Preventing postoperative pain by local anesthetic instillation after laparoscopic gynecologic surgery: a placebo-controlled comparison of bupivacaine and ropivacaine

Efficacy of Intraperitoneal 0.2% Ropivacaine With Dexmedetomidine Versus 0.2% Ropivacaine With Ketamine in Laparoscopic Surgeries: A Randomized Controlled Trial

BACKGROUND

Effective pain management modalities are the armamentarium for enhanced recovery in laparoscopic surgeries. Intraperitoneal instillation of local anaesthetics with adjuvants is advantageous in minimizing pain. So, we designed this study with the aim to compare the analgesic effectiveness of intraperitoneal ropivacaine with adjuvants like dexmedetomidine versus ketamine for postoperative analgesia.

OBJECTIVE

 The objective of this study is to assess the total duration of analgesia and total rescue analgesic dose requirements in the first 24 hours postoperatively.

MATERIALS AND METHODS

A total of 105 consenting patients for elective laparoscopic surgeries were enrolled and divided into three groups by computer-generated randomization as follows: Group 1: 30 ml of 0.2% ropivacaine with ketamine 0.5 mg/kg diluted to 1 ml; Group 2: 30 ml of 0.2% ropivacaine with dexmedetomidine 0.5 mcg/kg diluted to 1 ml; Group 3: 30 ml of 0.2% ropivacaine with 1 ml of normal saline. The postoperative visual analogue scale (VAS) score, total duration of analgesia, and total analgesic dose were calculated and compared among the three groups.

RESULTS

The postoperative analgesic duration after intraperitoneal instillation of Group 2 was longer as compared to Group 1. The total analgesic requirement was lower in Group 2 as compared to Group 1, and the p-value was significant (p ≤ 0.001) for both parameters. Demographic parameters and VAS scores among the three groups were not statistically significant.

CONCLUSION

We conclude that intraperitoneal instillation of local anaesthetics with adjuvants is effective for postoperative analgesia in laparoscopic surgeries, and ropivacaine 0.2% with dexmedetomidine 0.5 mcg/kg is more effective when compared to ropivacaine 0.2% with ketamine 0.5 mg/kg.

A Comparative Study on the Postoperative Analgesic Effects of the Intraperitoneal Instillation of Bupivacaine Versus Normal Saline Following Laparoscopic Cholecystectomy

Background Laparoscopic cholecystectomy is widely performed, and postoperative pain is an important factor in patient morbidity during recovery. Various modalities for postoperative pain relief have been proposed, with varying levels of success such as intravenous or intramuscular non-steroidal anti-inflammatory drugs (NSAIDs) and opioids, infiltration at the incision site with local anesthetics, intraperitoneal infiltration of local anesthetics, intraperitoneal infiltration of local anesthetics with adjuvants, regional anesthesia techniques such as epidurals and nerve blocks. The study was aimed to evaluate the efficacy of intraperitoneal instillation of bupivacaine and normal saline on postoperative analgesia, postoperative nausea, and vomiting after laparoscopic cholecystectomy. Methods This prospective, controlled, and randomized study included 60 American Society of Anesthesiologists (ASA) I and ASA II patients, aged 18-50 years, who were scheduled for laparoscopic cholecystectomy under general anesthesia. The patients were classified randomly into two groups with an equal number of participants: Group B received intraperitoneal instillation of 30 ml of plain bupivacaine 0.5% and Group N received 30 ml of normal saline. Postoperative pain was recorded using the visual analog scale (VAS) for 24 hours after surgery. Postoperative shoulder pain, nausea, vomiting, and the time taken to request rescue analgesia were noted. Results Patients receiving intraperitoneal bupivacaine showed a significant reduction in postoperative pain for the first six hours postoperatively (P = 0.04); moreover, the time taken to request rescue analgesia requirement was prolonged (P = 0.04). Side effects, such as nausea and vomiting, were similar between the two groups (P = 0.1 and p = 0.09, respectively) while shoulder pain was significantly lower in the bupivacaine group (P = 0.04). Conclusion Bupivacaine is effective in reducing postoperative pain, and it prolongs the requirement time for rescue analgesia. It also reduces the incidence of shoulder pain but does not decrease postoperative nausea and vomiting.

