Parietal Analgesia Decreases Postoperative Diaphragm Dysfunction Induced by Abdominal Surgery: A Physiologic Study

Continuous peripheral nerve blocks compared to thoracic epidurals or multimodal analgesia for midline laparotomy: a systematic review and meta-analysis

BACKGROUND

Continuous peripheral nerve blocks (CPNBs) have been investigated to control pain for abdominal surgery via midline laparotomy while avoiding the adverse events of opioid or epidural analgesia. The review compiles the evidence comparing CPNBs to multimodal and epidural analgesia.

METHODS

We conducted a systematic review using broad search terms in MEDLINE, EMBASE, Cochrane. Primary outcomes were pain scores and cumulative opioid consumption at 48 hours. Secondary outcomes were length of stay and postoperative nausea and vomiting (PONV). We rated the quality of the evidence using Cochrane and GRADE recommendations. The results were synthesized by meta-analysis using Revman.

RESULTS

Our final selection included 26 studies (1,646 patients). There was no statistically significant difference in pain control comparing CPNBs to either multimodal or epidural analgesia (low quality evidence). Less opioids were consumed when receiving epidural analgesia than CPNBs (mean difference [MD]: -16.13, 95% CI [-32.36, 0.10]), low quality evidence) and less when receiving CPNBs than multimodal analgesia (MD: -31.52, 95% CI [-42.81, -20.22], low quality evidence). The length of hospital stay was shorter when receiving epidural analgesia than CPNBs (MD: -0.78 days, 95% CI [-1.29, -0.27], low quality evidence) and shorter when receiving CPNBs than multimodal analgesia (MD: -1.41 days, 95% CI [-2.45, -0.36], low quality evidence). There was no statistically significant difference in PONV comparing CPNBs to multimodal (high quality evidence) or epidural analgesia (moderate quality evidence).

CONCLUSIONS

CPNBs should be considered a viable alternative to epidural analgesia when contraindications to epidural placement exist for patients undergoing midline laparotomies.

Effect of Thoracic Epidural Anesthesia in a Rat Model of Phrenic Motor Inhibition after Upper Abdominal Surgery

WHAT WE ALREADY KNOW ABOUT THIS TOPIC

WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: One important example of impaired motor function after surgery is diaphragmatic dysfunction after upper abdominal surgery. In this study, the authors directly recorded efferent phrenic nerve activity and determined the effect of the upper abdominal incision. The authors hypothesized that phrenic motor output would be decreased after the upper abdominal incision; it was also hypothesized that blocking sensory input from the incision using thoracic epidural anesthesia would diminish this incision-induced change in phrenic motor activity.

METHODS

Efferent phrenic activity was recorded 1 h to 10 days after upper abdominal incision in urethane-anesthetized rats. Ventilatory parameters were measured in unanesthetized rats using whole-body plethysmography at multiple time points after incision. The authors then determined the effect of thoracic epidural anesthesia on phrenic nerve activity and ventilatory parameters after incision.

RESULTS

Phrenic motor output remained reduced by approximately 40% 1 h and 1 day after incision, but was not different from the sham group by postoperative day 10. One day after incision (n = 9), compared to sham-operated animals (n = 7), there was a significant decrease in spike frequency area-under-the-curve (median [interquartile range]: 54.0 [48.7 to 84.4] vs. 97.8 [88.7 to 130.3]; P = 0.0184), central respiratory rate (0.71 [0.63 to 0.79] vs. 0.86 [0.82 to 0.93]/s; P = 0.0460), and inspiratory-to-expiratory duration ratio (0.46 [0.44 to 0.55] vs. 0.78 [0.72 to 0.93]; P = 0.0023). Unlike humans, a decrease, not an increase, in breathing frequency has been observed after the abdominal incision in whole-body plethysmography. Thoracic epidural anesthesia attenuated the incision-induced changes in phrenic motor output and ventilatory parameters.

