30 Dec 11

The effective analgesic dose of dexamethasone after laparoscopic hysterectomy

Posted in Anesthesia, Laparoscopic surgery at 1:01 by Laci

By R Jokela, J Ahonen, M Tallgren, P Marjakangas, K Korttila

Anesth Analg 2009;109:607-615

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

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

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

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

29 Dec 11

Pulse contour analysis and transesophageal echocardiography: a comparison of measurements of cardiac output during laparoscopic colon surgery

Posted in Anesthesia, Echocardiography, Laparoscopic surgery at 2:02 by Laci

By Mario R. Concha, V Mertz, L I Cortínez, K A González, J Butte

Anesth Analg 2009;109:114-118

Pulse wave analysis (PWA) allows cardiac output (CO) measurement after calibration by transpulmonary thermodilution. A PWA system that does not require previous calibration, the FloTrac/Vigileo (FTV), has been recently developed. We compared determinations of CO made with the FTV to simultaneous measurements using transesophageal echocardiography (TEE).

Ten ASA I-II patients scheduled for laparoscopic colorectal surgery were studied. A radial 20-gauge cannula was inserted and connected to a hemodynamic monitor and a FTV system for PWA and determination of CO (COPWA). TEE CO (COTEE) was determined as previously described. Measurements were made after intubation, 5 min after establishing the lithotomy position, 5 min after establishing pneumoperitoneum, every 30 min, or each time mean arterial blood pressure decreased below basal values. Statistical analysis was made with the Bland and Altman method.

Eighty-eight measurements were compared. The COTEE values ranged from 3.23 to 12 Lt/min (mean 6.21 ± 1.85). Values for COPWA ranged from 2.9 to 8.5 Lt/min (mean 4.84 ± 1.14). Bias was 1.17 and limits of agreement −2.02 and 4.37. The percentage error between all COTEE and COPWA measurements was 40% (27%-50%) mean (range).

During laparoscopic colon surgery, clinically important differences were observed between CO determinations made with TEE and FTV.

28 Dec 11

Preoperative ketamine improves postoperative analgesia after gynecologic laparoscopic surgery

Posted in Anesthesia, Laparoscopic surgery at 2:02 by Laci

By R Kwok, J Lim, M Chan, T Gin, W Chiu

Anesth Analg 2004;98:1044-1049

In this study, we evaluated the preemptive effect of a small dose of ketamine on postoperative wound pain. In a randomized, double-blinded, controlled trial, we compared the analgesic requirement in patients receiving preincision ketamine with ketamine after skin closure or placebo after gynecologic laparoscopic surgery. One-hundred-thirty-five patients were randomly assigned to receive preincision or postoperative ketamine 0.15 mg/kg or saline IV. Anesthetic technique was standardized. Patients were interviewed regularly up to 4 wk after surgery. Pain score, morphine consumption, side effects, and quality of recovery score were recorded. Patients receiving preincision ketamine had a lower pain score in the first 6 h after operation compared with the postoperative (P = 0.001) or placebo groups (P < 0.001). The mean (95% confidence intervals) time to first request for analgesia in the preincision group, 1.8 h (1.4–2.1), was longer than the postoperative group, 1.2 h (0.9–1.5; P < 0.001), or the placebo group, 0.7 h (0.4–0.9; P < 0.001). The mean ± sd morphine consumption in the preincision group, 1.5 ± 2.0 mg, was less than that in the postoperative group, 2.9 ± 3.1 mg (P = 0.04) and the placebo group, 3.4 ± 2.7 mg (P = 0.003). There was no significant difference among groups with respect to hemodynamic variables or side effects. No patient complained of hallucinations or nightmares. We conclude that a small dose of ketamine is not only safe, but it also provides preemptive analgesia in patients undergoing gynecologic laparoscopic surgery.

In women undergoing laparoscopic gynecologic surgery, a small preoperative dose of ketamine (0.15 mg/kg) produced preemptive analgesia. There were no significant hemodynamic and psychological side effects with this dose.

22 Dec 11

Preventing postoperative pain by local anesthetic instillation after laparoscopic gynecologic surger

Posted in Anesthesia, Laparoscopic surgery at 1:01 by Laci

By A Goldstein, P Grimault, A Henique, M Keller, A Fortin, E Darai

Anesth Analg 2000;91:403-407 

We tested the hypothesis that local anesthetics instilled at the end of laparoscopic gynecologic procedures are able to prevent postoperative pain at wake-up and during the first 24 h. A total of 180 patients were randomly assigned into three groups to receive an intraperitoneal instillation of 20 mL of either bupivacaine 0.5% (Group B), ropivacaine 0.75% (Group R) or saline (Group S) at the end of surgery. All patients received analgesia with acetaminophen and ketoprofen IV infusions. Pain was assessed by using a 0–10 graded numerical scale (NS) every 5 min in the postanesthesia care unit and IV morphine was administered if NS was >4. Assessment of pain was continued every 4 h on the ward, and subcutaneous morphine was injected if needed to keep the NS score < 4. Postoperative nausea and vomiting (PONV) was rated on a 4-point scale. The morphine consumption at wake-up and over the first 24 h was significantly lower (P < 0.05) in Group B (mean, 0.92 mg at wake-up; 3.08 mg over 24 h) and in Group R (mean, 0.25 mg at wake-up; 0.69 mg over 24 h), than in Group S (mean, 4.18 mg at wake-up; 12.93 mg over 24 h). The morphine-sparing effect of ropivacaine was significantly greater than that of bupivacaine. Both local anesthetics were effective in the prevention of PONV. We concluded that local anesthetics should be instilled in all gynecologic patients at the end of all laparoscopic procedures.

Local anesthetic instillation (ropivacaine rather than bupivacaine) at the end of laparoscopy prevents postoperative pain and dramatically decreases the need for morphine. This technique, compared with placebo, is safe, improves patient comfort, shortens the stay in the postoperative care unit and decreases nursing care in the ward.

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