Intracorporeal overlap gastro-gastrostomy for solo single-incision pylorus-preserving gastrectomy in early gastric cancer

This report discusses the technique of solo single-incision pylorus-preserving gastrectomy (SIPPG) for early gastric cancer. To overcome difficulties regarding lymph node dissection (LND), a scope holder and an energy device were used, allowing fine dissection in a fixed field of view. The overlap gastro-gastrostomy technique was used for anastomosis. Seventeen patients underwent solo SIPGG. The mean operation time was 150.1 ± 28.7 min, and no patients developed postoperative complications or delayed gastric emptying within 30 days of the operation. Using scope holders and performing fine dissection with the energy device, challenges regarding LND in SIPPG can be overcome. INTACT anastomosis was initially used; however, due to its inconsistency and the high degree of surgical skill required, it was changed to the overlap method. Solo SIPPG with overlap gastro-gastrostomy may be safe and feasible with good cosmetic results and fast patient recovery.

Intraperitoneal Ropivacaine with Dexmedetomidine or Fentanyl for Postoperative Analgesia Following Laparoscopic Cholecystectomy: A Comparative Randomized Trial

Background:

Intraperitoneal local anesthetic is an effective analgesic approach following laparoscopic cholecystectomy.

Aims:

The aim of the present study was to compare the antinociceptive effects of intraperitoneal ropivacaine plus fentanyl with ropivacaine plus dexmedetomidine in patients undergoing laparoscopic cholecystectomy.

Settings and Designs:

This was randomized, prospective, double-blinded, observational clinical study.

Methods:

A total of 80 patients, undergoing elective laparoscopic cholecystectomy under general anesthesia were randomly assigned to one of the two equal groups to receive either of the following: Group RF (n = 40) were given 30 mL of 0.2% ropivacaine combined with 1 μg/kg fentanyl (diluted in 2 mL normal saline) and Group RD (n = 40) were given 30 mL of 0.2% ropivacaine combined with 1 μg/kg dexmedetomidine (diluted in 2 mL normal saline) through trocars. The quality of analgesia was assessed using visual analog scale score (VAS). Time to the first request of analgesia, the total dose of analgesic in the first 24 h and adverse effects were noted.

Statistical Analysis:

The data were analyzed with the Students’ t-test and Chi-square test.

Results:

VAS score at different time intervals, overall VAS in 24 h was significantly lower (1.68 ± 0.46 vs. 4.47 ± 0.94), time to first request of analgesia (min) was longest (122.7 ± 24.5 vs. 89.3 ± 13.2) and total analgesic consumption (mg) was lowest (95.3 ± 15.6 vs. 135.7 ± 75.1) in RD group than in RF group.

Conclusion:

The antinociceptive effect of the intraperitoneal instillation of ropivacaine in combination with dexmedetomidine is superior to ropivacaine combined with fentanyl.

Efficacy of abdominal peripheral nerve block and caudal block during robot-assisted laparoscopic surgery: a retrospective clinical study

PURPOSE

We retrospectively analyzed the efficacy of abdominal peripheral nerve block (PNB) and caudal block (CB) in patients undergoing robot-assisted laparoscopic radical prostatectomy (RARP).

METHODS

Patients who underwent elective RARP at our hospital (Jan. 2015-Sept. 2016) were enrolled. We reviewed the 188 patients' anesthesia charts and medical records and divided the patients into three groups based on the anesthesia used in their cases: 76 patients in the total intravenous anesthesia (TIVA) group, 51 patients in the TIVA + abdominal PNB group (TI-PB group), and 61 patients in the TIVA + abdominal PNB + CB (TI-PB-CB group). We compared the groups' amounts of anesthetic drug usage, anesthesia times, and the presence/absence of additional opioid administration in the recovery room.