CONCLUSIONS

Upper abdominal incision decreased phrenic motor output and ventilatory parameters, and this incision-induced impairment was attenuated by thoracic epidural anesthesia. The authors' results provide direct evidence that afferent inputs from the upper abdominal incision induce reflex inhibition of phrenic motor activity.

Preperitoneal postcesarean section bupivacaine analgesia: Comparison between dexamethasone and dexmedetomidine as adjuvants

Background:

The peritoneal wound is frequently neglected during laparotomy. The preperitoneal local anesthetics and many adjuvants were effective for postcesarean analgesia. Analgesia may involve somatic and autonomic components. The preperitoneal bupivacaine and the promising adjuvants dexamethasone or dexmedetomidine were compared in this study.

Patients and Methods:

Sixty patients subjected to a cesarean section (CS) under general anesthesia divided into two groups using a bolus of preperitoneal bupivacaine 0.7 mg/kg with either 1ug/kg dexmedetomidine (Group P) or 8 mg dexamethasone (Group D). The time to the first analgesic request was the primary outcome.

Results:

There was a significantly prolonged time to the first analgesic request in the Group P than the Group D and less required preperitoneal injections in the Group P, also pain assessed by Numerical Rating Scale (NRS) was lower in the Group P than the Group D after 6 h postoperatively up to 24 h.

Conclusions:

Dexmedetomidine provided better analgesia than dexamethasone as an adjuvant to preperitoneal bupivacaine post-CS.

Optimal method for assessment of respiratory muscle strength in neuromuscular disorders using sniff nasal inspiratory pressure (SNIP)

Background

The ability to accurately determine respiratory muscle strength is vitally important in patients with neuromuscular disorders (NMD). Sniff nasal inspiratory pressure (SNIP), a test of inspiratory muscle strength, is easier to perform for many NMD patients than the more commonly used determination of maximum inspiratory pressure measured at the mouth (MIP). However, due to an inconsistent approach in the literature, the optimal technique to perform the SNIP maneuver is unclear. Therefore, we systematically evaluated the impact of performing the maneuver with nostril contralateral to the pressure-sensing probe open (SNIP_OP) versus closed (SNIP_CL), on determination of inspiratory muscle strength in NMD patients as well as control subjects with normal respiratory muscle function.

Methods

NMD patients (n = 52) and control subjects without respiratory dysfunction (n = 52) were studied. SNIP_OP, SNIP_CL, and MIP were measured during the same session and compared using ANOVA. Agreement and bias were assessed with intraclass correlation coefficients (ICC) and Bland-Altman plots.

Results

Mean MIP values were 58.2 and 94.0 cmH2O in NMD and control subjects, respectively (p<0.001). SNIP_CL was greater than SNIP_OP in NMD (51.9 ±31.0 vs. 36.9 ±25.4 cmH₂O; p<0.001) as well as in controls (89.2 ±28.1 vs. 69.2 ±29.2 cmH₂O; p<0.001). In both populations, the ICC between MIP and SNIP_CL (NMD = 0.78, controls = 0.35) was higher than for MIP and SNIP_OP (NMD = 0.53, controls = 0.06). In addition, SNIP_CL was more often able to exclude inspiratory muscle weakness than SNIP_OP.

Conclusions

SNIP_CL values are systematically higher than SNIP_OP in both normal subjects and NMD patients. Therefore, SNIP_CL is a useful complementary test for ruling out inspiratory muscle weakness in individuals with low MIP values.

Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice

Background

The present interdisciplinary consensus review proposes clinical considerations and recommendations for anaesthetic practice in patients undergoing gastrointestinal surgery with an Enhanced Recovery after Surgery (ERAS) programme.

Methods

Studies were selected with particular attention being paid to meta‐analyses, randomized controlled trials and large prospective cohort studies. For each item of the perioperative treatment pathway, available English‐language literature was examined and reviewed. The group reached a consensus recommendation after critical appraisal of the literature.

Results

This consensus statement demonstrates that anaesthesiologists control several preoperative, intraoperative and postoperative ERAS elements. Further research is needed to verify the strength of these recommendations.

