Reduction of laparoscopic-induced hypothermia, postoperative pain and recovery room length of stay by pre-conditioning gas with the Insuflow device: a prospective randomized controlled multi-center study.
OBJECTIVE: To assess the efficacy and safety of Insuflow (Georgia BioMedical, Inc.) filter heater hydrator device in reducing the incidence, severity and extent of hypothermia, length of recovery room stay and postoperative pain at the time of laparoscopy. DESIGN: Prospective, randomized, blinded, controlled multi-center study. Patients underwent gynecologic procedures via laparoscopy; surgeons, anesthesiologists and recovery room personnel assessed the results. SETTING: Seven North American institutions. PATIENTS: Seventy-two women for safety evaluation and efficacy studies. INTERVENTIONS: Intraoperative pre-conditioning of laparoscopic gas with the Insuflow device (treatment) or standard raw gas (control) during laparoscopic surgery and postoperatively. MAIN OUTCOME MEASURES: Incidence, severity and extent of hypothermia, postoperative pain perception and length of recovery room stay. RESULTS: The Insuflow group had significantly less intraoperative hypothermia, reduced length of recovery room stay and reduced postoperative pain. Pre-conditioning of laparoscopic gas by filtering heating and hydrating was well tolerated with no adverse effects. The safety profile of the Insuflow pre-conditioned gas showed significant benefits compared to currently used raw gas. CONCLUSIONS: Pre-conditioning laparoscopic gas by filtering heating and hydrating with the Insuflow device was significantly more effective than the currently used standard raw gas and was safe in reducing or eliminating laparoscopic-induced hypothermia, shortening recovery room length of stay and reducing postoperative pain. (+info)
Primary and secondary hyperalgesia in a rat model for human postoperative pain.
BACKGROUND: Previously, the authors developed and characterized a rat model for postoperative pain to learn more about pain produced by incisions. In this study, the responses to heat and mechanical stimuli were evaluated directly on or adjacent to the incision and at varying distances from the incision. METHODS: Rats were anesthetized with halothane and incisions were made at different locations in the plantar aspect of the foot. The response frequency to a blunt mechanical stimulus, the withdrawal threshold to von Frey filaments (15-522 mN), and the withdrawal latency to radiant heat were measured. Rats were tested before surgery, 2 h later, and then daily through postoperative day 9. RESULTS: After plantar incision, persistent hyperalgesia was observed immediately adjacent to or directly on the incision to punctate and blunt mechanical stimuli, respectively. The withdrawal threshold to punctate stimuli applied 1 cm from the incision was decreased through postoperative day 1. In a transitional area, between the distant and adjacent sites, the withdrawal threshold was intermediate and the duration of hyperalgesia was transient. Heat hyperalgesia was persistent but present when the stimulus was applied to the site of injury but not to a distant site. CONCLUSION: Robust primary hyperalgesia to punctate and blunt mechanical stimuli was present. Hyperalgesia distant to the wound, or secondary hyperalgesia, occurred in response to punctate mechanical stimuli, was short-lived, and required greater forces. These results suggest that the most persistent pain behaviors in this model are largely primary hyperalgesia. (+info)
Effects of aggressive early rehabilitation on the outcome of anterior cruciate ligament reconstruction with multi-strand semitendinosus tendon.
To evaluate the effects of aggressive early rehabilitation on the clinical outcome of anterior cruciate ligament reconstruction using semitendinosus (and gracilis) tendon, 103 of 110 consecutive patients who underwent ACL reconstruction using multistrand semitendinosus tendon (ST) or the central one-third of patellar tendon with bony attachments (BTB) were analyzed prospectively. Subjectively, the Lysholm score was not different among the groups. The Lachman test indicated a trend of less negative grade in the ST men's group than that in the BTB men's group. On the patellofemoral grinding test, only women patients of both groups showed pain, with less positive crepitation in the ST group than in the BTB group. KT measurements at manual maximum showed more patients with more than 5 mm differences in the ST group than in the BTB group. The results of this study suggest that aggressive early rehabilitation after the ACL reconstruction using the semitendinosus (and gracilis) tendon has more risk of residual laxity than with the BTB. (+info)
The role of fibular length and the width of the ankle mortise in post-traumatic osteoarthrosis after malleolar fracture.
We assessed the role of fibular length and the width of the ankle mortise as risk factors in the occurrence of post-traumatic osteoarthritis of the ankle joint by comparison of radiographs of the affected and unaffected sides. A shortened fibular malleolus (P < 0.01), a wide ankle mortise (P < 0.01) and Weber type B fracture (P < 0.01) were significantly associated with the development of osteoarthrosis but an elongated fibular (P > 0.05) and a narrowing of the ankle mortise (P > 0.07) were not. (+info)
The effect of using a tourniquet on the intensity of postoperative pain in forearm fractures. A randomized study in 32 surgically treated patients.
We have analysed the relationship between the intensity of postoperative pain and the use of a pneumatic tourniquet in procedures for operative fixation of fractures of the forearm. Thirty-two patients were divided randomly into two groups as a control (NT) and tourniquet (T). The pain scores in the NT group were significantly lower. Patients over the age of 30 had notably more pain than those younger after the use of a tourniquet. Avoidance of the tourniquet gave better postoperative analgesia in male patients and in those with comminuted fractures. When a tourniquet was used the best results were obtained if it was kept inflated for less than one hour. (+info)
Morbidity and cost-effectiveness analysis of outpatient analgesia versus general anaesthesia for testicular sperm extraction in men with azoospermia due to defects in spermatogenesis.
