| 1. |
- Axelsson, Kjell, et al.
(författare)
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Intraarticular administration of ketorolac, morphine, and ropivacaine combined with intraarticular patient-controlled regional analgesia for pain relief after shoulder surgery : a randomized, double-blind study
- 2008
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Ingår i: Anesthesia and Analgesia. - : Lippincott Williams & Wilkins. - 0003-2999 .- 1526-7598. ; 106:1, s. 328-333
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: In this study we assessed the efficacy of intraarticular regional analgesia on postoperative pain and analgesic requirements. METHODS: Fifty-one patients undergoing shoulder surgery (Bankart) were recruited into this double-blind study. At the end of the operation, patients were randomized to three groups to receive intraarticularly via a catheter: Group 1: ropivacaine 90 mg (9 mL), morphine 4 mg (10 mL), and ketorolac 30 mg (1 mL) (total volume 20 mL); Groups 2 and 3: saline (20 mL). In addition, Groups 1 and 3 received 1 mL saline IV while Group 2 received ketorolac 30 mg (1 mL) IV. Postoperatively, Group 1 received pain relief using 10 mL 0.5% ropivacaine on demand via the intraarticular catheter while Groups 2 and 3 received 10 mL of saline intraarticularly. Group 3 was the Control group. RESULTS: Postoperative pain at rest and on movement were lower in Group 1 than in Groups 2 and 3 during the first 30 and 120 min, respectively. The time to first request for local anesthetic infusion was longer in Group 1 than in Groups 2 and 3 (P < 0.001). The median morphine consumption during the first 24 postoperative hours was less in Groups 1 and 2 than in Group 3 (P < 0.001). There was no significant difference in analgesic consumption between Group 1 and Group 2. The median satisfaction score was higher in Group 1 compared with Groups 2 (P < 0.05) and 3 (P < 0.001). CONCLUSIONS: A combination of intraarticular ropivacaine, morphine, and ketorolac followed by intermittent injections of ropivacaine as needed provided better pain relief, less morphine consumption, and improved patient satisfaction compared with the control group. The group that received IV ketorolac consumed less morphine and was more satisfied with treatment than patients in the control group.
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| 2. |
- Axelsson, Kjell, et al.
(författare)
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Local anaesthetic adjuvants: neuraxial versus peripheral nerve block
- 2009
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Ingår i: Current Opinion in Anaesthesiology. - 0952-7907 .- 1473-6500. ; 22:5, s. 649-654
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Tidskriftsartikel (refereegranskat)abstract
- Purpose of review To present a review of the literature on the importance and the clinical characteristics relevant to adjuvants added to local anaesthetics in neuraxial and peripheral nerve blocks. Recent findings In neuraxial anaesthesia, both opioids and alpha-2 receptor agonists have beneficial effects. Intrathecally, fentanyl and sufentanil not only improve the postoperative analgesia but also make it possible to allow a decrease in the local anaesthetic dose. When clonidine or dexmedetomidine was added to intrathecal local anaesthetics, the regression of sensory, motor block increased dose-dependently and postoperative analgesia was prolonged. The potency of intrathecal clonidine:dexmedetomidine seems to be 10:1. In peripheral nerve block, when opioid was combined with local anaesthetics, no increased improvement in analgesia was reported in comparison with systemic controls in most of the studies, except buprenorphine. Also clonidine is controversial as an analgesic adjuvant. Special factors, such as type of local anaesthetics, block of upper or lower limb, are important for its the beneficial effect. Other adjuvants, except neuraxial low-dose neostigmine, are of minor importance. Summary Opioids and alpha-2 receptor agonists are important as neuraxial adjuvants to improve the quality of peroperative and postoperative analgesia in high-risk patients and in ambulatory procedures. In peripheral nerve blocks, however, some benefit is found only when clonidine is added to local anaesthetics under certain circumstances.
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| 3. |
- Essving, Per, et al.