RESULTS

The perioperative opioid use during anesthesia was significantly greater in the TIVA group than in the TI-PB-CB group. The total amount of muscle relaxant was significantly higher (p < 0.001) in the TIVA group than the TI-PB-CB group: 60.0 (50.0-70.0) mg vs. 50.0 (40.0-60.0) mg. Although there were no significant differences in the operation time, the frequency of the use of additional opioid administration was significantly higher (p < 0.01) in the TIVA group than the TI-PB group: 23.7% vs. 2.0%, respectively.

CONCLUSIONS

Although there was no influence on the anesthesia time, the muscle relaxant dose and the perioperative amount of opioid use were significantly less in the combined PNB + CB group. Our analyses suggest that not only PNB but also CB was useful for perioperative management in RARP.

CLINICAL TRIAL REGISTRATION

2016-1059.

Spinal Anesthesia and Spinal Anesthesia with Subdiaphragmatic Lidocaine in Shoulder Pain Reduction for Gynecological Laparoscopic Surgery: A Randomized Clinical Trial

OBJECTIVE

The aim of this study was to compare the effectiveness of spinal anesthesia with subdiaphragmatic lidocaine at the beginning of surgery versus spinal anesthesia in pain reduction for gynecological laparoscopic surgery.

METHODS

This was a clinical trial conducted in Arash Hospital, Tehran, Iran. Eighty-four patients were randomized to either spinal anesthesia with subdiaphragmatic lidocaine, spinal anesthesia, or general anesthesia (GA). The primary outcome was patients' pain perception during surgery, 2, 4, 6, and 12 hours after surgery, and prior to discharge and was assessed by visual analogue scale (VAS).

RESULTS

The results showed that there are no significant changes in pain perception over time in none of the three groups (F(4,76) = 0.37, P = 0.82). The severity of pain experienced by patients at all-time interval after surgery was similar between groups [F(2,79) = 0.54, P = 0.58].

CONCLUSION

The use of subdiaphragmatic lidocaine at the beginning of surgery combined with spinal anesthesia was not associated with a statistically significant difference in patients' postoperative VAS scores compared to spinal anesthesia and GA during and after gynecological surgical procedures. The study was registered in Iranian Registry of Clinical Trial by the number of IRCT2016022226698N1.

Effects of Intraperitoneal Local Anaesthetics Bupivacaine and Ropivacaine versus Placebo on Postoperative Pain after Laparoscopic Cholecystectomy: A Randomised Double Blind Study

INTRODUCTION

Laparoscopic Cholecystectomy (LC) is the most frequently performed elective daycare surgery and provision of postoperative pain relief is of importance. After laparoscopic cholecystectomy shoulder and abdominal pain causes considerable distress. Visceral pain during coughing, respiration and mobilization increases morbidity, hospital stay and costs.

AIM

To compare the analgesic efficacy of intraperitoneally instilled equipotent concentrations of bupivacaine and ropivacaine versus placebo in relieving postoperative pain after laparoscopic cholecystectomy when used as a part of multimodal analgesia.

MATERIALS AND METHODS

In this randomised, prospective, double blind, placebo controlled study, 90 ASA Class I or II patients were randomly divided into three groups of 30 each. Group S received intraperitoneal infiltration with 35 ml of 0.9% normal saline, Group B with 35 ml of 0.25% bupivacaine and Group R with 35 ml of 0.375% ropivacaine. All groups received standard general endotracheal anaesthesia and analgesia with IV paracetamol 15 mg/kg and diclofenac 1.5 mg/kg. Numerical Rating Scale (NRS) score of analgesia at rest and on cough/movement, duration of analgesia, haemodynamic parameters, need for a rescue analgesic (IV tramadol 1 mg/kg) was recorded and adverse effects of procedure and drugs if any were monitored. Data was analysed with SPSS statistical software version 21.0. One way ANOVA or the Kruskal-Wallis test was used to compare continuous data across all three groups as appropriate. Subsequent analysis of continuous data between two groups was achieved by Tukey's post hoc test. Significance was accepted as p<0.05.

