14 Dec 11

A dose-ranging Study of the effect of transversus abdominis block on postoperative quality of recovery and analgesia after outpatient laparoscopy

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

By G S De Oliveira Jr, P C Fitzgerald, R-J Marcus,  S Ahmad, R J McCarthy

Anesth  Analg 2011;113:1218-1225

Postoperative pain can delay functional recovery after outpatient surgery. Multimodal analgesia can improve pain and possibly improve quality of recovery. In this study, we evaluated the dose-dependent effects of a preoperative transversus abdominis plane (TAP) block on patient recovery using the Quality of Recovery 40 (QoR-40) questionnaire after ambulatory gynecological laparoscopic surgery. Global QoR-40 scores range from 40 to 200, representing very poor to outstanding quality of recovery, respectively.

Methods
Healthy women undergoing outpatient gynecological laparoscopy were randomly allocated to receive a preoperative TAP block using saline, ropivacaine 0.25%, or ropivacaine 0.5%. Needle placement for the TAP blocks was performed using ultrasound guidance and 15 mL of the study solution was injected bilaterally by a blinded investigator. QoR-40 score and analgesic use were assessed 24 hours postoperatively. The primary outcome was global QoR-40 score at 24 hours after surgery. Data were analyzed using the Kruskal-Wallis test. Post hoc pairwise comparisons were made using the Dunn test with P values and 95% confidence intervals Bonferroni corrected for 6 comparisons.

Results
Seventy-five subjects were enrolled and 70 subjects completed the study. The median (range) for the QoR-40 score after the TAP block was 157 (127–193), 173 (133–195), and 172 (130–196) for the saline group and 0.25% and 0.5% ropivacaine groups, respectively. The median difference (99.2% confidence interval) in QoR-40 score for 0.5% bupivacaine (16 [1–30], P = 0.03) and 0.25% bupivacaine (17 [2–31], P = 0.01) was more than saline but not significantly different between ropivacaine groups (−1 [−16 to 12], P = 1.0). Increased global QoR-40 scores correlated with decreased area under the pain score time curve during postanesthesia recovery room stay (ρ = −0.56, 99.2% upper confidence limit [UCL] = −0.28), 24-hour opioid consumption (ρ = −0.61, 99.2% UCL = −0.34), pain score (0–10 scale) at 24 hours (ρ = −0.53, 99.2% UCL = −0.25), and time to discharge readiness (ρ = −0.65, 99.2% UCL = −0.42). The aforementioned variables were lower in the TAP block groups receiving ropivacaine compared with saline.

Conclusions
The TAP block is an effective adjunct in a multimodal analgesic strategy for ambulatory laparoscopic procedures. TAP blocks with ropivacaine 0.25% and 0.5% reduced pain, decreased opioid consumption, and provided earlier discharge readiness that was associated with better quality of recovery.

08 Dec 11

Intraperitoneal ropivacaine nebulization for pain management after laparoscopic cholecystectomy

Posted in Anesthesia, Laparoscopic surgery at 0:01 by Laci

By M Bucciero, P M Ingelmo, R Fumagalli, E Noll, A Garbagnati, M Somaini, G Joshi, G Vitale, V Giardini, P Diemunsch

Anesth  Analg 2011;113:1266-1271

Studies evaluating intraperitoneal local anesthetic instillation for pain relief after laparoscopic procedures have reported conflicting results. In this randomized, double-blind study we assessed the effects of intraperitoneal local anesthetic nebulization on pain relief after laparoscopic cholecystectomy.

Methods
Patients undergoing elective laparoscopic cholecystectomy were randomly assigned to receive either instillation of ropivacaine 0.5%, 20 mL after induction of the pneumoperitoneum, or nebulization of ropivacaine 1%, 3 mL before and after surgery. Anesthetic and surgical techniques were standardized. Degree of pain at rest and on deep breathing, incidence of shoulder pain, morphine consumption, unassisted walking time, and postoperative nausea and vomiting were evaluated at 6, 24, and 48 hours after surgery.

