral intake and duration of intravenous hydration were compared in both groups.

RESULTS

Data analysis showed that the overall incidence of early and late vomiting was significantly lesser in dexamehasone group than the control one. The time to first oral intake and duration of IV therapy were also significantly shorter in dexamethasone group.

CONCLUSION

A single dose of dexamethasone significantly decreased the incidence of postoperative vomiting in early and late recovery phase and shortened the time to first oral intake and the duration of IV therapy.

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).

[Systemic analgesia adapted to the children's condition]

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.

Perioperative pain management

The under-treatment of postoperative pain has been recognised to delay patient recovery and discharge from hospital. Despite recognition of the importance of effective pain control, up to 70% of patients still complain of moderate to severe pain postoperatively. The mechanistic approach to pain management, based on current understanding of the peripheral and central mechanisms involved in nociceptive transmission, provides newer options for clinicians to manage pain effectively. In this article we review the rationale for a multimodal approach with combinations of analgesics from different classes and different sites of analgesic administration. The pharmacological options of commonly used analgesics, such as opioids, NSAIDs, paracetamol, tramadol and other non-opioid analgesics, and their combinations is discussed. These analgesics have been shown to provide effective pain relief and their combinations demonstrate a reduction in opioid consumption. The basis for using non-opioid analgesic adjuvants is to reduce opioid consumption and consequently alleviate opioid-related adverse effects. We review the evidence on the opioid-sparing effect of ketamine, clonidine, gabapentin and other novel analgesics in perioperative pain management. Most available data support the addition of these adjuvants to routine analgesic techniques to reduce the need for opioids and improve quality of analgesia by their synergistic effect. Local anaesthetic infiltration, epidural and other regional techniques are also used successfully to enhance perioperative analgesia after a variety of surgical procedures. The use of continuous perineural techniques that offer prolonged analgesia with local anaesthetic infusion has been extended to the care of patients beyond hospital discharge. The use of nonpharmacological options such as acupuncture, relaxation, music therapy, hypnosis and transcutaneous nerve stimulation as adjuvants to conventional analgesia should be considered and incorporated to achieve an effective and successful perioperative pain management regimen.

Predictive factors of long hospital stay after laparoscopic cholecystectomy

OBJECTIVE

Laparoscopic cholecystectomy (LC) is the most common minimally invasive surgery in Hong Kong. However, ambulatory LC is not a common practice in Hong Kong. This study aims to identify the causes of long hospital stay after elective LC and to delineate a guideline for ambulatory LC.

METHODS

A retrospective analysis of 278 patients who underwent successful elective LC in a single unit between 1 January 2002 and 31 December 2003 was performed. They were divided into two groups: LS group had a long hospital stay (>24 hours after operation) and SS group had a short hospital stay. A total of 18 variables, including five patient variables, nine operative variables and four postoperative variables, were identified for univariate analysis. Significant pre- and postoperative factors were included in the multivariate analysis to identify independent predictive factors for long hospital stay.

RESULTS

Of the 278 patients, 118 (44.2%) could be discharged within 24 hours, while 149 (55.8%) had long hospital stay. Nine significant factors were identified in the univariate analysis; three independent factors were found to predict long hospital stay in the multivariate analysis. Patients with age more than 60 years had double risk of long hospital stay. Patients who could not tolerate diet within 8 hours or took more than two tablets of oral analgesia (dologesics) had a four- and threefold increase in risk of long hospital stay, respectively.

CONCLUSION

With careful patient selection, optimal postoperative pain control and early resumption of diet with better management of postoperative nausea and vomiting, ambulatory LC was feasible and safe.

Post-operative recovery profile after laparoscopic cholecystectomy: a prospective, observational study of a multimodal anaesthetic regime

BACKGROUND

Laparoscopic cholecystectomy is now often an ambulatory procedure, but dependent on short-term post-operative complaints of pain and post-operative nausea and vomiting (PONV). The efficacy of post-anaesthesia care units (PACUs) is therefore important to facilitate return to normal functions. We investigated the feasibility and efficacy of a standardized, evidence-based anaesthesia/analgesic regime to identify residual problems in the early post-operative phase.

METHODS

One hundred and thirty-four consecutive patients admitted for elective laparoscopic cholecystectomy at Hvidovre University Hospital between 15 March and 30 September 2005 were included in the study. The standardized, evidence-based regime consisted of total intravenous (i.v.) anaesthesia (propofol-remifentanil), well-defined fluid therapy, dexamethasone, ketorolac, ondansetron, sufentanil and incisional bupivacaine intra-operatively, and in the PACU on demand (prn) administration of sufentanil, morphine, paracetamol, ondansetron, droperidol, oral fluids and oxygen (if SpO(2) < 93%) with PACU discharge using a modified Aldrete score.

RESULTS

Protocol violations were moderate and occurred unsystematically, 8% had medical violations and 10% did not receive the pre-planned fluid amount. Severe PONV was seen in 2%. Thirteen per cent experienced severe pain, and the presence of any pain and/or PONV were predictors of an extended PACU stay. Mean oxygen demand was 46 min (range, 0-300 min), which influenced time to discharge (mean, 88 min). There were on average 2.7 treatment interventions (range, 0-11) before discharge.

