Continuous Preperitoneal Infusion of Ropivacaine Provides Effective Analgesia and Accelerates Recovery after Colorectal Surgery: A Randomized, Double-blind, Placebo-controlled Study.
Pain and Regional Anesthesia
Beaussier, Marc M.D., Ph.D. ; El'Ayoubi, Hanna M.D. ; Schiffer, Eduardo M.D. ; Rollin, Maxime M.D. ; Parc, Yann M.D., Ph.D. ; Mazoit, Jean-Xavier M.D., Ph.D. ; Azizi, Louisa M.D. ; Gervaz, Pascal M.D. ; Rohr, Serge M.D., Ph.D. ; Biermann, Celine M.D. ; Lienhart, Andre M.D., Ph.D. ; Eledjam, Jean-Jacques M.D., Ph.D. 
Anesthesiology. 107(3):461-468, September 2007.

Abstract:
Background: Blockade of parietal nociceptive afferents by the use of continuous wound infiltration with local anesthetics may be beneficial in a multimodal approach to postoperative pain management after major surgery. The role of continuous preperitoneal infusion of ropivacaine for pain relief and postoperative recovery after open colorectal resections was evaluated in a randomized, double-blinded, placebo-controlled trial.
Methods: After obtaining written informed consents, a multiholed wound catheter was placed by the surgeon in the preperitoneal space at the end of surgery in patients scheduled to undergo elective open colorectal resection by midline incision. They were thereafter randomly assigned to receive through the catheter either 0.2% ropivacaine (10-ml bolus followed by an infusion of 10 ml/h during 48 h) or the same protocol with 0.9% NaCl. In addition, all patients received patient-controlled intravenous morphine analgesia.
Results: Twenty-one patients were evaluated in each group. Compared with preperitoneal saline, ropivacaine infusion reduced morphine consumption during the first 72 h and improved pain relief at rest during 12 h and while coughing during 48 h. Sleep quality was also better during the first two postoperative nights. Time to recovery of bowel function (74 +/- 19 vs. 105 +/- 54 h; P = 0.02) and duration of hospital stay (115 +/- 25 vs. 147 +/- 53 h; P = 0.02) were significantly reduced in the ropivacaine group. Ropivacaine plasma concentrations remained below the level of toxicity. No side effects were observed.
Conclusions: Continuous preperitoneal administration of 0.2% ropivacaine at 10 ml/h during 48 h after open colorectal resection reduced morphine consumption, improved pain relief, and accelerated postoperative recovery.

Sedation and Anesthesia Care for Ophthalmologic Surgery during Local/Regional Anesthesia.
Review Article
Vann, Mary Ann M.D. ; Ogunnaike, Babatunde O. M.D. ; Joshi, Girish P. M.B., B.S., M.D., F.F.A.R.C.S.I. 
Anesthesiology. 107(3):502-508, September 2007.

Abstract:
Anesthesia care for the patients undergoing ophthalmologic surgical procedures during local/regional anesthesia balances goals of patient comfort with safety and an optimal outcome in a highly cost-conscious environment. This article discusses current practices and trends in anesthesia care with respect to sedation for eye surgery during local/regional anesthesia. Although there is no evidence that one local/regional anesthesia technique or sedation analgesia regimen is superior to the others, this review highlights important differences between these varied approaches. The type of block used for the ophthalmologic surgery alters the sedation requirements. Changes in surgical techniques have increased the popularity of topical anesthesia, which reduces the need for sedation analgesia and may lessen the need for an anesthesia practitioner. The involvement of an anesthesia practitioner in eye surgery varies from facility to facility based on costs, anesthesiologist availability, and local standards. Anesthesia care choices are often made based on surgeon skill and anesthesiologist comfort, as well as the expectations and needs of the patient.

ACTA ANAESTHESIOLOGICA SCANDINAVICA - TOP

Comparison of transmucosal midazolam with inhalation sedation for dental extractions in children. A randomized, cross-over, clinical trial
K. E. Wilson, R. R. Welbury, N. M. Girdler
Acta Anaesthesiologica Scandinavica 2007; 51 (8), 1062–1067.

