Volume 5, Issue 1 S A M B A T A L K S - PAGE 3 June, 2005

FROM THE LITERATURE: - TOP


ANESTHESIA AND ANALGESIA - TOP

A Randomized, Double-Blind Comparison Between Parecoxib Sodium and Propacetamol for Parenteral Postoperative Analgesia After Inguinal Hernia Repair in Adult Patients.
M. Beaussier, H. Weickmans, C. Paugam, S. Lavazais, J. P. Baechle, P. Goater, A. Buffin, J. F. Loriferne, J. F. Perier, J. P. Didelot, A. Mosbah, R. Said, and A. Lienhart.
Anesth Analg 2005;100:1309-1315

The newly injectable cyclooxygenase-2 selective nonsteroidal antiinflammatory drug, parecoxib, has never been compared with propacetamol, a parenteral formulation of acetaminophen. In this prospective, randomized, double-blind, double-dummy study, we randomly assigned 182 patients scheduled for initial inguinal hernia repair under general anesthesia to receive a single injection of 40 mg parecoxib or 2 injections of 2 g propacetamol within the first 12 h after surgery. The study variables were morphine consumption, pain at rest and while coughing, and patient satisfaction throughout the first 12 h postoperatively. For statistical analysis, we used the Student’s t-test, x 2, and covariance analysis. Total morphine consumption did not differ between the two groups. Pain was less intense in the parecoxib group at rest (P = 0.035) but did not differ for pain while coughing. The incidence of side effects was similar. Significantly more patients in the parecoxib group rated their pain management as good or excellent (87% versus 70% in the propacetamol group, P = 0.001). Within the first 12 h after inguinal hernia repair in adult patients, a single injection of parecoxib 40 mg compares favorably with 2 injections of propacetamol 2 g.

Music and Ambient Operating Room Noise in Patients Undergoing Spinal Anesthesia
Chakib M. Ayoub, MD, Laudi B. Rizk, MD, Chadi I. Yaacoub, MD, Dorothy Gaal, MD, and Zeev N. Kain, MD, MBA
Anesth Analg 2005;100:1316-1319

Previous studies have indicated that music decreases intraoperative sedative requirements in patients undergoing surgical procedures under regional anesthesia. In this study we sought to determine whether this decrease in sedative requirements results from music or from eliminating operating room (OR) noise. A secondary aim of the study was to examine the relationship of response to intraoperative music and participants’ culture (i.e., American versus Lebanese). Eighty adults (36 American and 54 Lebanese) undergoing urological procedures with spinal anesthesia and patient-controlled IV propofol sedation were randomly assigned to intraoperative music, white noise, or OR noise. We found that, controlling for ambient OR noise, intraoperative music decreases propofol requirements (0.004 ± 0.002 mg · kg^-1 · min^-1 versus 0.014 ± 0.004 mg · kg^-1 · min^-1 versus 0.012 ± 0.002 mg · kg^-1 · min^-1; P = 0.026). We also found that, regardless of group assignment, Lebanese patients used less propofol as compared with American patients (0.005 ± 0.001 mg · kg^-1 · min^-1 versus 0.017 ± 0.003 mg · kg^-1 · min^-1; P = 0.001) and that, in both sites, patients in the music group required less propofol (P < 0.05). We conclude that when controlling for ambient OR noise, intraoperative music decreases propofol requirements of both Lebanese and American patients who undergo urological surgery under spinal anesthesia.

ANESTHESIOLOGY - TOP

Effect of Metoclopramide on Gastric Fluid Volumes in Diabetic Patients Who Have Fasted before Elective Surgery.
Jellis, WS ; Kartha, V ; Fluder, E ; Slogoff, S.
Anesthesiology. 102(5):904-909, May 2005.