CONCLUSION

An evidence-based, multimodal approach to the anaesthetic/analgesic management in laparoscopic cholecystectomy is feasible and advantageous in the early post-operative phase. Pain and PONV are predictors of a complicated recovery profile and deserve further attention. Transient oxygen desaturations postpone discharge from the PACU, but the clinical significance of this fact is questionable.

Analgesic and antiemetic effect of ketorolac vs. betamethasone or dexamethasone after ambulatory surgery

BACKGROUND

Glucocorticoids are known to provide slower onset and more prolonged duration of analgesic effect than ketorolac. In the present study, we wanted to evaluate the effect over time from a single dose of either intravenous (i.v.) dexamethasone or an intramuscular (i.m.) depot formulation of betamethasone compared with i.v. ketorolac.

MATERIALS AND METHODS

One hundred and seventy-nine patients admitted for mixed ambulatory surgery were included in the study. After induction of general i.v. anaesthesia, the patients were randomized to receive double-blindly either dexamethasone 4 mg i.v. (Group D) or betamethasone depot formulation 12 mg i.m. (Group B) or ketorolac 30 mg i.v. (Group K). Fentanyl was used for rescue analgesic medication in the post-operative care unit (PACU) and codeine with paracetamol after discharge, for a study period of 3 days.

RESULTS

There was significantly less post-operative pain in the ketorolac group during the stay in the unit (88% with minor or less pain in Group K vs. 74% and 67% in Groups D and B, respectively, P < 0.05), significantly less need for rescue medication (P < 0.05) and significantly less nausea or vomiting (12% in Group K vs. 30% in the other groups pooled, P < 0.05). The ketorolac patients were significantly faster for ready discharge, median 165 min vs. 192 min and 203 min in Groups D and B, respectively (P < 0.01). There were no differences between the groups in perceived pain, nausea, vomiting or rescue analgesic consumption in the 4- to 72-h period.

CONCLUSION

Dexamethasone 4 mg or bethamethasone 12 mg did not provide prolonged post-operative analgesic effect compared with ketorolac 30 mg, which was superior for analgesia and antiemesis in the PACU.

The Exploration of the Establishment of Cutpoints to Categorize the Severity of Acute Postoperative Pain

OBJECTIVES

Although several studies have established different cutpoints (CPs) for mild, moderate, and severe pain for a variety of chronic pain conditions, only one study by Mendoza and colleagues reported on CPs for acute postoperative pain that were derived using ratings of worst pain. The purpose of this study was to explore the establishment of the optimal CPs for mild, moderate, and severe postoperative pain using ratings of average and worst pain and to determine if these CPs distinguished among the pain severity groups on several outcomes.

METHODS

The study is a reanalysis of data from patients who underwent hip and knee replacement surgery. Using the methodology described by Serlin et al, a series of CP derivations were performed based on both single item scores for pain intensity and mean scores for pain intensity. One-way analyses of variance, chi analyses, or Kruskal-Wallis tests were conducted to determine if the optimal CPs for pain severity distinguished among the 3 pain severity groups on several outcomes.

RESULTS

CPs 3,5 were found using a mean score based on patients' ratings of average and worst pain on the third postoperative day. Findings suggest that mean pain scores of >3 have a significant effect on general activity, mood, walking ability, and sleep.

DISCUSSION

Possible explanations for the differences in the CPs found in this study compared with the results by Mendoza and colleagues are discussed. The findings warrant replication in other samples of postoperative patients.

Epidural dexamethasone reduces postoperative pain and analgesic requirements

PURPOSE

Epidural steroids may have potential advantages for providing postoperative analgesia. We therefore undertook a study to evaluate the efficacy of epidurally administered dexamethasone in reducing postoperative morphine requirements, as a measure of analgesia following laparoscopic cholecystectomy.

METHODS

In a randomized, double-blind study, 94 patients undergoing laparoscopic cholecystectomy were randomly assigned to one of three groups. Group 1 (Control) patients received dexamethasone 5 mg iv with epidural injection of 0.25% bupivacaine 8 mL and normal saline 2 mL, Group 2 (D1) patients received normal saline 2 mL iv with epidural injection of 0.25% bupivacaine 8 mL and dexamethasone 5 mg in normal saline 2 mL, and Group 3 (D2) patients received normal saline 2 mL iv with epidural injection of dexamethasone 5 mg in normal saline 10 mL. After surgery, morphine 2-4 mg iv was administered as needed for analgesia. Postoperative morphine requirements, visual analogue scale (VAS) pain scores at rest and with effort, and time to first analgesic administration were recorded by a blinded observer.