Conclusions

Based on the evidence available for each element of perioperative care pathways, the Enhanced Recovery After Surgery (ERAS ^®) Society presents a comprehensive consensus review, clinical considerations and recommendations for anaesthesia care in patients undergoing gastrointestinal surgery within an ERAS programme. This unified protocol facilitates involvement of anaesthesiologists in the implementation of the ERAS programmes and allows for comparison between centres and it eventually might facilitate the design of multi‐institutional prospective and adequately powered randomized trials.

Preperitoneal catheter analgesia is an effective method for pain management after colorectal surgery: the results of 100 consecutive patients

Background

In a previous prospective randomized trial, we showed that local anesthetic infusion using a preperitoneal catheter is an effective postoperative analgesic method following colorectal resections. Over time, we have improved the technique of preperitoneal catheter analgesia. In this prospective cohort study, we report the results of 100 consecutive patients who underwent colorectal resections.

Materials and methods

Preperitoneal catheter analgesia was performed via a multihole catheter placed in the preperitoneal space using 10 mL 0.5% levobupivacaine every 4 hours following the operation for the first 3 days. Additional analgesics were used whenever necessary. Postoperative pain was assessed with the visual analog scale score. Short-term clinical outcomes, such as need for systemic analgesics, time to first gas and stool discharge, length of hospital stay, and morbidity, particularly surgical site infections, were reported.

Results

From May 2009 to May 2010, 100 consecutive patients were recruited in the study. A total of 83 patients were operated on for malignancy, and the tumor was located in the rectum in 52 patients and in the colon in 31 patients. The median pain score was 4 (0–6), 3 (0–9), 2 (0–8), 1 (0–8), 1 (0–6), 0 (0–6), and 0 (0–3) at postoperative hours 0, 1, 4, 12, 24, 48, and 72, respectively. Additional analgesics were required in 34 patients: 21 of them required only nonsteroidal anti-inflammatory drugs, and 13 patients needed opioids additionally. The median amounts of opioid analgesics and nonsteroidal anti-inflammatory drugs were 1.76±0.78 mg and 6.70±1.18 mg, respectively. However, almost all of the additional analgesics were given in the first 24 hours. Surgical site infections were detected in eight patients.

Conclusion

Preperitoneal catheter analgesia is an effective analgesic method. When applied and used properly, it may even be used as the sole analgesic method in some patients.

The postoperative analgesic efficacy of preperitoneal continuous wound infusion compared to epidural continuous infusion with local anesthetics after colorectal cancer surgery: a randomized controlled multicenter study

BACKGROUND

Open colorectal cancer (CRC) surgery induces severe and prolonged postoperative pain. The optimal method of postoperative analgesia in CRC surgery has not been established. We evaluated the efficacy of preperitoneal continuous wound infusion (CWI) of ropivacaine for postoperative analgesia after open CRC surgery in a multicenter randomized controlled trial.

METHODS

Candidates for open CRC surgery randomly received preperitoneal CWI analgesia or continuous epidural infusion (CEI) analgesia with ropivacaine 0.2% 10 mL/h for 48 hours after surgery. Fifty-three patients were allocated to each group. All patients received patient-controlled IV morphine analgesia.

RESULTS

Over the 72-hour period after the end of surgery, CWI analgesia was not inferior to CEI analgesia. The difference of the mean visual analog scale score between CEI and CWI patients was 1.89 (97.5% confidence interval = -0.42, 4.19) at rest and 2.76 (97.5% confidence interval = -2.28, 7.80) after coughing. Secondary end points, morphine consumption and rescue analgesia, did not differ between groups. Time to first flatus was 3.06 ± 0.77 days in the CWI group and 3.61 ± 1.41 days in the CEI group (P = 0.002). Time to first stool was shorter in the CWI than the CEI group (4.49 ± 0.99 vs 5.29 ± 1.62 days; P = 0.001). Mean time to hospital discharge was shorter in the CWI group than in the CEI group (7.4 ± 0.41 and 8.0 ± 0.38 days, respectively). More patients in the CWI group reported excellent quality of postoperative pain control (45.3% vs 7.6%). Quality of night sleep was better with CWI analgesia, particularly at the postoperative 72-hour evaluation (P = 0.009). Postoperative nausea and vomiting was significantly less frequent with CWI analgesia at 24 hours (P = 0.02), 48 hours (P = 0.01), and 72 hours (P = 0.007) after surgery evaluations.