Background: Diabetes-induced gastroparesis is believed to increase fasting gastric fluid volume before elective surgery. Metoclopramide is routinely administered preoperatively to reduce gastric fluid volume in these patients. This study compared nondiabetic controls to non-insulin-dependent and insulin-dependent diabetics to determine the effect of metoclopramide, administered before surgery, on gastric volumes in patients who fasted before surgery.
Methods: Control and diabetic patients fasted preoperatively before receiving either placebo or 10 mg intravenous metoclopramide 20 min before induction of anesthesia. After intubation, a gastric tube was placed, and stomach contents were aspirated with volumes compared among the groups.
Results: Both groups of diabetic patients were older than the control group, and insulin-dependent patients had a higher incidence of comorbidities compared with the non-insulin-dependent group. Fasting blood sugar and hemoglobin A1C values were higher in both insulin-dependent and non-insulin-dependent patients. Gastric fluid volumes were similar in control, non-insulin-dependent, and insulin-dependent patients (8.0 +/- 2.6 vs. 9.6 +/- 4.1 vs. 17.7 +/- 2.5 ml, respectively). In insulin-dependent diabetic patients, metoclopramide decreased gastric volume compared with placebo treatment (17.7 +/- 2.5 vs. 7.8 +/- 2.9 ml; P = 0.027). After stratification, a subpopulation of patients with poorly controlled diabetes, regardless of type, were identified to have increased gastric residual volumes.
Conclusion: In elective surgical patients who have fasted before surgery, gastric volumes are minimal, even in diabetics with severe neuropathic symptoms. Metoclopramide prophylaxis to reduce gastric volumes seems to be unnecessary unless the patient has a prolonged history of poor blood glucose control.

Endoscopic Study of Mechanisms of Failure of Endotracheal Tube Advancement into the Trachea during Awake Fiberoptic Orotracheal Intubation.
Johnson, D; From, A; Smith, R ; From, R ; Maktabi, M.
Anesthesiology. 102(5):910-914, May 2005.

Background: Advancing the endotracheal tube (ETT) over a flexible bronchoscope (FB) during awake fiberoptic orotracheal intubation is often impeded. The goal of this study was to identify the sites and mechanisms that inhibit the passing of the ETT into the trachea.
Methods: Forty-five consenting patients underwent a clinically indicated awake fiberoptic orotracheal intubation. After topical anesthesia, nerve block, or both, an awake fiberoptic orotracheal intubation was performed. The placement of the FB and advancement of the ETT over the FB were videotaped using a second nasally inserted FB. An otolaryngologist later reviewed the videotaped data.
Results: The right arytenoid or the interarytenoid soft tissues inhibited advancement of the ETT in 42 and 11% of all patients, respectively. In all cases in which the FB was located on the right side of the larynx, failure of ETT advancement almost always occurred at the right arytenoid. Withdrawing the ETT and rotating it 90 degrees counterclockwise resulted in successful intubation on the second, third, and fourth attempts in 26.6, 20, and 0.7% of patients, respectively.
Conclusion: The right arytenoid frequently inhibits advancement of the ETT over the FB into the trachea during awake fiberoptic orotracheal intubation. The FB position in the larynx before tube advancement and the orientation of the ETT are relevant factors in failure of advancement of the ETT into the trachea. The authors recommend positioning the FB in the center of the larynx and orienting the bevel of the ETT to face posteriorly during the first attempt at intubation.

For Outpatient Rotator Cuff Surgery, Nerve Block Anesthesia Provides Superior Same-day Recovery over General Anesthesia.
Hadzic, A ; Williams, B ; Karaca, P ; Hobeika, P; Unis, G; Dermksian, J ; Yufa, M ; Thys, DM; Santos, AC.
Anesthesiology. 102(5):1001-1007, May 2005.

Background: Both general and nerve block anesthesia are effective for shoulder surgery. For outpatient surgery, it is important to determine which technique provides more efficient recovery. The authors' goal was to compare nerve block with general anesthesia with respect to recovery profile and patient satisfaction after rotator cuff surgery.
Methods: In this clinical trial, 50 consenting outpatients (aged 18-70 yr) were randomly assigned to receive either fast-track general anesthesia followed by bupivacaine (0.25%) wound infiltration or interscalene brachial plexus block (0.75% ropivacaine), each under standardized protocols. Blinded recovery room nurses assessed the need for pain treatment and rated patient eligibility for bypass of the phase 1 postanesthesia care unit and for discharge home. Patients were followed up for 2 weeks postoperatively. The primary outcome measures were postanesthesia care unit bypass and same-day discharge. Other same-day recovery outcomes included severity of and treatment for pain and time to ambulation. Postoperative outcomes at home included satisfaction with the anesthesia technique and absence of complications (at 2 weeks).
Results: Patients who received nerve block (vs. general anesthesia) bypassed the postanesthesia care unit more frequently (76 vs. 16%; P < 0.001), reported less pain, ambulated earlier, were ready for home discharge sooner (123 vs. 286 min; P < 0.001), had no unplanned hospital admissions (vs. 4 of 25 patients who underwent general anesthesia; P = 0.05), and were more satisfied with their care. No complications were reported in either treatment group.
Conclusions: Nerve block anesthesia for outpatient rotator cuff surgery provides several same-day recovery advantages over general anesthesia.