RESULTS

Total morphine consumption for the first 24 hr following surgery was lower in both epidural dexamethasone groups (D1, D2) compared to the control group (P < 0.05). The percentage reduction in morphine consumption in Group D1 was 53.9% and in Group D2 was 52.9% in the first 24 hr. Postoperatively at 12 hr, 18 hr and 24 hr, the VAS scores at rest and during effort were also lower in the epidural dexamethasone groups (D1, D2) compared to the control group (P < 0.05). The percentage reductions in VAS scores with effort at 12 hr, 18 hr and 24 hr in Group D1 were 50%, 52.9% and 50% respectively, and in Group D2 percentage reductions in pain scores with effort were 54.8%, 58.8% and 55.5% at corresponding sampling intervals.

CONCLUSION

Preoperative epidural administration of dexamethasone 5 mg, with or without bupivacaine, reduces postoperative pain and morphine consumption following laparoscopic cholecystectomy.

Placement of 0.5% bupivacaine-soaked Surgicel in the gallbladder bed is effective for pain after laparoscopic cholecystectomy

BACKGROUND

This study aimed to determine the character of pain after laparoscopic cholecystectomy and its relief with 0.5% bupivacaine-soaked Surgicel placed in the gallbladder bed.

METHODS

For this study, 60 patients with chronic cholecystitis were divided into four groups of 15 each: group A (bupivacaine-soaked Surgicel kept in gallbladder bed), group B (bupivacaine infiltrated at trocar sites), group C (bupivacaine infiltrated into the gallbladder bed and at trocar sites, and group D (normal saline in the gallbladder bed and at trocar sites). Postoperatively, the character of pain was noted, and its relief was assessed with visual analog scale (VAS) scoring.

RESULTS

The findings showed that 78.33% of the patients had visceral pain, 70% experienced parietal, and 23.33% reported shoulder pain after laparoscopic cholecystectomy. The visceral pain was significantly less in the group A patients than in the control subjects (p < 0.05), and none of them experienced shoulder pain. The mean VAS score at 4, 8, and, 24 h in the group A patients also was less than in control group D: 26.37 +/- 16.24 versus 38.30 +/- 9.51, 23.23 +/- 14.28 versus 33.73 +/- 7.96, and 18.36 +/- 13.00 versus 28.60 +/- 9.42, respectively. Trocar-site infiltration alone was not effective in relieving the parietal pain.

CONCLUSION

Visceral pain is prominent after laparoscopic cholecystectomy and can be effectively controlled by 0.5% bupivacaine-soaked Surgicel in the gallbladder bed alone. Trocar-site infiltration alone is ineffective.

Drugs for preventing postoperative nausea and vomiting

BACKGROUND

Drugs can prevent postoperative nausea and vomiting, but their relative efficacies and side effects have not been compared within one systematic review.

OBJECTIVES

The objective of this review was to assess the prevention of postoperative nausea and vomiting by drugs and the development of any side effects.

SEARCH STRATEGY

We searched The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2004), MEDLINE (January 1966 to May 2004), EMBASE (January 1985 to May 2004), CINAHL (1982 to May 2004), AMED (1985 to May 2004), SIGLE (to May 2004), ISI WOS (to May 2004), LILAC (to May 2004) and INGENTA bibliographies.

SELECTION CRITERIA

We included randomized controlled trials that compared a drug with placebo or another drug, or compared doses or timing of administration, that reported postoperative nausea or vomiting as an outcome.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted outcome data.

MAIN RESULTS

We included 737 studies involving 103,237 people. Compared to placebo, eight drugs prevented postoperative nausea and vomiting: droperidol, metoclopramide, ondansetron, tropisetron, dolasetron, dexamethasone, cyclizine and granisetron. Publication bias makes evidence for differences among these drugs unreliable. The relative risks (RR) versus placebo varied between 0.60 and 0.80, depending upon the drug and outcome. Evidence for side effects was sparse: droperidol was sedative (RR 1.32) and headache was more common after ondansetron (RR 1.16).

AUTHORS' CONCLUSIONS

Either nausea or vomiting is reported to affect, at most, 80 out of 100 people after surgery. If all 100 of these people are given one of the listed drugs, about 28 would benefit and 72 would not. Nausea and vomiting are usually less common and, therefore, drugs are less useful. For 100 people, of whom 30 would vomit or feel sick after surgery if given placebo, 10 people would benefit from a drug and 90 would not. Between one to five patients out of every 100 people may experience a mild side effect, such as sedation or headache, when given an antiemetic drug. Collaborative research should focus on determining whether antiemetic drugs cause more severe, probably rare, side effects. Further comparison of the antiemetic effect of one drug versus another is not a research priority.

Efficacy and safety of steroid use for postoperative pain relief. Update and review of the medical literature

Despite the availability of various analgesic regimens, patient surveys have indicated that moderate-to-severe postoperative pain is still poorly managed. The use of corticosteroids for postoperative pain relief, although popular, has yet to gain wider acceptance because of concerns over side effects, in particular adrenal suppression, osteonecrosis, impaired wound-healing, and concerns about efficacy. The medical literature provides evidence that should substantially decrease these concerns with regard to low and short-dose applications. The results of randomized trials have shown low, short-dose corticosteroid regimens to be safe and effective for reducing postoperative pain. There is strong, grade-A evidence supporting the use of corticosteroids in multimodal analgesia protocols to contribute to the postoperative recovery of the patient by minimizing opioid doses and therefore side effects. However, the optimal mode, dose, and timing of administration remain unclear.