RESULTS

The mean NRS was <5 till only four hours in Group S, till eight hours in Group B and till 16 hours in Group R. The duration of analgesia was 13.47±1.38 hours in Group R, 7.93±1.44 hours in Group B and 4.47±0.86 hours in Group S.

CONCLUSION

Intraperitoneal infiltration of LA significantly reduces pain intensity scores in the early postoperative period after LC surgery and helps in improving the postoperative recovery profile and outcome. This makes LC surgery more amenable to day care surgical setup. Ropivacaine (0.375%) is more efficacious, longer acting with a higher intensity of postoperative analgesia than bupivacaine (0.25%).

Which intraperitoneal insufflation pressure should be used for less postoperative pain in transperitoneal laparoscopic urologic surgeries?

Purpose

To determine whether using different intraperitoneal insufflation pressures for transperitoneal laparoscopic urologic surgeries decreases postoperative pain.

Materials and Methods

76 patients who underwent transperitoneal laparoscopic upper urinary tract surgery at different insufflation pressures were allocated into the following groups: 10mmHg (group I, n=24), 12mmHg (group II, n=25) and 14mmHg (group III, n=27). These patients were compared according to age, gender, body mass index (BMI), type and duration of surgery, intraoperative bleeding volume, postoperative pain score and length of hospital stay. A visual analog scale (VAS) was used for postoperative pain.

Results

Demographic characteristics, mean age, gender, BMI and type of surgeries were statistically similar among the groups. The mean operation time was higher in group I than group II and group III but this was not statistically significant (P=0.810). The mean intraoperative bleeding volume was significantly higher in group I compared with group II and group III (P=0.030 and P=0.006). The mean length of postoperative hospital stays was statistically similar among the groups (P=0.849). The mean VAS score at 6h was significantly reduced in group I compared with group III (P=0.011). At 12h, the mean VAS score was significantly reduced in group I compared with group II and group III (P=0.009 and P<0.001). There was no significant difference in the mean VAS scores at 24h among three groups (P=0.920).

Conclusion

Lower insufflation pressures are associated with lower postoperative pain scores in the early postoperative period.

Challenges of pain control and the role of the ambulatory pain specialist in the outpatient surgery setting

Ambulatory surgery is on the rise, with an unmet need for optimum pain control in ambulatory surgery centers worldwide. It is important that there is a proportionate increase in the availability of acute pain-management services to match the rapid rise of clinical patient load with pain issues in the ambulatory surgery setting. Focus on ambulatory pain control with its special challenges is vital to achieve optimum pain control and prevent morbidity and mortality. Management of perioperative pain in the ambulatory surgery setting is becoming increasingly complex, and requires the employment of a multimodal approach and interventions facilitated by ambulatory surgery pain specialists, which is a new concept. A focused ambulatory pain specialist on site at each ambulatory surgery center, in addition to providing safe anesthesia, could intervene early once problematic pain issues are recognized, thus preventing emergency room visits, as well as readmissions for uncontrolled pain. This paper reviews methods of acute-pain management in the ambulatory setting with risk stratification, the utilization of multimodal interventions, including pharmacological and nonpharmacological options, opioids, nonopioids, and various routes with the goal of preventing delayed discharge and unexpected hospital admissions after ambulatory surgery. Continued research and investigation in the area of pain management with outcome studies in acute surgically inflicted pain in patients with underlying chronic pain treated with opioids and the pattern and predictive factors for pain in the ambulatory surgical setting is needed.

Comparative study of postoperative analgesic effect of intraperitoneal instillation of dexmedetomidine with bupivacaine and bupivacaine alone after laparoscopic surgery

AIMS:

This prospective double-blinded study was designed with the aim of comparing the analgesic effect of intraperitoneal instillation of dexmedetomidine with bupivacaine with that with bupivacaine alone in patients undergoing laparoscopic surgeries.