(författare)
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Reduced hospital stay, morphine consumption, and pain intensity with local infiltration analgesia after unicompartmental knee arthroplasty
- 2009
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Ingår i: ACTA ORTHOPAEDICA. - : Medical Journals Sweden AB. - 1745-3674 .- 1745-3682. ; 80:2, s. 213-219
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Tidskriftsartikel (refereegranskat)abstract
- Background and purpose The degree of postoperative pain is usually moderate to severe following knee arthroplasty. We investigated the efficacy of local administration of analgesics into the operating area, both intraoperatively and postoperatively. Methods 40 patients undergoing unicompartmental knee arthroplasty (UKA) were randomized into 2 groups in a double-blind study (ClinicalTrials.gov identifier: NCT00653926). In group A (active), 200 mg ropivacaine, 30 mg ketorolac, and 0.5 mg epinephrine (total volume 106 mL) were infiltrated intraoperatively into the soft tissue, while in group P (placebo), no injections were given. 21 hours postoperatively, 150 mg ropivacain, 30 mg ketorolac, and 0.1 mg epinephrine were injected intraarticularly via a catheter in group A, whereas patients in group P were injected with the same volume of saline (22 mL). Results Median hospital stay was shorter in group A than in group P: 1 (1-6) days as opposed to 3 (1-6) days (p 0.001). Postoperative pain in group A was statistically significantly lower at rest after 6 h and 27 h and on movement after 6, 12, 22, and 27 h. Morphine consumption was statistically significantly lower in group A for the first 48 h, resulting in a lower frequency of nausea, pruritus, and sedation. Postoperatively, there were improved functional scores (Oxford knee score and EQ-5D) in both groups relative to the corresponding preoperative values. Interpretation Local injection of analgesics periarticularly at the end of the operation and intraarticularly at 21 h postoperatively provided excellent pain relief and earlier home discharge following UKA. There was a high degree of patient satisfaction in both groups after 6 months.
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| 4. |
- Essving, Per, et al.
(författare)
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Reduced hospital stay, morphine consumption, and pain intensity with local infiltration analgesia after unicompartmental knee arthroplasty : a randomized double-blind study of 40 patients
- 2009
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Ingår i: Acta Orthopaedica. - Lund : Taylor & Francis. - 1745-3674 .- 1745-3682. ; 80:2, s. 213-219
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND AND PURPOSE: The degree of postoperative pain is usually moderate to severe following knee arthroplasty. We investigated the efficacy of local administration of analgesics into the operating area, both intraoperatively and postoperatively. METHODS: 40 patients undergoing unicompartmental knee arthroplasty (UKA) were randomized into 2 groups in a double-blind study (ClinicalTrials.gov identifier: NCT00653926). In group A (active), 200 mg ropivacaine, 30 mg ketorolac, and 0.5 mg epinephrine (total volume 106 mL) were infiltrated intraoperatively into the soft tissue, while in group P (placebo), no injections were given. 21 hours postoperatively, 150 mg ropivacain, 30 mg ketorolac, and 0.1 mg epinephrine were injected intraarticularly via a catheter in group A, whereas patients in group P were injected with the same volume of saline (22 mL). RESULTS: Median hospital stay was shorter in group A than in group P: 1 (1-6) days as opposed to 3 (1-6) days (p < 0.001). Postoperative pain in group A was statistically significantly lower at rest after 6 h and 27 h and on movement after 6, 12, 22, and 27 h. Morphine consumption was statistically significantly lower in group A for the first 48 h, resulting in a lower frequency of nausea, pruritus, and sedation. Postoperatively, there were improved functional scores (Oxford knee score and EQ-5D) in both groups relative to the corresponding preoperative values. INTERPRETATION: Local injection of analgesics periarticularly at the end of the operation and intraarticularly at 21 h postoperatively provided excellent pain relief and earlier home discharge following UKA. There was a high degree of patient satisfaction in both groups after 6 months (Clinical Trials.gov: NCT 00653926).
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| 5. |
- Gupta, Anil
(författare)
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Evidence-based medicine in day surgery
- 2007
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Ingår i: Current Opinion in Anaesthesiology. - 0952-7907 .- 1473-6500. ; 20:6, s. 520-525
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Forskningsöversikt (refereegranskat)abstract
- PURPOSE OF REVIEW: To present the evidence available for the management of pain, for the prevention of nausea and vomiting, and for the best anaesthetic technique during ambulatory surgery.RECENT FINDINGS: Paracetamol and nonsteroidal anti-inflammatory drugs are effective analgesics with a low number needed to treat, and are recommended when not contraindicated. Droperidol, dexamethasone and ondansetron are equally effective in the prevention of postoperative nausea and vomiting during ambulatory surgery. The choice of the anaesthetic technique appears to play a minor role in recovery from anaesthesia or in the occurrence of minor postoperative complications or home discharge, except for the use of total intravenous anaesthesia for the prevention of postoperative nausea and vomiting.SUMMARY: Pain should be prevented adequately and treated vigorously. Postoperative nausea and vomiting is common and should be prevented in the at-risk patient. The choice of inhalation agents during ambulatory surgery is of minor importance in recovery from anaesthesia.
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| 6. |
- Gupta, Anil, et al.