Superiority of preemptive analgesia with intraperitoneal instillation of bupivacaine before rather than after the creation of pneumoperitoneum for laparoscopic cholecystectomy: a randomized, double-blind, placebo-controlled study

BACKGROUND

This study aimed to evaluate the optimal timing of preemptive analgesia with bupivacaine peritoneal instillation in a prospective, randomized, double-blind, placebo-controlled trial.

METHODS

In this study, 120 patients qualified for laparoscopic cholecystectomy were randomized to four groups. Group A received 2 mg/kg of bupivacaine in 200 ml of normal saline before creation of pneumoperitoneum. Group B received 2 mg/kg of bupivacaine in 200 ml of normal saline after creation of pneumoperitoneum. Group C received 200 ml of normal saline before creation of pneumoperitoneum. Group D received 200 ml of normal saline after creation of pneumoperitoneum. Local wound infiltration with bupivacaine was used before skin incisions. The primary end points of the study were postoperative pain intensity on a visual analog scale and incidence of shoulder tip pain. The secondary end points included the latency of nurse-controlled analgesia activation, the analgesia request rate, and analgesic consumption.

RESULTS

Significantly lower visual analog scores were observed in group A versus groups C and B versus group D during the initial 48 and 24 h, respectively. The patients in group A versus group B reported significantly lower pain at 4 h (p < 0.001) and 8 h (p = 0.003) postoperatively, but the difference was not significant after 12, 24, and 48 h. None of the group A patients reported shoulder tip pain, whereas it was reported by 3 patients in group B, 6 patients in group C, and 7 patients in group D (p < 0.01). The latency of nurse-controlled analgesia activation was 426.8 +/-57.2 min in group A, as compared with 307 +/- 39.8 min in group B, 109.3 +/- 51 min in group C, and 109 +/- 46.5 min in group D (p < 0.001). A significantly lower analgesia request rate was observed in group A versus C, as compared with group B versus D, throughout the entire study period (p < 0.05).

CONCLUSIONS

Preemptive analgesia with bupivacaine peritoneal instillation is much more effective for pain relief if used before creation of pneumoperitoneum. Although the effect of bupivacaine peritoneal instillation is also noticeable when used after creation of pneumoperitoneum, it confers significantly lower benefits.

Open cholecystectomy for all patients in the era of laparoscopic surgery - a prospective cohort study

Background

Open cholecystectomy through a small incision is an alternative to laparoscopic cholecystectomy.

Methods

From 1 January 2002 through 31 December 2003, all operations upon the gallbladder in a district hospital with emergency admission and responsibility for surgical training were done as intended small-incision open cholecystectomy.

Results

182 women and 90 men with a median age of 56 (interquartile range 45 to 68 years) underwent cholecystectomy for symptomatic gallbladder disease, 170 as elective and 102 as emergency cases. Trainee surgeons assisted by consultants or registrars having passed an examination for open cholecystectomy performed surgery in 194 cases (71%). The common bile duct was explored in 52 patients. Total postoperative morbidity was six percent. Median postoperative stay was one day and mean total (pre- and postoperative) hospital stay 3.1 days. 32 operations (12%) were done as day surgery procedures. Nationally in Sweden in 2002, mean total hospital stay was 4.4 days, and 13% of all cholecystectomies were performed on an outpatient basis.

Conclusion

Open, small-incision cholecystectomy for all patients is compatible with short hospital stay, evidence-based gall-bladder surgery, and training of surgical residents.

Role of pre-operative dexamethasone as prophylaxis for postoperative nausea and vomiting in laparoscopic surgery

INTRODUCTION

Laparoscopic surgery provides tremendous benefits to patients, including faster recovery, shorter hospital stay and prompt return to normal activities. Despite the minimally invasive nature of laparoscopy, high incidence of postoperative nausea and vomiting remains a major cause for morbidity. The aim of the present study was to investigate whether preoperative Dexamethasone can reduce PONV in patients undergoing laparoscopic Surgery.

MATERIALS AND METHODS

The study included 200 patients undergoing laparoscopic cholecystectomy. We divided the patients into two groups; one group received preoperative Dexamethasone (group 1) and the other group received Ondansetron (group 2). After surgery, patients were observed for any episode of nausea or vomiting, or whether the patient required any anti-emetic drug in the postoperative period.

RESULTS

The two groups, (Dexamethasone and Ondansetron) were comparable in outcome, in terms of post-operative nausea and vomiting, in patients undergoing laparoscopic cholecystectomy. In group I, 24% of patients had nausea, as compared to 30% in group II (P=0.2481). Similarly, 12% of patients in group I and 18% of patients in group II had vomiting (P=0.3574).

CONCLUSION

We conclude that, preoperative intravenous low dose Dexamethasone reduces the incidence of PONV and is comparable to intravenous Ondansetron.