MATERIALS AND METHODS:

A total of 100 patients of either sex undergoing elective laparoscopic surgery were randomly divided into two groups containing 50 patients in each group. Group B received intraperitoneal instillation with 50 mL of bupivacaine 0.25% (125 mg) and groups B + D received 50 mL of bupivacaine 0.25% (125 mg) + 1 μg/kg of dexmedetomidine. Pain was assessed using visual analogue scale (VAS) at 0.5 h, 1 h, 2 h, 4 h, 6 h, and 24 h after the surgery. The requirement of rescue analgesics were recorded.

RESULT:

Duration of analgesia was longer in group B+D (14.5 hr) compared to group B (13.06 hr). The requirement of rescue analgesic in 24 hours was less in group B+D (1.76) compared to group B (2.56) which were statistically significant (P < 0.05). The mean number of total rescue analgesia given in 24 h was less in group B+D was 1.76 whereas in group B was 2.56 that were statistically significant.

CONCLUSION:

Intraperitoneal instillation of dexmedetomidine with bupivacaine prolongs the duration of postoperative analgesia as compared to that with bupivacaine alone. And also there is less number of rescue analgesics that are required postoperatively when dexmedetomidine is supplemented as an adjuvant to bupivacaine.

Magnesium Versus Bupivacaine Infiltration in Controlling Postoperative Pain in Inguinal Hernia Repair

Background:

Postoperative pain is one of the most common problems after hernia repair. Decrease in postoperative pain accelerates functional recovery, decreases duration of hospital stay and postoperative morbidity.

Objectives:

To compare postoperative analgesic effect of infiltration of magnesium versus bupivacaine into incision of inguinal hernia repair.

Patients and Methods:

In a double blind clinical trial, 80 patients’ candidates for elective inguinal hernia repair were enrolled. Right before closure of incision, in Bupivacaine group 5 mL Bupivacaine 0.5% added to 5 mL normal saline and in Magnesium group, 10 mL Magnesium sulfate 20% was infused subcutaneously. Pain score was measured using numeric rating score (NRS) at 1, 3, 6, 12 and 24 hours postoperatively. If NRS was above 3, 1 mg morphine was administered as rescue analgesic until patient felt comfortable or NRS < 3.

Results:

Postoperative pain scores at 1 and 3 hours were not significantly different between bupivacaine and magnesium groups (P = 0.21, 0.224; respectively). However, at 6 (P = 0.003), 12 (P = 0.028) and 24 (P = 0.022) hours postoperative, pain score (NRS) was significantly lower in bupivacaine group. Number of patients needed at least 1 dose of rescue morphine (P = 0.001), mean number of episodes asked for morphine during next 24 hours (P = 0.001) and total dose of morphine requirement (P = 0.01) were significantly lower in bupivacaine group.

Conclusions:

Magnesium infiltration did not decrease total dose and number of episodes needed for morphine rescue analgesic. Bupivacaine infiltration into surgical site was more effective than magnesium sulfate infiltration in postoperative pain control.

Efficacy and safety of intraperitoneal dexmedetomidine with bupivacaine in laparoscopic colorectal cancer surgery, a randomized trial

OBJECTIVE

Our objective is to investigate the efficacy and safety of intraperitoneal dexmedetomidine (Dex) combined with bupivacaine in patients undergoing laparoscopic colorectal cancer surgery.

DESIGN

Randomized double-blind study.

SETTING

Academic medical center.

PATIENTS AND METHODS

Forty-five patients scheduled for laparoscopic colorectal cancer surgery were randomly assigned for intraperitoneal administration of 50 mL saline (control group; GI, n = 15), 50 mL bupivacaine 0.25% (125 mg; GII, n = 15), or 50 mL bupivacaine 0.25% (125 mg) +1 μg/kg Dex (GIII, n = 15). Patients were assessed during the first 24 hours postoperatively for hemodynamics, visual analogue scale (VAS), time to first request of analgesia, total analgesic consumption, shoulder pain, and side effects.