Background: The transmucosal route for conscious sedation in children has been reported widely in the field of medicine, but less so in dental patients. The aim of this study was to evaluate the efficacy and safety profile of midazolam (0.2 mg/kg) administered by the buccal transmucosal route, in comparison with nitrous oxide/oxygen inhalation sedation, for orthodontic extractions in 10–16-year-old dental patients.
Methods: Each patient attended for two visits and was randomly allocated to receive buccal midazolam (0.2 mg/kg) or nitrous oxide/oxygen titrated to 30%/70% at the first visit, the alternative being used at the second visit. The patients’ vital signs, sedation levels and behavioural scores were recorded throughout. Post-operatively, side-effects, recall of the visit and satisfaction levels were recorded via questionnaire.
Results: Thirty-six patients, with a mean age of 12.9 years, completed both arms of the trial. The maximum level of sedation was achieved with buccal midazolam in a mean time of 14.42 min, compared with 7.05 min with inhalation sedation. The vital signs with both types of sedation remained within acceptable limits and the reported side-effects were of no clinical significance. Buccal midazolam was found to be acceptable by 65.7%. Only 28.6% of cases preferred this technique, the main disadvantage being the taste of the solution.
Conclusion: Buccal midazolam sedation (0.2 mg/kg) seems to be equally as safe and effective as nitrous oxide/oxygen for the extraction of premolar teeth in anxious children. However, further research is required to refine the midazolam vehicle to improve acceptability.

BRITISH JOURNAL OF ANAESTHESIA - TOP

Perioperative antiplatelet therapy: the case for continuing therapy in patients at risk of myocardial infarction (REVIEW ARTICLE)
P.-G. Chassot, A. Delabays and D. R. Spahn
British Journal of Anaesthesia 2007 99(3):316-328

Recent clinical data show that the risk of coronary thrombosis after antiplatelet drugs withdrawal is much higher than that of surgical bleeding if they are continued. In secondary prevention, aspirin is a lifelong therapy and should never be stopped. Clopidogrel is regarded as mandatory until the coronary stents are fully endothelialized, which takes 3 months for bare metal stents, but up to 1 yr for drug-eluting stents. Therefore, interruption of antiplatelet therapy 10 days before surgery should be revised. After reviewing the data on the use of antiplatelet drugs in cardiology and in surgery, we propose an algorithm for the management of patients, based on the risk of myocardial ischaemia and death compared with that of bleeding, for different types of surgery. Even if large prospective studies with a high degree of evidence are still lacking on different antiplatelet regimens during non-cardiac surgery, we propose that, apart from low coronary risk situations, patients on antiplatelet drugs should continue their treatment throughout surgery, except when bleeding might occur in a closed space. A therapeutic bridge with shorter-acting antiplatelet drugs may be considered.

Faster wash-out and recovery for desflurane vs sevoflurane in morbidly obese patients when no premedication is used
L. La Colla, A. Albertin, G. La Colla and A. Mangano
British Journal of Anaesthesia 2007 99(3):353-358

Background: The aim of this study was to compare desflurane vs sevoflurane kinetics and dynamics in morbidly obese patients and their recovery profile when no premedication had been used.
Methods: Twenty-eight unpremedicated obese patients were randomly allocated to receive either sevoflurane (n = 14) or desflurane (n = 14) as the main anaesthetic agent. After induction of anaesthesia, either sevoflurane 2% or desflurane 6% was administered for 30 min via a non-rebreathing circuit. The kinetics of sevoflurane and desflurane were determined by measuring and recording end-tidal samples during this time. The bispectral index was used to indicate the level of hypnosis. At the end of the procedure, the end-tidal concentrations of sevoflurane and desflurane were recorded during the first 5 min after stopping their administration. Time from discontinuation of the anaesthetic drugs to eye opening on verbal command, squeezing the observer's hand on command, extubation, stating their name, giving their correct date of birth, discharge from the recovery room, and duration of the surgery and anaesthesia were also recorded.
Results: The FA/FI ratio was significantly higher in the desflurane group from the 15th to the 30th min. The wash-out phase was faster for desflurane during the total observation period. When desflurane was used, recovery was also faster.
Conclusions: Desflurane provides faster wash-in and wash-out than sevoflurane in morbidly obese patients, and recovery is much faster after desflurane administration when no premedication has been used.