CONCLUSIONS

Preperitoneal CWI analgesia with ropivacaine 0.2% continuous infusion at 10 mL/h during 48 hours after open CRC surgery provided effective postoperative pain relief not inferior to CEI analgesia.

Anesthesia and perioperative management of colorectal surgical patients - A clinical review (Part 1)

Colorectal surgery is commonly performed for colorectal cancer and other pathology such as diverticular and inflammatory bowel disease. Despite significant advances, such as laparoscopic techniques and multidisciplinary recovery programs, morbidity and mortality remain high and vary among surgical centers. The use of scoring systems and assessment of functional capacity may help in identifying high-risk patients and predicting complications. An understanding of perioperative factors affecting colon blood flow and oxygenation, suppression of stress response, optimal fluid therapy, and multimodal pain management are essential. These fundamental principles are more important than any specific choice of anesthetic agents. Anesthesiologists can significantly contribute to enhance recovery and improve the quality of perioperative care.

[Respiratory preparation before surgery in patients with chronic respiratory failure]

Scheduled and/or thoracic, abdominal surgeries increase the risk of respiratory postoperative complications. In patients with chronic respiratory failure, preoperative evaluation should be performed to evaluate respiratory function in aim to optimize perioperative management. Preoperative gas exchange abnormalities (hypoxemia or hypercapnia) are associated with respiratory postoperative complications. Respiratory physiotherapy and prophylactic non-invasive ventilation should be integrated in a global rehabilitation management for cardiothoracic or abdominal surgery procedures, which are at high risk of postoperative respiratory dysfunction. Stopping tobacco consummation should be benefit, but decease risk of postoperative complications is relevant only after a period for 6 to 8 weeks of cessation. Bronchodilatator aerosol therapy (beta-agonists and atropinics) and inhaled corticotherapy allow a rapid preparation for 24 to 48 h. Systematic preoperative antibiotherapy should not be recommended.

[Continuous infusion of local anesthetic at the site of the abdominal surgical wound for postoperative analgesia: a systematic review]

OBJECTIVES

We present a systematic review of clinical trials to evaluate the efficacy of infusing local anesthetic through a catheter placed in the abdominal surgical wound.

METHODS

The Jadad (Oxford) scoring system was used to select trials. The variables considered in relation to each trial selected were as follows: type of intervention and incision; type, dose, and concentration of local anesthetic; site where the catheter was placed; rescue analgesia required; opioid use; and incidence of adverse events.

RESULTS

Fifteen clinical trials with a mean Jadad score of 4.6 were selected. The 1139 patients enrolled in the trials were grouped according to catheter placement: subfascial (6 trials), subcutaneous (8 trials), and both (1 trial). Six additional unpublished trials registered at ClinicalTrials.gov were also located.

CONCLUSIONS

Surgical wound analgesia is a safe technique whose effectiveness has been observed in cesarean sections and hysterectomies performed with Pfannenstiel incisions. Outcomes for other types of surgery are inconsistent. There is a lack of studies of the optimal site for catheter placement as well as of adequate anesthetic concentration and volume.

Local infiltration analgesia

Pain after major abdominal, orthopedic, and thoracic surgeries can be significant causing unacceptable morbidity. Poorly controlled pain results in patient dissatisfaction and may also be associated with major morbidities, including perioperative myocardial ischemia, pulmonary complications, altered immune function, and postoperative cognitive dysfunction. Various techniques are currently used to manage this pain, and opioids are amongst the most frequently used. Recent literature supports the use of regional anesthesia in the form of various peripheral nerve blocks as a better alternative. This article discusses the role and evidence for wound infiltration analgesia in general surgery, orthopedic surgery, neurosurgery, and thoracic surgery.