Results
Of the 60 patients included, 3 exclusions occurred for conversion to open surgery. There were no differences between groups in pain scores or in morphine consumption. No patients in the nebulization group presented significant shoulder pain in comparison with with 83% of patients in the instillation group (absolute risk reduction −83, 95% CI −97 to −70, P < 0.001). Nineteen (70%) patients receiving nebulization walked without assistance within 12 hours after surgery in comparison with 14 (47%) patients receiving instillation (absolute risk reduction −24, 95% CI −48 to 1, P = 0.04). One (3%) patient in the instillation group vomited in comparison with 6 (22%) patients in the nebulization group (absolute risk reduction −19%, 95% CI −36 to −2, P = 0.03).

Conclusions
Intraperitoneal ropivacaine nebulization was associated with reduced shoulder pain and unassisted walking time but with an increased incidence of postoperative vomiting after laparoscopic cholecystectomy.

26 Nov 11

The effects of intraabdominally insufflated carbon dioxide on hepatic blood flow during laparoscopic surgery assessed by transesophageal echocardiography

Posted in Anesthesia, Laparoscopic surgery at 1:09 by Laci

By R Meierhenrich,  A Gauss, P Vandenesch,  M Georgieff, B Poch, W Schütz

 Anesth Analg 2005;100:340-347

Conflicting results have been published about the effects of carbon dioxide (CO2) pneumoperitoneum on splanchnic and liver perfusion. Several experimental studies described a pressure-related reduction in hepatic blood flow, whereas other investigators reported an increase as long as the intraabdominal pressure (IAP) remained less than 16 mm Hg. Our goal in the present study was to investigate the effects of insufflated CO2 on hepatic blood flow during laparoscopic surgery in healthy adults. Blood flow in the right and middle hepatic veins was assessed in 24 patients undergoing laparoscopic surgery by use of transesophageal Doppler echocardiography. Hepatic venous blood flow was recorded before and after 5, 10, 20, 30, and 40 min of pneumoperitoneum, as well as 1 and 5 min after deflation. Twelve patients undergoing conventional hernia repair served as the control group. The induction of pneumoperitoneum produced a significant increase in blood flow of the right and middle hepatic veins. Five minutes after insufflation of CO2 the median right hepatic blood flow index increased from 196 mL/min/m2 (95% confidence interval (CI), 140–261 mL/min/m2) to 392 mL/min/m2 (CI, 263–551 mL/min/m2) (P < 0.05) and persisted during maintenance of pneumoperitoneum. In the middle hepatic vein the blood flow index increased from 105 mL/min/m2 (CI, 71–136 mL/min/m2) to 159 mL/min/m2 (CI, 103–236 mL/min/m2) 20 min after insufflation of CO2. After deflation blood flow returned to baseline values in both hepatic veins. Conversely, in the control group hepatic blood flow remained unchanged over the entire study period. We conclude that induction of CO2 pneumoperitoneum with an IAP of 12 mm Hg is associated with an increase in hepatic perfusion in healthy adults.

Implications
Blood flow in the right and middle hepatic veins was studied by use of transesophageal echocardiography in 24 patients undergoing laparoscopic surgery. CO2 pneumoperitoneum induced a significant increase in hepatic venous blood flow. This finding is in contrast to results of experimental studies suggesting that CO2 pneumoperitoneum may be harmful to liver function as a result of impaired perfusion.

16 Nov 11

Laparoscopic surgery in a patient with Fontan physiology

Posted in Anesthesia, Laparoscopic surgery at 0:06 by Laci

By C D McClain, F X McGowan, P Kovatsis

Anesth Analg 2006;103:856-858

Laparoscopic surgery represents a significant advance in surgical technique, but a number of physiologic sequelae result from positioning and insufflation. These physiologic changes may be more significant in patients with complex congenital heart disease. We present the anesthetic management of a patient with Fontan physiology who successfully underwent two separate laparoscopic procedures.

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