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

We compared methylprednisolone 125 mg IV (n = 68) and parecoxib 40 mg IV (n = 68) with placebo (n = 68) given before breast augmentation surgery in a randomized, double-blind parallel group study. Surgery was performed under local anesthesia combined with propofol/fentanyl sedation. Methylprednisolone and parecoxib decreased pain at rest and dynamic pain intensity from 1 to 6 h after surgery compared with placebo (mean summed pain intensity(1-6 h): methylprednisolone [17.25; 95% confidence interval [CI], 14.85-19.65] versus placebo [21.7; 95% CI, 19.3-24.1]; P < 0.03; parecoxib [15.25; 95% CI, 13.25-17.25] versus placebo; P < 0.001; mean summed dynamic pain intensity(1-6 h): methylprednisolone [22.7; 95% CI, 20.1-23.3] versus placebo [28.4; 95% CI, 26.0-30.8]; P < 0.01; parecoxib [20.9; 95% CI, 18.6-23.2] versus placebo; P < 0.001). Both rescue drug consumption and actual pain (all observations before and after rescue) during the first 6 h were similar in the two active drug groups and significantly reduced compared with placebo. Using a composite score of actual pain intensity and rescue analgesic use, the active drugs were significantly superior to placebo (P < 0.001 for both active drugs). Postoperative nausea and vomiting was reduced after methylprednisolone administration (incidence, 30%), but not after parecoxib (incidence, 37%), during the first 24 h compared with placebo (incidence, 60%; P < 0.001). Fatigue was reduced by methylprednisolone (incidence, 44%), but not by parecoxib (incidence, 59%), compared with placebo (incidence, 66%; P < 0.05). In conclusion, methylprednisolone 125 mg IV given before breast augmentation surgery had analgesic and rescue analgesic-sparing effects comparable with those of parecoxib 40 mg IV. Methylprednisolone, but not parecoxib, reduced nausea, vomiting, and fatigue.

Use of intravenous steroids at induction of anaesthesia for adult tonsillectomy to reduce post-operative nausea and vomiting and pain: a double-blind randomized controlled trial

OBJECTIVE

To assess the effectiveness of intravenous steroids at induction of anaesthetic to reduce post-operative nausea and vomiting and pain after adult tonsillectomy.

DESIGN

Prospective, double-blind, randomized, placebo controlled trial, with ethical approval, following Consolidated Standards of Reporting Trials guidelines.

SETTING

District General Hospital in Scotland, UK.

PARTICIPANTS

Seventy-two adults between 16 and 70 years, American Association of Anaethetists (ASA) 1, listed for elective tonsillectomy.

INTERVENTION

Single dose of either 10 mg of dexamethasone or 2 mL of saline after induction with a consistent anaesthetic technique.

MAIN OUTCOME MEASURES

Patients filled in a visual analogue scale relating to pain and post-operative nausea and vomiting for the day of operation and 7 days after operation. The time to first ingestion of food and drink after operation was also noted.

RESULTS

Data completion rate of 64% (46 of 72 patients enrolled). Statistically significant relative decrease (62%P = 0.001) in the incidence of post-operative nausea and vomiting was seen in those treated with dexamethasone. Statistically significant relative decrease (23%P = 0.016) in post-operative pain scores for the day of operation was seen in those treated with dexamethasone. Significant decrease (17.5%, P < 0.001) in mean pain score for seven post-operative days was seen in those treated with dexamethasone. No adverse effects were seen.

CONCLUSIONS

Dexamethasone given as a single dose of 10 mg at induction of anaesthesia for adult tonsillectomy is an effective, safe and inexpensive method for reducing morbidity in adult tonsillectomy.

Randomized clinical trial of the effect of preoperative dexamethasone on nausea and vomiting after laparoscopic cholecystectomy

Background

Preoperative dexamethasone may reduce disabling symptoms such as pain, nausea and vomiting after laparoscopic cholecystectomy.

Methods

This was a randomized, double-blind, placebo-controlled trial. Between March and December 2004, 101 patients undergoing laparoscopic cholecystectomy were randomized to receive 8 mg dexamethasone (n = 49) or placebo (n = 52) intravenously before surgery. Six patients were excluded from the study. All patients received a standardized anaesthetic, surgical and multimodal analgesic treatment. The primary endpoints were: first, postoperative nausea, vomiting and pain; second, postoperative analgesic and antiemetic requirements. The pain scores (visual analogue and verbal response scales), the episodes of nausea (verbal response scale) and vomiting were recorded at 1, 3, 6 and 24 h, respectively, after the operation. Analgesic and antiemetic requirements were also recorded.

Results

No apparent drug side-effects were noted. Seven patients (14 per cent) in the treatment group reported nausea and vomiting compared with 24 (46 per cent) in the control group (P = 0·001). In the group of patients treated with dexamethasone, five (10 per cent) required antiemetics versus 23 (44 per cent) of those receiving placebo (P &lt; 0·001). No difference in postoperative pain scores and analgesic requirements was detected between groups.

Conclusion

Preoperative dexamethasone reduces postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy, with no side-effects, and may be recommended for routine use.