(författare)
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Postoperative analgesia after radical retropubic prostatectomy : a double-blind comparison between low thoracic epidural and patient-controlled intravenous analgesia
- 2006
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Ingår i: Anesthesiology. - : Wolters Kluwer. - 0003-3022 .- 1528-1175. ; 105:4, s. 784-793
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Postoperative pain after radical retropubic prostatectomy can be severe unless adequately treated. Low thoracic epidural analgesia and patient-controlled intravenous analgesia were compared in this double-blind, randomized study.METHODS: Sixty patients were randomly assigned to receive either low thoracic epidural analgesia (group E) or patient-controlled intravenous analgesia (group P) for postoperative pain relief. All patients had general anesthesia combined with thoracic epidural analgesia during the operation. Postoperatively, patients in group E received an infusion of 1 mg/ml ropivacaine, 2 microg/ml fentanyl, and 2 microg/ml adrenaline, 10 ml/h during 48 h epidurally, and a placebo patient-controlled intravenous analgesia pump intravenously. Patients in group P received a patient-controlled intravenous analgesia pump with morphine intravenously and 10 ml/h placebo epidurally. Pain, the primary outcome variable, was measured using the numeric rating scale at rest (incision pain and "deep" visceral pain) and on coughing. Secondary outcome variables included gastrointestinal function, respiratory function, mobilization, and full recovery. Health-related quality of life was measured using the Short Form-36 questionnaire, and plasma concentration of fentanyl was measured in five patients to exclude a systemic effect of fentanyl.RESULTS: Incisional pain and pain on coughing were lower in group E compared with group P at 2-24 h, as was deep pain between 3 and 24 h postoperatively (P < 0.05). Maximum expiratory pressure was greater in group E at 4 and 24 h (P < 0.05) compared with group P. No difference in time to home discharge was found between the groups. The mean plasma fentanyl concentration varied from 0.2 to 0.3 ng/ml during 0-48 h postoperatively. At 1 month, the scores on emotional role, physical functioning, and general health of the Short Form-36 were higher in group E compared with group P. However, no group x time interaction was found in the Short Form-36.CONCLUSIONS: The authors found evidence for better pain relief and improved expiratory muscle function in patients receiving low thoracic epidural analgesia compared with patient-controlled analgesia for radical retropubic prostatectomy. Low thoracic epidural analgesia can be recommended as a good method for postoperative analgesia after abdominal surgery.
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| 7. |
- Gupta, Anil
(författare)
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Preoperative screening and risk assessment in the ambulatory surgery patient
- 2009
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Ingår i: CURRENT OPINION IN ANESTHESIOLOGY. - 0952-7907. ; 22:6, s. 705-711
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Tidskriftsartikel (refereegranskat)abstract
- Purpose of review With the rapid increase in the number of sicker patients with multiple co-morbidities and extremes of age who are undergoing ambulatory surgery, a thorough and detailed preoperative workup has become increasingly important. Case cancellation on the morning of surgery should be an exception. Therefore, much attention is focused on the optimization of the sicker patients. Although the anesthesiologist plays a central role in the preoperative assessment, a multidisciplinary approach is critical. This review was done to provide the reader with current trends and practices in preoperative assessment of the ambulatory surgical patient. Recent findings The risk factors that may influence major morbidity, death or hospital admission include age greater than 85 years, hospital admission within the previous 6 months and invasiveness of surgery. The American Society of Anesthesiologists physical status greater than 2 can predict in-hospital adverse events. Routine preoperative investigations in the healthy patient, including electrocardiogram are, today, unwarranted and have not been shown to improve outcome. Summary Risk management involves the identification of the patient at risk, optimization of preoperative health status, risk reduction through medical intervention as well as appropriate perioperative care. Thus, patient outcome can be improved, specifically for the sicker patients at a higher risk.
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| 8. |
- Holmfred, Anette, et al.
(författare)
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Intrathecal catheters with subcutaneous port systems in patients with severe cancer-related pain managed out of hospital : the risk of infection
- 2006
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Ingår i: Journal of Pain and Symptom Management. - : Elsevier. - 0885-3924 .- 1873-6513. ; 31:6, s. 568-572
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Tidskriftsartikel (refereegranskat)abstract
- Intrathecal catheters have been used for many years to treat severe pain resistant to conventional treatment modalities. Previous studies have found a rate of serious infection of 2%-3% using these catheters in home situations. However, many authors used prophylactic antibiotics routinely in this group of patients, which are both costly and associated with a risk of developing antibiotic resistance. We were interested in studying whether improved hygiene during insertion and care of these catheters in the hospice or home environment would reduce the incidence of catheter-related infections. The results show that prophylactic antibiotic is not necessary, but a careful handling of the system with aseptic technique is important. The infections we registered appeared more than 2 weeks after insertion of the catheters. We now use this method routinely when inserting an intrathecal catheter with a subcutaneous port.