ACTA ANAESTHESIOLOGICA SCANDINAVICA - TOP

Effect of preoperative Cox-II-selective NSAIDs (coxibs) on postoperative outcomes: A systematic review of randomized studies
S. Straube, S. Derry, H. J. McQuay and R. A. Moore
Acta Anaesthesiologica Scandinavica Volume 49 Issue 5 Page 601  - May 2005

Background:  Preoperative use of coxibs has been claimed to reduce postoperative pain and analgesic consumption, and to affect other postoperative outcomes.
Methods:  Systematic review of randomized trials comparing preoperative coxib with preoperative placebo, or active comparator. Searching of PubMed and Cochrane Library to August 2004. A qualitative and a quantitative analysis.
Results: Twenty-two included trials with 2246 patients had high reporting quality and validity scores, though treatment group sizes were small, with a median size of 30 patients. Most trials used oral preoperative rofecoxib (mainly 50 mg) or celecoxib (mainly 200 mg). Preoperative coxibs significantly reduced both postoperative pain and analgesic consumption compared with preoperative placebo in 15/20 trials. In one further trial postoperative pain was reduced and in one analgesic consumption. There was no significant difference in the incidence of postoperative nausea and vomiting in 13/17 studies or when data were pooled. Postoperative antiemetic use was significantly reduced in all five trials reporting it; the NNT to prevent one patient using postoperative antiemetic was 10 (5.5 to 66). No trial reported any significant difference in intraoperative blood loss or recovery from anaesthesia. Patient satisfaction was significantly increased with preoperative coxib use. No conclusions could be drawn from the three trials comparing preoperative coxib with preoperative NSAID. One study reported significantly improved cost-efficacy with rofecoxib.
Conclusion: Preoperative coxibs had clear benefits in terms of reduced postoperative pain, analgesic consumption and patient satisfaction compared with placebo. Effects on postoperative nausea and vomiting remain uncertain, as do those on recovery from surgery or economic benefit. Future trials should be larger and more pragmatic in nature.

Intentional lateral epidural catheter placement for anterior cruciate ligament reconstr uction
M. Dauri, T. Sidiropoulou, E. Fabbi, P. P. Mariani and A. F. Sabato
Acta Anaesthesiologica Scandinavica Volume 49 Issue 5 Page 671  - May 2005

Background:  Unilateral epidural block might constitute a clinical option in lower limb orthopedic surgery.
Methods:  Seventy-five patients undergoing anterior cruciate ligament reconstruction (ACLR) were randomized to either a laterally directed epidural catheter (IUEC, n = 40) or a classic midline catheter (CMEC, n = 35). Paresthesia encountered during catheter insertion was registered. The start dose of the anesthetic mixture clonidine 60 µg (0.4 ml), sufentanil 15 µg (0.3 ml) and ropivacaine 10 mg ml1(10.3 ml) in 11 ml of total volume) was set at 5 ml and was increased by 2 ml if anesthesia was inadequate after assessment for sensory blockade to cold and pin-prick. Data were registered intra- and postoperatively regarding pain scores as well as motor block, hemodynamic parameters, adverse effects and need for supplemental analgesia other than a continuous postoperative epidural infusion.
Results:  In the IUEC group 80% of patients reported a light paresthesia of the affected side during catheter insertion, whereas 71% of patients in the CMEC group reported no paresthesia at all. The amount of anesthetic used to establish surgical anesthesia was lower in the IUEC group (6.2 ± 0.8 vs. 8 ± 1.9 ml, P < 0.001). Motor block (Bromage score) of the unaffected side was significantly lower in the IUEC group (P < 0.001). Pain intensity scores, hemodynamic parameters, and supplemental analgesia given were similar between the two groups except for VAS scores at 12 h postoperatively, which were higher in the CMEC group (P < 0.01). Urinary retention was significantly more frequent in the CMEC group (19/35 vs. 5/40, P < 0.001).
Conclusion:  These results suggest that the IUEC technique is a feasible and efficient method for providing anesthesia and analgesia for ACLR and is associated with a lower consume of anesthetics, less motor block and a reduced incidence of urinary retention.

