18 Sep 12

The beneficial effect of transversus abdominis plane block after laparoscopic cholecystectomy in day-case surgery

Posted in Anesthesia, Regional anaesthesia at 0:47 by Laci

By P Petersen, P Stjernholm, V Kristiansen, H Torup, E Hansen, A Mitchell, A Moeller, J Rosenberg, J Dahl and O Mathiesen

Anesth Anal, 2012;115:527-533

Laparoscopic cholecystectomy is associated with postoperative pain of moderate intensity in the early postoperative period. Recent randomized trials have demonstrated the efficacy of transversus abdominis plane (TAP) block in providing postoperative analgesia after abdominal surgery. We hypothesized that a TAP block may reduce pain while coughing and at rest for the first 24 postoperative hours, opioid consumption, and opioid side effects in patients undergoing laparoscopic cholecystectomy in day-case surgery.

Methods
In this randomized, double-blind study, 80 patients undergoing laparoscopic cholecystectomy in our day-case surgery unit were allocated to receive either bilateral ultrasound-guided posterior TAP blocks (20 mL 0.5% ropivacaine) or placebo blocks. Postoperative pain treatment consisted of oral acetaminophen 1000 mg × 4, oral ibuprofen 400 mg × 3, IV morphine (0–2 hours postoperatively), and oral ketobemidone (2–24 hours postoperatively). The primary outcome was postoperative pain scores while coughing calculated as area under the curve for the first 24 postoperative hours (AUC/24 h). Secondary outcomes were pain scores at rest (AUC/24 h), opioid consumption, and side effects. Patients were assessed 0, 2, 4, 6, 8, and 24 hours postoperatively. Group-wise comparisons of visual analog scale (VAS) pain (AUC/24 h) were performed with the 2-sample t test. Morphine and ketobemidone consumption were compared with the Mann-Whitney test for unpaired data. Categorical data were analyzed using the χ2 test.

Results
The primary outcome variable, VAS pain scores while coughing (AUC/24 h), was significantly reduced in the TAP versus the placebo group (P = 0.04); group TAP: 26 mm (SD 13) (weighted average level) versus group placebo: 34 (18) (95% confidence interval): 0.5–15 mm). VAS pain scores at rest (AUC/24 h) showed no significant difference between groups. Median morphine consumption (0–2 hours postoperatively) was 7.5 mg (interquartile range: 5–10 mg) in the placebo group compared with 5 mg (interquartile range: 0–5 mg) in the TAP group (P < 0.001). The odds ratio of a random patient in group TAP having less morphine consumption than a random patient in group placebo was P (group TAP < group placebo) = 0.26 (confidence interval: 0.15, 0.37) where 0.5 represents no difference between groups. There were no between-group differences in total ketobemidone consumption, levels of nausea and sedation, number of patients vomiting, or consumption of ondansetron.

Conclusions
TAP block after laparoscopic cholecystectomy may have some beneficial effect in reducing pain while coughing and on opioid requirements, but this effect is probably rather small.

12 Sep 12

Perioperative morbidity: lessons from recent clinical trials

Posted in Anesthesia, Early goal directed therapy, Fluid management at 3:31 by Laci

By R Thiele, J Huffmyer, J Raphael, Jacob

Curr Opin Crit Care 2012;18:358-365

To identify the recent literature supporting the ability of anesthesiologists to impact morbidity and mortality outside of the immediate intraoperative period.

Recent findings
Hemodynamic management designed to optimize cardiac output and stroke volume can significantly lower the risk of perioperative morbidity, and, in some cases, mortality. The implications of the POISE trial, which upended the previously accumulating data in support of indiscriminate perioperative β-blockade by demonstrating worsened outcomes, were supported by high-quality, propensity-matched, prospectively collected data. Data supporting the safety of colloid use has been threatened by the retraction of 88 publications of a single author, as well as prospective, nonrandomized data, suggesting increased renal morbidity in critically ill patients receiving synthetic colloids. Large datasets continue to suggest an association between red blood cell transfusion and mortality. Analysis of the operating room strongly implicates anesthesia providers as a potential mechanism for bacterial contamination.

Summary
Anesthesiologists should consider implication of goal-directed therapy in high-risk surgical patients, adhere to the American College of Cardiology/American Heart Association guidelines with regard to perioperative β-blockade, critically assess the data to support their choice of synthetic colloids over crystalloids, explore all possible strategies for avoiding perioperative transfusion, and be cognizant of their potential contribution to perioperative infectious morbidity.

22 Aug 12

Peripartum management of dual antiplatelet therapy and neuraxial labor analgesia after bare metal stent insertion for acute myocardial infarction

Posted in Anesthesia, Antiplatelet therapy at 2:42 by Laci

By M Bauer, S Bauer, A Rabbani and J Mhyre

Anesth Analg, 2012;115:613-615

A 31-year-old woman at 32 weeks’ gestation presented with an ST segment elevation myocardial infarction with subsequent bare metal stent placement. A multidisciplinary team coordinated the delivery plan, including anticoagulation and delivery mode. Because the patient was at high risk for stent thrombosis, clopidogrel was discontinued after 4 weeks and bridged with eptifibatide for 7 days. Eptifibatide was stopped for induction of labor. Twelve hours after eptifibatide was discontinued, hemostatic function was assessed with thromboelastography before initiating neuraxial analgesia. A successful operative vaginal delivery was performed, followed by an uncomplicated recovery. Clopidogrel was resumed 24 hours postpartum.

01 Aug 12

Enhanced recovery pathways as a way to reduce surgical morbidity

Posted in Anesthesia, Enhanced recovery at 0:00 by Laci

By M Grocott, D Martin, M Mythen

Curr Opin Crit Care 2012;18:385-392

The aim of this review is to summarize important publications in enhanced recovery during 2010–2011 and to highlight key themes. Specifically, we focus on updated systematic reviews of high-quality clinical trials of enhanced recovery in colorectal surgery, exemplar studies of enhanced recovery in other specialties, and exploration of which elements of the enhanced recovery package might be associated with improved patient outcome.

Recent findings
An expanding evidence base of clinical trials and implementation evaluations supports the effectiveness of enhanced recovery programmes in improving outcome following major elective surgery. The majority of this literature derives from the study of patients undergoing colorectal surgery, but increasingly enhanced recovery is spreading to other surgical specialties. The combination of reduced length of hospital stay (a surrogate for morbidity) with no increase in readmissions to hospital suggests that morbidity is reduced with enhanced recovery. Inconsistency in morbidity reporting limits the value of pooling data between studies, but within study comparisons in general support this conclusion. Patients adhering to an enhanced recovery programme return to normal function faster than those following traditional care pathways.

Summary
Enhanced recovery adoption is likely to continue to grow (range of specialties and penetration within specialties). This progression is supported by the available published data.

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