Post-tetanic count at adductor pollicis is a better indicator of early diaphragmatic recovery than train-of-four count at corrugator supercilii
G. Dhonneur, K. Kirov, C. Motamed, R. Amathieu, W. Kamoun, V. Slavov and S-K. Ndoko
British Journal of Anaesthesia 2007 99(3):376-379

Background: Because the intensity of neuromuscular block at the diaphragm (DIA) is indirectly assessed, the electromyographic measurements of the DIA (DIAEMG) from surface electrodes were related to information provided by visual estimation of neuromuscular transmission at the adductor pollicis (AP) and the corrugator supercilii (CSC) during recovery from vecuronium block.
Methods: Twelve adult patients were studied during balanced anaesthesia. After induction of anaesthesia and tracheal intubation without neuromuscular blocking agent, supramaximal stimulations were applied to phrenic, ulnar and facial nerves. During recovery from vecuronium 0.1 mg kg–1 an independent observer blinded to DIAEMG counted visually detectable train-of-four (TOF) at CSC (TOFCSC) and post-tetanic AP (PTCAP) responses. Times to recovery of PTCAP = 1, 5, <10 and >10, and TOFCSC = 1–4 responses were related to DIAEMG. Values are means (SD).
Results: Reappearance of the first response to PTCAP occurred significantly (P < 0.05) earlier and for a lower recovery of DIAEMG than that of TOFCSC [24 (8) min vs 33 (9) min, and 10 (10)% vs 25 (8)%, respectively]. With PTCAP 5 response, DIAEMG recovery was 21 (11)%. Recovery of TOFCSC = 1 and 2 coincided with DIAEMG recovery of 25 (8)% and 47 (9)%, respectively.
Conclusions: PTCAP may better reflect early recovery of vecuronium-induced DIA paralysis than TOFCSC. The findings suggested that PTCAP 5 warranted deep neuromuscular block of the DIA.

Comparison of i.v. cannula and Stevens’ cannula for sub-Tenon's block
C. M. Mather
British Journal of Anaesthesia 2007 99(3):421-424

Background: Sub-Tenon's local anaesthesia (STLA) is growing in popularity for ophthalmic surgery, and is widely regarded as safer than the alternative sharp needle techniques. Although safe, STLA is not devoid of risk. Therefore, the effectiveness of a plastic i.v. cannula was compared with the traditional metal Stevens’ cannula for delivering STLA.
Methods: In a randomized, controlled trial, the efficacy of STLA administered by either a Stevens’ sub-Tenon's metal cannula or a standard 20 G Optiva i.v. plastic cannula was compared; 120 patients, undergoing cataract surgery, were randomly allocated to one of the two groups. After STLA, the primary outcome measure, kinesia of the globe, was recorded at 5 and 10 min.
Results: There was no significant difference in the mean total ocular movement scores after STLA performed by either the 20 G i.v. cannula or standard 19 G sub-Tenon's cannula (P = 0.10). There was also no significant difference in any of the secondary outcome measures.
Conclusions: A 20 G Optiva i.v. cannula and the Stevens’ sub-Tenon's cannula were equally effective at providing STLA.

CANADIAN JOURNAL OF ANESTHESIA - TOP

The effects of prophylactic coronary revascularization or medical management on patient outcomes after noncardiac surgery - a meta-analysis
Elise Y.W. Wong, DDS, Herenia P. Lawrence, PhD and David T. Wong, MD
Canadian Journal of Anesthesia 54:705-717 (2007)

Purpose: The benefits of prophylactic coronary revascularization for patients undergoing noncardiac surgery are uncertain. The purpose of this study was to systematically evaluate the effect of coronary revascularization and medical management on short- and long-term outcomes after noncardiac surgery.
Method: Ten electronic databases including MEDLINE and EMBASE (1980 to February 2006), and bibliographies of included articles were searched without language restrictions. Studies comparing effects of coronary revascularization and medical management before noncardiac surgery were included. Patient outcome data including perioperative mortality, myocardial infarction, long-term mortality, or late adverse cardiac events were extracted and entered into a meta-analysis.
Results: The quality of published evidence was modest, comprising one randomized controlled trial and six retrospective studies. A total of 3,949 patients undergoing high-risk noncardiac surgery were included in the quantitative analysis. There was no significant difference between coronary revascularization and medical management groups with regards to postoperative mortality and myocardial infarction; the odds ratios (95% confidence intervals) were 0.85 (0.48–1.50) and 0.95 (0.44–2.08), respectively. There were no long-term outcome benefits associated with prophylactic coronary revascularization; the odds ratios (95% confidence intervals) were 0.81 (0.40–1.63) and 1.65 (0.70–3.86) for long-term mortality and late adverse cardiac events, respectively.
Conclusion: In patients with stable coronary artery disease, prophylactic coronary revascularization before high-risk noncardiac surgery does not confer any beneficial effects, when compared with optimized medical management, in terms of perioperative mortality, myocardial infarction, long-term mortality, or adverse cardiac events.

PUB MED - TOP

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