RESULTS

A significant reduction was observed in VAS in GIII at base line, 2, 4, and 24 hours postoperatively in comparison to GI and GII (P < 0.05). The time to first analgesic requirement was significantly prolonged in GIII (P < 0.05). The mean total consumption of rescue analgesia was significantly reduced in GIII.

CONCLUSION

We conclude that intraperitoneal administration of Dex 1 μg/kg combined with bupivacaine improves the quality and the duration of postoperative analgesia and provides an analgesic sparing effect compared to bupivacaine alone without significant adverse effects in patients undergoing laparoscopic colorectal cancer surgery.

Effects of intravenous diclofenac on postoperative sore throat in patients undergoing laparoscopic surgery at Aga Khan University Hospital, Nairobi: a prospective, randomized, double blind controlled trial

BACKGROUND

postoperative sore throat is the commonest complication after endotracheal intubation. The efficacy of intravenous non-steroidal anti-inflammatory drugs in alleviating postoperative sore throat has not been investigated.

OBJECTIVE

To evaluate the effect of intravenous diclofenac sodium on the occurrence and severity of postoperative sore throat.

METHODS

42 in-patients scheduled for laparoscopic surgery were randomized into two equal groups to receive either a single dose of 75mg intravenous diclofenac sodium in addition to standard treatment taken at our hospital for the prevention of postoperative sore throat or to receive standard treatment only. All patients were interviewed postoperatively at 2, 6 and 18 hours. Data of the baseline characteristics, the incidence and severity of sore throat were collected. If sore throat was present, a Visual Analogue Score was used to assess its severity.

RESULTS

the baseline characteristics of the participants were similar. The majority of the patients undergoing laparoscopic surgery were women. There was no statistically significant difference in the occurrence or severity of postoperative sore throat between the diclofenac and standard treatment groups at 2, 6 and 18 hours postoperatively.

CONCLUSION

Intravenous diclofenac sodium does not reduce the occurrence or severity of postoperative sore throat.

Regional anesthesia for laparoscopic surgery: a narrative review

Laparoscopic surgery has advanced remarkably in recent years, resulting in reduced morbidity and shorter hospital stay compared with open surgery. Despite challenges from the expanding array of laparoscopic procedures performed with the use of pneumoperitoneum on increasingly sick patients, anesthesia has remained largely unchanged. At present, most laparoscopic operations are usually performed under general anesthesia, except for patients deemed "too sick" for general anesthesia. Recently, however, several large, retrospective studies questioned the widely held belief that general anesthesia is the best anesthetic method for laparoscopic surgery and suggested that regional anesthesia could also be a reasonable choice in certain settings. This narrative review is an attempt to critically summarize current evidence on regional anesthesia for laparoscopic surgery. Because most available data come from large, retrospective studies, large, rigorous, prospective clinical trials comparing regional vs. general anesthesia are needed to evaluate the true value of regional anesthesia in laparoscopic surgery.

The effects of magnesium sulfate infiltration on perioperative opioid consumption and opioid-induced hyperalgesia in patients undergoing robot-assisted laparoscopic prostatectomy with remifentanil-based anesthesia

BACKGROUND

Opioids not only exert an antinociceptive effect, but also modulate central N-methyl-D-aspartate (NMDA) receptors, resulting in hyperalgesia and acute opioid tolerance. This study was aimed to investigate the effect of the NMDA receptor antagonist, magnesium in preventing remifentanil-induced hyperalgesia.

METHODS

For this study, 75 patients scheduled for robot-assisted laparoscopic prostatectomy were randomly allocated into three groups of patients whose incision sites were infiltrated: Group M, with 25% magnesium sulfate 80 mg/kg; Group S, with the same volume of saline under remifentanil-based anesthesia, and Group D, with the same volume of saline under desflurane based anesthesia. All three groups were infiltrated into incision sites after pneumoperitoneum. Intraoperative evaluation included mean remifentanil dose, and postoperative evaluation included pain severity at time intervals of 30 min, 6, 12, 24 and 36 hours, time to first postoperative analgesic requirement, and analgesic dosage required during 24 hours.