Efficacy of vertical infraclavicular plexus block vs. modified axillary plexus block: a prospective, randomized, observer-blinded study
F. M. Heid, J. Jage, M. Guth, N. Bauwe and A. M. Brambrink
Acta Anaesthesiologica Scandinavica Volume 49 Issue 5 Page 677  - May 2005

Background:  Despite containing severe risks, infraclavicular approaches to the brachial plexus gained increasing popularity. Likewise, the vertical infraclavicular plexus block improved anesthesia compared to the standard axillary approach but contains the risk of pneumothorax. Therefore we modified the standard axillary technique by inserting a proximal directed catheter, referred to as a high axillary plexus block. We prospectively compared quality and onset of neural blockade after vertical infraclavicular plexus block (VIP) and high axillary plexus block (HAP) in two randomized groups (30 patients in each).
Methods:  In group VIP the insulated needle was inserted midway between the ventral process of the acromion and the jugular notch. In group HAP, first an axillary needle was placed. Through this a stimulating catheter was inserted in a proximal direction (1015 cm); correct placement was confirmed by nerve stimulation. All patients received 40 ml ropivacaine 0.75% (300 mg). Discriminating between analgesia and anesthesia, a blinded observer assessed progression of neural blockade every 5 min for 60 min by pin prick. Incomplete blocks were supplemented 60 min after initial injection.
Results:  All patients in both groups demonstrated sufficient surgical anesthesia. No patient needed systemic supplementation or general anesthesia. However, vertical infraclavicular plexus block indicated superior anesthesia compared to high axillary plexus block, regarding musculocutaneous, axillary and radial nerve, which were completely blocked with a higher success rate and in a shorter time interval (P < 0.05).
Conclusions:  While both techniques provide sufficient surgical anesthesia, vertical infraclavicular plexus block demonstrated a partially higher success rate and a faster onset than high axillary plexus block.

Posterior labat vs. lateral popliteal sciatic block: posterior sciatic block has quicker onset and shorter duration of anaesthesia
R. Fournier, A. Weber and Z. Gamulin
Acta Anaesthesiologica Scandinavica Volume 49 Issue 5 Page 683  - May 2005

Background:  During foot and ankle surgery, a combination of a sciatic and femoral nerve block is a well-recognized technique for providing anaesthesia and post-operative analgesia. Our hypothesis is that the posterior gluteal sciatic block (PSB) is more efficient than the lateral popliteal sciatic block (LPSB), and this study compared the anaesthetic characteristics between these two techniques performed for elective ankle and foot surgery.
Methods:  This retrospective database analysis reviewed the onset, duration of action, success rate and complications among 287 patients who were operated upon using sciatic block. PSB was performed in 149 patients and LPSB in 138 patients, all with the use of 30 ml of 5 mg/ml ropivacaine (150 mg).
Results:  In the PSB group, the time to perform the block was shorter than in the LPSB group (2.5 ± 1 vs. 4.5 ± 4 min, P < 0.001), as was the time to complete sensory block (13 ± 13 vs. 23 ± 26 min, respectively; P < 0.001). However, the duration of sensory block was longer in the LPSB group (1130 ± 470 vs. 960 ± 310 min, respectively; P < 0.006).
Conclusion:  PSB is easier to perform, and has a quicker onset of sensory blockade whereas LPSB has a longer duration of analgesia.

Comparison of a combination of midazolam and diazepam and midazolam alone as oral premedication on preanesthetic and emergence condition in children
Y-C. P. Arai, K. Fukunaga and S. Hirota
Acta Anaesthesiologica Scandinavica Volume 49 Issue 5 Page 698  - May 2005