From acute to chronic pain after laparoscopic cholecystectomy: a prospective follow-up analysis

OBJECTIVE

The pathogenesis and risk of chronic pain after cholecystectomy are unknown. In this prospective study of 150 consecutive patients undergoing laparoscopic cholecystectomy, the preoperative clinical data, cold pressor test, state of neuroticism and early postoperative pain intensity were assessed.

MATERIAL AND METHODS

Follow-up questionnaires were sent to all patients 1 year after surgery. Patients with moderate/severe chronic pain were interviewed and invited to participate in a structured examination programme.

RESULTS

The questionnaire response rate was 100%. Twenty patients reported moderate or severe chronic pain. The 1-year in-office interview revealed that two patients without chronic pain had misinterpreted the questionnaire. Sixteen patients were enrolled for the examination programme. Demonstrable pathology explained the aetiology of chronic pain in 8 patients (5%); another 8 patients with moderate (n=6) or severe (n=2) chronic pain were without pathological findings. In total, 132 patients had no chronic pain. Chronic pain patients suffered significantly more intense acute postoperative pain compared with those without chronic pain (p < or =0.05). The incidence of chronic pain patients was higher in the group of patients with intense acute postoperative pain than in patients with low acute postoperative pain (p = 0.030-0.063). Development of chronic pain was not statistically related to a preoperative cold pressor nociceptive stimulus, preoperative state of neuroticism or to any other variables examined.

CONCLUSIONS

The risk of significant chronic pain after laparoscopic cholecystectomy for symptomatic cholecystolithiasis is low but was significantly associated with the intensity of acute postoperative pain. Patients should be carefully examined to exclude somatic causes of chronic pain after laparoscopic cholecystectomy.

Effect of warmed, humidified insufflation gas and anti-inflammatory agents on cytokine response to laparoscopic nephrectomy: porcine model

PURPOSE

We evaluated the effects of warmed, humidified CO2 and anti-inflammatory agents on the local and systemic cytokine response after laparoscopic nephrectomy.

MATERIALS AND METHODS

A total of 15 pigs were randomized to undergo standard laparoscopic nephrectomy, laparoscopic nephrectomy with warmed, humidified CO2 gas or laparoscopic nephrectomy with perioperative administration of intravenous dexamethasone and oral rofecoxib. At baseline, and 1, 4, 24 and 48 hours after surgery duplicate blood and peritoneal samples were drawn to analyze cortisol, glucose, tumor necrosis factor-alpha (TNF-alpha), interleukin (IL)-1beta and IL-6 via a microassay technique. Body temperature was determined at operation, intraoperatively and 1 hour postoperatively. Surgical parameters, including operative time, gas volume used and blood loss, were recorded.

RESULTS

Pigs in the warmed, humidified CO2 and anti-inflammatory arms maintained higher intraoperative and postoperative core body temperatures than controls. Warmed, humidified CO2 did not affect peritoneal or systemic cytokine levels. Peak peritoneal TNF-alpha levels in the anti-inflammatory group were significantly higher than in controls at 4 hours. Considerably higher serum TNF-alpha levels in the anti-inflammatory group were observed at 48 hours. Peritoneal IL-1beta and IL-6 levels in the anti-inflammatory group remained similar to those in controls, while serum levels were noticeably lower. There was no observable difference in serum cortisol or the glucose response to laparoscopic nephrectomy among the groups.

CONCLUSIONS

While preserving core body temperature, humidified, warmed CO2 did not affect local or systemic trends of pro-inflammatory mediators. The administration of perioperative anti-inflammatory agents produced conflicting local and systemic cytokine response of uncertain clinical significance.

[Adrenal cortex and steroids. Supplementary therapy in the perioperative phase]

Since the publication of two case reports that are considered to represent the first clinical demonstration of iatrogenic adrenal insufficiency, it has been the generally accepted practice to cover steroid-treated patients undergoing surgery with glucocorticoids in the perioperative period. Both the inclusion criteria for the patients and the extent of the substitution pattern have been selected on an empirical rather than on a rational basis. Scientific advances over the past 50 years in the knowledge of the hypothalamic-pituitary-adrenal system's physiology and the molecular mechanism of action of its biologically active components are, for the most part, not reflected in current clinical practice and instead seem to be ignored. Clinical and experimental evidence suggests, however, that even glucocorticoid-treated patients undergoing surgery do not require maximum stress doses of hydrocortisone, which should be reserved for the treatment of sepsis. With regard to the broad spectrum of efficacy of glucocorticoids and their side effects, revision and modification of the historical regimen appear prudent.

Bacterial antigen induced release of soluble vascular endothelial growth factor (VEGF) and VEGFR1 before and after surgery

OBJECTIVE

The influence of surgery on release of soluble vascular endothelial growth factor (sVEGF) and the soluble inhibitory receptor (sVEGFR1) is unknown. The effect of major and minor surgery on variations in sVEGF and sVEGFR1 concentrations in vivo was studied, and on bacterial antigen-induced release of sVEGF and sVEGFR1 from whole blood in vitro.