RESULTS

Mean remifentanil doses during the intraoperative periods in group M were significantly lower than those in group S (P < 0.001). The time to first postoperative analgesic requirement in postoperative period in groups M and D was significantly longer than that in group S (P < 0.001). Visual analog scale scores for pain in groups M and D were significantly lower than those in group S for 12 hours after operation.

CONCLUSIONS

A relatively high dose and continuous infusion of remifentanil were associated with opioid induced hyperalgesia. Wound infiltration with magnesium sulfate decreased opioid consumption and reduces opioid induced hyperalgesia.

Postoperative analgesia for gynecological laparoscopy

Gynecological laparoscopy is a commonly performed procedure. Providing anesthesia for this can present a challenge, particularly in the day surgery population. Poor analgesia, nausea, and vomiting can cause distress to the patient and increased cost for the health system, because of overnight admission. In this review we discuss anesthetic and analgesic techniques for day-case gynecological laparoscopy. The principles include multimodal analgesia, the use of the oral route wherever possible, and the contribution of the surgeon.

Wound infiltration with plain bupivacaine as compared with bupivacaine fentanyl mixture for postoperative pain relief after abdominal surgery

AIM

To compare the efficacy of wound infiltration with Bupivacaine or Bupivacaine with fentanyl for post operative analgesia.

BACKGROUND

The role of Bupivacaine and fentanyl mixture as wound infiltration for post operative analgesia is less explored in human subjects.

MATERIALS AND METHODS

This prospective, randomized included 60 ASA grade I, II, and III patients in the age group of 20-75 years of age. The patients were randomized into two groups of 30 patients each: Group A received wound infiltration with a solution containing 0.5% bupivacaine (2 mg/kg), while, Group B received infiltration with a solution containing fentanyl 25 μg added to 0.5% bupivacaine (2 mg/kg).

RESULTS

None of the patients in both groups had unbearable incisional pain but addition of fentanyl to 0.5% bupivacaine reduced analgesic consumption in the postoperative period (P<0.05).

CONCLUSION

Addition of opioids to local anesthetics results in better postoperative analgesia and reduced opioid requirement post operatively.

Preemptive multimodal analgesia facilitates same-day discharge following robot-assisted hysterectomy

We aimed to determine whether early hospital discharge following minimally invasive surgery can be achieved through the use of preemptive multimodal analgesia without compromising patient safety or comfort. Data were retrospectively collected for 150 patients who underwent robotic-assisted laparoscopic hysterectomy for benign indications from 9 December 2009 to 6 October 2010 at Cox Health Systems (Springfield, MO, USA). One surgeon performed 100 consecutive cases with all patients receiving preemptive multimodal treatment with celecoxib and ropivacaine. These cases were compared with 50 patients treated with an opioid-based postoperative analgesia regimen by one of four other surgeons at the same center. Patient characteristics, perioperative outcomes, opioid requirement, and time to discharge were compared between groups. The patients in the multimodal group had significantly reduced opioid requirements intraoperatively (25.0 mg vs. 29.9 mg, P = 0.0077), postoperatively on the day of surgery (10.9 mg vs. 17.9 mg, P = 0.0030), and on the first postoperative day (3.1 mg vs. 15.3 mg, P = 0.0001). There were no differences in procedure time, transfusions, or readmission rates between groups. Time in the Post-Anesthesia Care Unit (PACU) was decreased in the multimodal group (72.0 min vs. 88.4 min, P < 0.0001), as was time to discharge from the hospital (8.5 h vs. 30.2 h, P < 0.0001). Age and body mass index were both significantly lower in the multimodal group; however, regression analyses demonstrated that analgesia regimen was the only parameter that predicted opioid requirement and time to discharge. Preemptive multimodal analgesia reduced the total dose of rescue opioids, facilitating same-day discharge without compromising patient comfort or safety.