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| 9. |
- Ng, Huey-Ping, et al.
(författare)
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Efficacy of intra-articular bupivacaine, ropivacaine, or a combination of ropivacaine, morphine, and ketorolac on postoperative pain relief after ambulatory arthroscopic knee surgery : a randomized double-blind study
- 2006
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Ingår i: Regional anesthesia and pain medicine. - : BMJ. - 1098-7339 .- 1532-8651. ; 31:1, s. 26-33
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Effective pain relief is important after diagnostic and therapeutic arthroscopic knee surgery to permit early discharge and improve comfort and mobility at home. The aim of this study was to assess the efficacy of bupivacaine, ropivacaine, or a combination of ropivacaine, morphine, and ketorolac injected intra-articularly for postoperative pain relief after arthroscopic knee surgery. METHODS: Sixty-three healthy patients undergoing knee arthroscopy under local anesthesia (LA) were randomized to receive 1 of the following substances intra-articularly postoperatively: group B: 30 mL of bupivacaine (150 mg); group R: 30 mL of ropivacaine (150 mg); and group RMK: ropivacaine 150 mg, morphine 4 mg, and ketorolac 30 mg in normal saline (total volume 30 mL). Oral paracetamol 1g and tramadol 50 mg were used as rescue drugs. Postoperatively, pain was assessed at rest and movement, and side effects were recorded. The patients were asked to self-assess pain for 7 days and record analgesic consumption as well as activities of daily living (ADLs). Plasma concentration of LA was measured in another 8 patients. RESULTS: All groups had excellent analgesia at 0 and 4 hours postoperatively. Group RMK had significantly lower visual analog pain score at rest at 8 hours and during movement at 8 and 24 hours compared with the other groups (P<.05). Group RMK required less paracetamol and tramadol on day 1 (P<.05), had less sleep disturbances because of pain, more patients were ready to work on days 1 and 2 (P<.05), and were more satisfied on days 1 and 4 to 7. Postoperatively, plasma concentrations of ropivacaine and lidocaine were far below known systemic toxic concentrations in all patients. CONCLUSION: Addition of morphine and ketolorac to ropivacaine intra-articularly enhances analgesic efficacy of LA, reduces postdischarge analgesic consumption, and improves ADLs without increasing side effects after ambulatory arthroscopic knee surgery.
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| 10. |
- Oscarsson Tibblin, Anna, et al.
(författare)
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Predictors of cardiac events in high-risk patients undergoing emergency surgery
- 2009
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Ingår i: Acta Anaesthesiologica Scandinavica. - : Wiley-Blackwell. - 0001-5172 .- 1399-6576. ; 53:8, s. 986-994
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Tidskriftsartikel (refereegranskat)abstract
- Background: The aim of this study was to determine the incidence of myocardial damage and left ventricular myocardial dysfunction and their influence on outcome in high-risk patients undergoing non-elective surgery.Methods: In this prospective observational study, 211 patients with American Society of Anesthesiologists classification III or IV undergoing emergent or urgent surgery were included. Troponin I (TnI) was measured pre-operatively, 12 and 48 h post-operatively. Pre-operative N-terminal fragment of B-type natriuretic peptide (NT-proBNP), as a marker for left ventricular systolic dysfunction, was analyzed. The diagnostic thresholds were set to TnI andgt; 0.06 mu g/l and NT-proBNP andgt; 1800 pg/ml, respectively. Post-operative major adverse cardiac events (MACE), 30-day and 3-months mortality were recorded.Results: Elevated TnI levels were detected in 33% of the patients post-operatively. A TnI elevation increased the risk of MACE (35% vs. 3% in patients with normal TnI levels, P andlt; 0.001) and 30-day mortality (23% vs. 7%, P=0.003). Increased concentrations of NT-proBNP were seen in 59% of the patients. Elevated NT-proBNP was an independent predictor of myocardial damage post-operatively, odds ratio, 6.2 [95% confidence interval (CI) 2.1-18.0] and resulted in an increased risk of MACE (21% vs. 2.5% in patients with NT-proBNP andlt; 1800 pg/ml, P andlt; 0.001).Conclusion: Myocardial damage is common in a high-risk population undergoing unscheduled surgery. These results suggest a close correlation between myocardial damage in the post-operative period and increased concentration of NT-proBNP before surgery. The combinations of TnI and NT-proBNP are reliable markers for monitoring patients at risk in the peri-operative period as well as useful tools in our risk assessment pre-operatively in emergency surgery.
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