MATERIAL AND METHODS

Sixty-one patients with abdominal diseases undergoing five different surgical procedures were included in the study. Blood samples were drawn from patients before and after the operation. White blood cells and platelets were counted, and plasma sVEGF and sVEGFR1 were determined. Whole blood from each blood sample was stimulated in vitro with bacteria-derived antigens (lipopolysaccharides or protein A) and sVEGF and sVEGFR1 levels were subsequently determined in the supernatants.

RESULTS

Neither sVEGF nor sVEGFR1 concentrations in plasma changed during surgery. In vitro stimulation of blood samples with bacteria-derived antigens resulted in a significant increase in sVEGF (p < 0.0001) and a less pronounced but still significant increase in sVEGFR1 (p < 0.01). Bacterial antigen-induced release of sVEGF correlated significantly with neutrophil cell counts (0.53 < r < 0.78; p < 0.0001). Bacterial antigen-induced sVEGFR1 release did not correlate with cell counts.

CONCLUSIONS

Plasma sVEGF and sVEGFR1 concentrations did not change during surgery. In vitro bacterial stimulation led to increased release of sVEGF, which was not compensated for by an equivalent increase in sVEGFR1. There was a positive impact of major abdominal surgery on release of sVEGF. The bacterial antigen-induced changes in sVEGF may be related to the number of circulating neutrophils.

A procedure-specific systematic review and consensus recommendations for postoperative analgesia following laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy has advantages over the open procedure for postoperative pain. However, a systematic review of postoperative pain management in this procedure has not been conducted.

METHODS

A systematic review was conducted according to the guidelines of the Cochrane Collaboration. Randomized studies examining the effect of medical or surgical interventions on linear pain scores in patients undergoing laparoscopic cholecystectomy were included. Qualitative and quantitative analyses were performed. Recommendations for patient care were derived from review of these data, evidence from other relevant procedures, and clinical practice observations collated by the Delphi method among the authors.

RESULTS

Sixty-nine randomized trials were included and 77 reports were excluded. Recommendations are provided for preoperative analgesia, anesthetic and operative techniques, and intraoperative and postoperative analgesia.

CONCLUSIONS

A step-up approach to the management of postoperative pain following laparoscopic cholecystectomy is recommended. This approach has been designed to provide adequate analgesia while minimizing exposure to adverse events.

Prevention and treatment of postoperative nausea and vomiting

PURPOSE

The physiology, risk factors, and prevention and treatment of postoperative nausea and vomiting (PONV) are discussed.

SUMMARY

Factors to consider when determining a patient's risk for PONV include sex, history of PONV, history of motion sickness, smoking status, duration of anesthesia, use of opioids, and type of surgery. Receptors that, when activated, can cause nausea or vomiting or both include dopamine type 2, serotonin type 3, histamine type 1, and muscarinic cholinergic type 1 receptors. Patients at moderate to high risk for PONV benefit from the administration of a prophylactic antiemetic agent that blocks one or more of these receptors. Effective agents include transdermal scopolamine, prochlorperazine, promethazine, droperidol, ondansetron, dolasetron, granisetron, and dexamethasone. In high-risk patients, combining two or more antiemetics with different mechanisms of action has been shown to be more effective than using a single agent. In addition to administering a prophylactic antiemetic, it is important to reduce the patient's risk by considering regional anesthesia, considering inducing and maintaining general anesthesia with propofol, ensuring good intravenous hydration, avoiding hypotension, and providing effective analgesia. If PONV occurs in the immediate postoperative period, it is best treated with an antiemetic agent from a pharmacologic class different from that of the prophylactic agent.

CONCLUSION

Prophylactic antiemetic therapy for PONV is effective, but combinations of agents may be necessary for high-risk patients. Nonpharmacologic strategies are also important.

Qualidade de vida do doador após transplante hepático intervivos

RACIONAL: A qualidade de vida do doador após transplante hepático intervivos ainda não foi avaliada em nosso meio. OBJETIVO: Avaliar a qualidade de vida do doador após transplante hepático intervivos. MÉTODOS: De um total de 300 transplantes hepáticos, 51 foram de doadores vivos. Doadores com seguimento menor do que 6 meses e os que não quiseram participar do estudo foram excluídos. Os doadores responderam a um questionário de 28 perguntas abordando os vários aspectos da doação, sendo também avaliados dados demográficos e clínicos dos mesmos. RESULTADOS: Trinta e sete doadores aceitaram participar do estudo. Destes, 32 eram parentes de primeiro ou de segundo grau do receptor. O esclarecimento sobre o caráter voluntário da doação foi adequado para todos pacientes. Apenas um (2%) não doaria novamente. A dor pós-operatória foi pior do que o esperado para 22 doadores (59%). O retorno às atividades normais ocorreu em menos de 3 meses para 21 doadores (57%). Vinte e um doadores (57%) tiveram perda financeira com a doação devido a gastos com medicamentos, exames, transporte ou perda de rendimentos. Trinta e três (89%) não tiveram modificação ou limitação na sua vida após a doação. Os aspectos mais negativos da doação foram a dor pós-operatória e a presença de cicatriz cirúrgica. A maioria das complicações pós-operatória foi resolvida com o tratamento clínico, mas complicações graves ou potencialmente fatais ocorreram em dois pacientes. CONCLUSÕES: A maioria dos doadores apresentou boa recuperação e retornou completamente as suas atividades normais poucos meses após a doação. O aspecto mais negativo da doação foi a dor pós-operatória.