Background:  Preanesthetic anxiety and emergence agitation are major challenges for anesthesiologists in pediatric anesthesia. Thus, midazolam has been used as premedication for children. However, midazolam alone is not effective for emergence agitation. The present study tested the effect of a combination of midazolam and diazepam on the preanesthetic condition and emergence behavior in children.
Methods:  Forty-two children were allocated to one of three groups: the NoPre group received no premedication; the Mi group received midazolam 0.5 mg kg1 orally; and the Mi + Di group received midazolam 0.25 mg kg1 and diazepam 0.25 mg kg1 orally. When anesthesia was induced with 7% sevoflurane in 100% oxygen, qualities of mask induction and sedation were rated. Anesthesia was maintained with sevoflurane (35%) in 100% oxygen. During emergence from anesthesia, the score of the child's emergence behavior was rated.
Results:  Children in the Mi and Mi + Di groups were more sedated than those in the NoPre group. A combination of midazolam and diazepam provided a better quality of mask induction, when compared with no premedication. Also, the children in the Mi + Di group were less agitated than those in the other groups during the emergence.
Conclusion:  Children in the Mi + Di group were significantly more sedated at induction of anesthesia and less agitated during emergence from anesthesia.

BRITISH JOURNAL OF ANAESTHESIA - TOP

Predicting postoperative analgesia outcomes: NNT league tables or procedure-specific evidence?
A. Gray, H. Kehlet, F. Bonnet and N. Rawal
British Journal of Anaesthesia 2005 94(6):710-714

Number needed to treat (NNT) values have been recommended and used to assess efficacy of analgesics for acute pain management. However, the data analysed come from a variety of procedures, which may potentially hinder the interpretation of the NNT value for specific procedures. We reanalysed available NNT data with acetaminophen in relation to the magnitude of surgical injury. Acetaminophen was less effective for pain relief after orthopaedic procedures than after dental procedures. The relative risk ratio for more than 50% pain relief, compared with placebo, was only 1.87 compared with 3.77 (P<0.05). Although NNT can give a valuable overview of efficacy, this concept is not necessarily applicable to all types of surgery. We suggest that estimates of NNT should be related to specific surgical procedures.

Antagonism of neuromuscular blockade but not muscle relaxation affects depth of anaesthesia
F. C. Vasella, P. Frascarolo, D. R. Spahn and L. Magnusson
British Journal of Anaesthesia 2005 94(6):742-747

Background. Conflicting effects of neuromuscular blocking drugs and anticholinesterases on depth of anaesthesia have been reported. Therefore we evaluated the effect of atracurium and neostigmine on bispectral index (BIS) and middle-latency auditory evoked potentials (AAI).
Methods. We studied 40 patients (ASA I–II) aged 18–69 yr. General anaesthesia consisted of propofol and remifentanil by target-controlled infusion and neuromuscular function was monitored by electromyography. When BIS reached stable values, patients were randomly assigned to one of two groups. Group 1 received atracurium 0.4 mg kg^-1 and, 5 min later, the same volume of NaCl 0.9%; group 2 received saline first and then atracurium. When the first twitch of a train of four reached 10% of control intensity, patients were again randomized: one group (N) received neostigmine 0.04 mg kg^-1 and glycopyrrolate 0.01 mg kg^-1, and the control group (G) received only glycopyrrolate.
Results. Injection of atracurium or NaCl 0.9% had no effect on BIS or AAI. After neostigmine–glycopyrrolate, BIS and AAI increased significantly (mean maximal change of BIS 7.1 [SD 7.5], P<0.001; mean maximal change of AAI 9.7 [10.5], P<0.001). When glycopyrrolate was injected alone BIS and AAI also increased (mean maximal change of BIS 2.2 [3.4], P=0.008; mean maximal change of AAI 3.5 [5.7], P=0.012), but this increase was significantly less than in group N (P=0.012 for BIS; P=0.027 for AAI).
Conclusion. These data suggest that neostigmine alters the state of propofol–remifentanil anaesthesia and may enhance recovery.

CANADIAN JOURNAL OF ANESTHESIA - TOP

A lidocaine/metoclopramide combination decreases pain on injection of propofol
Yoshitaka Fujii, and Masahiro Nakayama.
Canadian Journal of Anesthesia 52:474-477 (2005)