[Continuous wound infusion of local anesthetics: importance in postoperative pain therapy]

Continuous wound infusion of local anesthetics, which is mainly used in general surgery and orthopedics, is an interesting technique in postoperative pain therapy. Continuous wound infusion of local anesthetics is able to reduce postoperative opioid requirements and results in decreased pain scores. Recent studies indicate that rehabilitation seems to be enhanced and postoperative hospital stay may be shorter. Continuous wound infusion is an effective analgesic technique, which is simple to perform. Comparisons with other analgesic techniques, such as peripheral nerve blocks, epidural analgesia and other multimodal analgesic concepts are still required.

The analgesic efficacy of continuous wound instillation with ropivacaine after open hepatic surgery

The analgesic efficacy of continuous local anaesthetic wound instillation after open hepatic surgery was evaluated. Forty-eight patients scheduled for elective liver surgery were assigned to receive either ropivacaine 0.25% or saline infusion at 4 ml.h(-1) for 68 h via two multi-orifice indwelling catheters placed within the musculo-fascial layer before skin closure; plasma ropivacaine concentrations were measured during the infusion. Supplemental analgesia was provided by intravenous patient-controlled analgesia morphine. Patients in the ropivacaine group had decreased mean (SD) total morphine consumption (58 (30) mg vs 86 (44) mg, p = 0.01) and less pain at rest as well as after spirometry at 4, 12, 24, 48 and 72 h postoperatively (p < 0.01). Forced vital capacity was reduced postoperatively in both groups, but the reduction was greater in the saline group at 12 and 24 h (p = 0.03). The mean plasma concentration of ropivacaine increased to 2.05 (0.78) μg.ml(-1) at the point when the infusion was terminated.

Update on local anesthetics

PURPOSE OF REVIEW

Local anesthetics are not only used as drugs to block the sodium channel to provide analgesia and antiarrhythmic action. The purpose of this review is to highlight the new indications and limitations of this class of drugs.

RECENT FINDINGS

Recent research has focused on the use of intravenous local anesthetics to improve bowel function after surgery or trauma, to protect the central nervous system, to find new clues about local anesthetic effects in chronic neuropathic pain, and to investigate the long-term effect of anesthesia/analgesia provided by local anesthetics on cancer recurrence. Recent facts dealing with myotoxicity and chondrotoxicity are presented.

SUMMARY

There is growing evidence that local anesthetics have a broad spectrum of indications in addition to analgesia and antiarrhythmic effect. Most of them are still insufficiently known and investigated. These new indications will no doubt be intensively studied in the coming years.

Chronic, painful lower extremity wounds: postoperative pain management through the use of continuous infusion of regional anaesthesia supplied by a portable pump device

Reducing and preventing postoperative pain are currently a topic of great interest. There are different modalities for providing analgesia that can provide an alternative or adjunct to opioid therapy. One mode of therapy involves the use of portable pain pump devices that can deliver continuous local anaesthesia directly to the site of interest. A considerable amount of attention in literature has been dedicated to using regional anaesthesia postoperatively for various surgical applications. However, to our knowledge, little or no work has been published concerning the use of infusion of regional anaesthesia in the treatment of painful lower extremity wounds. We present a case report of a 55-year-old gentleman with a complex past medical history, 2-year history of opioid dependency and a 2-week history of intractable pain associated with the combination of debilitating painful diabetic neuropathy and painful lower extremity wounds. After surgical debridement of the lower extremity wounds, substantial analgesia was achieved postoperatively through the implantation of a portable direct infusion pump device. The device supplied 2 ml/hour of 0.25% bupivacaine and resulted in a reduction in pain within the first hour of implantation. Although the device achieved maximal analgesia at 6 hours, we found that this could have been likely reduced through the use of a 5-ml bolus dose of 0.25% bupivacaine at the time of implantation. The device provided sufficient analgesia to the patient without any observed adverse effects, and showed significant potential in avoiding an increase in his requirement for other systemic analgesia including opioids.