Prospective analysis of convalescence and early pain after uncomplicated laparoscopic fundoplication

BACKGROUND

The aim of this study was to define factors that limit a short period of convalescence and to characterize the pain experienced after laparoscopic fundoplication.

METHODS

This prospective study included 60 consecutive patients who underwent uncomplicated laparoscopic Nissen fundoplication for gastro-oesophageal reflux disease. Patients were recommended to convalesce for 2 days after operation. Duration of convalescence, dysphagia, fatigue, nausea, vomiting and different pain components were registered daily during the first week and on days 10 and 30 after fundoplication.

RESULTS

Thirty-nine patients took a median of 13 (range 3-41) days off work and 60 stayed away from recreational activity for a median of 4 (range 1-22) days. Pain, fatigue and plans made before operation were the main contributors to prolonged convalescence. Some 30-40 per cent of the patients reported moderate or severe dysphagia during the study period. Fatigue scores were significantly increased for 6 days after surgery (P < 0 . 001). Visceral pain dominated over incisional and shoulder pain throughout the study. At day 30, 17 per cent of the patients reported moderate or severe visceral pain.

CONCLUSION

Pain and dysphagia are significant problems after uncomplicated total laparoscopic fundoplication. The time taken off work and away from recreational activity exceeded the recommended 2 days of convalescence, justifying further efforts to optimize early clinical outcome after total laparoscopic fundoplication.

Methylprednisolone intravenously 1 day after surgery has sustained analgesic and opioid-sparing effects

BACKGROUND

In previous studies on glucocorticoids for postoperative pain, the test drug has been given perioperatively, usually before measurement of baseline pain. In order to evaluate the time course and magnitude of the analgesic effect of a glucocorticoid in well-established postoperative pain, we compared methylprednisolone with ketorolac and placebo, after assessment of baseline pain on the first postoperative day.

METHODS

This was a double-blind, single dose, randomized, parallel comparison of intravenous (i.v.) methylprednisolone 125 mg, ketorolac 30 mg as an active control, and placebo in 75 patients with moderate to severe pain 1 day after orthopaedic surgery. Outcome variables were pain intensity (0-100 VAS), pain relief (0-4 PAR) and rescue opioid consumption.

RESULTS

Methylprednisolone was not significantly different from ketorolac and gave significantly lower pain intensity from 1 h (0-6 h, P < 0.02), and more pain relief 2-6 h after test drugs (P < 0.05) compared with placebo. After 24 h, pain intensity was lower in both active drug groups compared with placebo (methylprednisolone, P < 0.0001; ketorolac, P < 0.007). Number needed to treat (NNT) calculated from patients having more than at least 50% of maximum obtainable total pain relief during the first 6 h (>50%maxTOTPAR(6 h)) was 3.6 for methylprednisolone and 3.1 for ketorolac. Number needed to treat calculated from the percentage reporting at least 50% pain relief for at least 4 h (>50%PAR(4 h)) was 2.8 for both groups. Opioid consumption was significantly reduced for 72 h after methylprednisolone compared with ketorolac (P < 0.02) and placebo (P < 0.003).

CONCLUSION

Methylprednisolone 125 mg i.v. 1 day after surgery gave similar early reduction of pain as i.v. ketorolac 30 mg. Less pain than placebo 24 h after methylprednisolone, and lower opioid consumption for 72 h compared with ketorolac and placebo indicate sustained analgesic effects of methylprednisolone.

'Protective premedication': an option with gabapentin and related drugs? A review of gabapentin and pregabalin in in the treatment of post-operative pain

Substantial progress has been made during the last decades in our understanding of acute pain mechanisms, and this knowledge has encouraged the search for novel treatments. Of particular interest has been the observation that tissue injury initiates a number of modulations of both the peripheral and the central pain pathways, which convert the system from a 'physiological' to a 'pathological' mode of processing afferent information. Gabapentin, which binds to the alpha(2)delta subunit of the voltage-dependent calcium channel, is active in animal models of 'pathological' but not in models of 'physiological' pain. Consequently, attention has so far been focused on neuropathic pain as a target for the clinical use of gabapentin and analogues. Recently, several reports have indicated that gabapentin may have a place in the treatment of post-operative pain. This article presents a brief summary of the potential mechanisms of post-operative pain, and a systematic review of the available data of gabapentin and pregabalin for post-operative analgesia. It is concluded that the results with gabapentin and pregabalin in post-operative pain treatment published so far are promising. It is suggested that future studies should explore the effects of 'protective premedication' with combinations of various antihyperanalgesic and analgesic drugs for post-operative analgesia.