Purpose: Injection pain is a well-known adverse effect of propofol which distresses patients. Lidocaine pretreatment is the most popular method for reducing this pain but this drug cannot entirely eliminate the problem. The purpose of this study was to examine the analgesic effect of lidocaine/metoclopramide combination, compared with lidocaine alone, during propofol injection.
Methods: In a randomized, double-blind, placebo-controlled trial, 90 patients, 40 males and 50 females, scheduled for elective plastic surgery received either lidocaine 20 mg plus metoclopramide 10 mg iv, lidocaine 20 mg iv, or placebo (saline); (n = 30 in each), with venous occlusion for one minute, followed by administration of propofol 0.5 mg•kg^-1 into a dorsal hand vein. Pain was assessed on a four-point scale (0 = none, 1 = mild, 2 = moderate, 3 = severe) during propofol injection.
Results: 25 patients (83%) complained of pain in the placebo group, compared with 12 (40%) in the lidocaine group (P < 0.05) and three (10%) in the combination group (P < 0.05). Pain score (median) was less in the lidocaine (0) and combination (0) groups than in the placebo group (2); (P < 0.05). The difference in the incidence of pain between the combination and lidocaine groups was significant (P < 0.05).
Conclusion: A lidocaine/metoclopramide combination is more effective than lidocaine alone for reducing pain on injection of propofol in a peripheral vein.

Prospective application of a simplified risk score to prevent postoperative nausea and vomiting
Dirk Rüsch, Leopold Eberhart, Andreas Biedler, Jürgen Dethling, and Christian C. Apfel.
Canadian Journal of Anesthesia 52:478-484 (2005)

Purpose: To compare the risk-adapted approach with ondansetron against ondansetron plus dexamethasone to prevent postoperative nausea and vomiting (PONV) in a randomized clinical trial.
Methods: 460 patients scheduled for elective surgery were enrolled in this prospective study and stratified according to a simplified risk score for PONV. Patients having no or one risk factor were considered at low risk (group L) and did not receive study medication. Those with two to four risk factors were considered high risk and were randomized to receive 4 mg ondansetron plus placebo (group H-O) or 4 mg ondansetron plus 8 mg dexamethasone (group H-OD). Incidence and intensity of PONV were observed for 24 hr after surgery. Data were analyzed with Fisher’s exact or Student’s t tests; P < 0.05 was considered statistically significant.
Results: The incidence of PONV was 9% in group L (n = 87), 31% in those receiving ondansetron (group H-O, n = 185), and 22% in those receiving both drugs (group H-OD, n = 181). The incidence of PONV was significantly smaller in both high-risk groups than predicted without treatment (P < 0.001). While the incidence of PONV failed statistical significance between the two intervention groups (P = 0.08), the mean number of episodes of PONV and the mean maximal intensity of each episode of PONV were lower in group H-OD (P = 0.03 and P = 0.01, respectively). Patients of group H-OD required less antiemetic rescue therapy (P = 0.004).
Conclusions: Ondansetron plus dexamethasone prevents PONV more effectively than ondansetron alone in patients at high risk for PONV.

Prevention of PONV by acustimulation with capsicum plaster is comparable to ondansetron after middle ear surgery
Mahender Nath Misra, Asok Jayaraj Pullani, and Zubair Umer Mohamed.
Canadian Journal of Anesthesia 52:485-489 (2005)

Purpose: To compare the efficacy of stimulation of P6 acupoint with capsicum plaster in comparison with iv ondansetron for the prevention of postoperative nausea and vomiting (PONV).
Methods: 120 patients of either sex, ASA I–II, undergoing elective middle ear surgeries under general anesthesia were included in this randomized, prospective, double-blinded and placebo-controlled study. The anesthetic technique was standardized. Patients were divided into three groups. Group I was the control group. Capsicum plaster (1 x 1cm) was affixed at the P6 acupoint on both forearms 30 min before induction of anesthesia in patients of Group II. Patients of Groups I and III received an inactive adhesive plaster at the same site. Ondansetron 4 mg iv was given to patients of Group III at the end of surgery and the rest of the patients received a placebo. The plasters were removed six hours after transferring the patients to the postoperative unit. Criteria were fixed for the administration of rescue antiemetics (ondansetron 4 mg iv). PONV and the requirement for rescue antiemetics were recorded by a blinded observer.
Results: The incidence of PONV and the requirement for rescue antiemetics were significantly lower in both the acustimulation and ondansetron groups at six hours. At 24 hr there was a reduction in the requirement for rescue medication in the ondansetron group.
Conclusion: Stimulation of the P6 acupoint with capsicum plaster is an effective method for prevention of PONV after middle ear surgery and its efficacy is comparable to ondansetron for the first six hours after surgery.

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