Pilot study to assess the safety of local lidocaine injections during endoscopic submucosal dissection for early gastric cancer

BACKGROUND

In Japan, endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) is performed by endoscopists on patients under sedation. There is an increased risk of anesthesia-related complications due to the higher sedative doses required during lengthier ESDs, so we sought to determine whether a local pain control method could safely reduce such doses.

METHODS

Twenty EGC patients enrolled in this study received local lidocaine injections during ESDs at our hospital (lidocaine group; LG). Electrocardiography, heart rate, oxygen saturation, and blood pressure were monitored during and after the ESDs, along with the doses of midazolam and pentazocine. Pain assessments were recorded for LG patients on the day of their ESDs and the following day.

RESULTS

The mean volume of lidocaine injection solution was 55.4 ml and the mean dose of lidocaine was 236 mg (range, 100-300 mg). The mean size of the resected specimens was 39.3 mm and mean procedure time was 66.0 min. There were no lidocaine-related complications, and electrocardiography, heart rate, oxygen saturation and blood pressure measurements were normal. In comparison to 157 consecutive patients (control group; CG), who had similar characteristics and had undergone ESDs previously with submucosal injections of conventional normal saline solution, the mean +/- SD pentazocine dose of 15.8 +/- 10.3 mg in the LG was significantly lower (P < 0.01) than the dose of 23.1 +/- 9.5 mg in the CG, and none of the LG patients complained of abdominal pain on the day of their ESDs, whereas such pain was reported by 17% (27/157) of the CG.

CONCLUSION

Local lidocaine injections into the submucosal layer were safe when administered during ESDs performed on EGC patients under sedation.

Randomized trial of preemptive local analgesia in vaginal surgery

Preemptive analgesia in vaginal surgery has had conflicting efficacy reported in the existing literature. This study was designed to clarify the usefulness of preemptive local analgesia (PLA) in patients undergoing vaginal hysterectomy. A prospective, randomized, double-blinded trial of PLA in 90 women undergoing vaginal hysterectomy was conducted. PLA consisted of 20 ml of 0.5% bupivacaine with 1:200,000 epinephrine injected in a paracervical-type fashion. Total narcotic use and pain (using a visual analog scale (VAS)) was recorded at 30 min, 3, 12, and 24 h postoperatively. The mean total dose of narcotic was significantly less in the PLA group versus the placebo group (P = 0.009) at every time point postoperatively. Additionally, the mean pain VAS 30 min and 3 h postoperatively was 43% (P = 0.003) and 33% (P = 0.02) lower, respectively, in the PLA group. PLA with bupivacaine prior to vaginal hysterectomy is associated with significantly lower pain scores and a reduction in narcotic use postoperatively.

A placebo-controlled comparison of bupivacaine and ropivacaine instillation for preventing postoperative pain after laparoscopic cholecystectomy

PURPOSE

The aim of this study was to determine the effect of local anesthetic instillation, to compare bupivacaine and ropivacaine in patients undergoing a laparoscopic cholecystectomy.

METHODS

A total of 80 patients were randomly assigned to four groups to receive the intraperitoneal instillation of 21 ml of either 100 mg bupivacaine (Group B), 100 mg ropivacaine (Group R1), 150 mg ropivacaine (Group R2) or saline with epinephrine 1/200,000 at the end of the surgery. The postoperative pain was evaluated and the analgesic requirement was also assessed.

RESULTS

The intraperitoneal instillation of 100 mg bupivacaine, 100 mg ropivacaine, or 150 mg ropivacaine at the end of a laparoscopic cholecystectomy significantly reduced the morphine consumption during the first 24 h. For preventing postoperative pain 150 mg ropivacaine proved to be significantly more effective than either 100 mg bupivacaine or 100 mg ropivacaine.

CONCLUSION

We herein showed that the intraperitoneal instillation of local anesthetic during laparoscopic cholecystectomy is a noninvasive, rapid, safe and simple analgesic technique that reduces the total morphine consumption during first 24 h.