The outcome and costs of testicular sperm extraction under outpatient local analgesia or general anaesthesia were compared in men with non-obstructive azoospermia. Nineteen consecutive patients were allocated to receive general anaesthesia, while the subsequent 21 consecutive patients received outpatient analgesia in the form of i.v. midazolam sedation, lignocaine spray, scrotal infiltration with local anaesthetic and spermatic cord block. Blood pressure, pulse rate and respiratory rate were determined. Sedation and testicular pain were assessed by subjective scoring. Both groups showed haemodynamic stability with little alteration in blood pressure, pulse rate and oxygen saturation. Toxic symptoms of local anaesthetic were not encountered in the outpatient group. No relationship was found between testicular size and the duration of the operation. The median postoperative pain intensity, sedation scores and analgesic requirements were significantly less in the outpatient group (P < 0.05). These advantages led to a shorter recovery time (P < 0.0001), 3-fold cheaper care and greater patient satisfaction (P < 0.0001) in the outpatient group. (+info)
Postoperative analgesia and vomiting, with special reference to day-case surgery: a systematic review.
BACKGROUND: Day-case surgery is of great value to patients and the health service. It enables many more patients to be treated properly, and faster than before. Newer, less invasive, operative techniques will allow many more procedures to be carried out. There are many elements to successful day-case surgery. Two key components are the effectiveness of the control of pain after the operation, and the effectiveness of measures to minimise postoperative nausea and vomiting. OBJECTIVES: To enable those caring for patients undergoing day-case surgery to make the best choices for their patients and the health service, this review sought the highest quality evidence on: (1) the effectiveness of the control of pain after an operation; (2) the effectiveness of measures to minimise postoperative nausea and vomiting. METHODS: Full details of the search strategy are presented in the report. RESULTS - ANALGESIA: The systematic reviews of the literature explored whether different interventions work and, if they do work, how well they work. A number of conclusions can be drawn. RESULTS-ANALGESIA, INEFFECTIVE INTERVENTIONS: There is good evidence that some interventions are ineffective. They include: (1) transcutaneous electrical nerve stimulation in acute postoperative pain; (2) the use of local injections of opioids at sites other than the knee joint; (3) the use of dihydrocodeine, 30 mg, in acute postoperative pain (it is no better than placebo). RESULTS-ANALGESIA, INTERVENTIONS OF DOUBTFUL VALUE: Some interventions may be effective but the size of the effect or the complication of undertaking them confers no measurable benefit over conventional methods. Such interventions include: (1) injecting morphine into the knee joint after surgery: there is a small analgesic benefit which may last for up to 24 hours but there is no clear evidence that the size of the benefit is of any clinical value; (2) manoeuvres to try and anticipate pain by using pre-emptive analgesia; these are no more effective than standard methods; (3) administering non-steroidal anti-inflammatory drugs (NSAIDs) by injection or per rectum in patients who can swallow; this appears to be no more effective than giving NSAIDs by mouth and, indeed, may do more harm than good; (4) administering codeine in single doses; this has poor analgesic efficacy. RESULTS-ANALGESIA, INTERVENTIONS OF PROVEN VALUE: These include a number of oral analgesics including (at standard doses): (1) dextropropoxyphene; (2) tramadol; (3) paracetamol; (4) ibuprofen; (5) diclofenac. Diclofenac and ibuprofen at standard doses give analgesia equivalent to that obtained with 10 mg of intramuscular morphine. Each will provide at least 50% pain relief from a single oral dose in patients with moderate or severe postoperative pain. Paracetamol and codeine combinations also appear to be highly effective, although there is little information on the standard doses used in the UK. The relative effectiveness of these analgesics is compared in an effectiveness 'ladder' which can inform prescribers making choices for individual patients, or planning day-case surgery. Dose-response relationships show that higher doses of ibuprofen may be particularly effective. Topical NSAIDs (applied to the skin) are effective in minor injuries and chronic pain but there is no obvious role for them in day-case surgery. RESULTS-POSTOPERATIVE NAUSEA AND VOMITING: The proportion of patients who may feel nauseated or vomit after surgery is very variable, despite similar operations and anaesthetic techniques. Systematic review can still lead to clear estimations of effectiveness of interventions. Whichever anti-emetic is used, the choice is often between prophylactic use (trying to prevent anyone vomiting) and treating those people who do feel nauseated or who may vomit. Systematic reviews of a number of different anti-emetics show clearly that none of the anti-emetics is sufficiently effective to be used for prophylaxis. (ABSTRACT TRUNCATE (+info)
Effect of i.v. ketamine in combination with epidural bupivacaine or epidural morphine on postoperative pain and wound tenderness after renal surgery.
We studied 60 patients undergoing operation on the kidney with combined general and epidural anaesthesia, in a double-blind, randomized, controlled study. Patients were allocated to receive a preoperative bolus dose of ketamine 10 mg i.v., followed by an i.v. infusion of ketamine 10 mg h-1 for 48 h after operation, or placebo. During the first 24 h after surgery, all patients received 4 ml h-1 of epidural bupivacaine 2.5 mg ml-1. From 24 to 48 h after operation, patients received epidural morphine 0.2 mg h-1 preceded by a bolus dose of 2 mg. In addition, patient-controlled analgesia (PCA) with i.v. morphine (2.5 mg, lockout time 15 min) was offered from 0 to 48 h after operation. Patients who received ketamine felt significantly more sedated at 0-24 h, but not at 24-48 h after operation, compared with patients who received placebo (P = 0.002 and P = 0.127, respectively). There were no significant differences in pain (VAS) at rest, during mobilization or cough, PCA morphine consumption, sensory block to pinprick, pressure pain detection threshold assessed with an algometer, touch and pain detection thresholds assessed with von Frey hairs, peak flow or side effects other than sedation. The power of detecting a reduction in VAS scores of 20 mm in our study was 80% at the 5% significance level. We conclude that we were unable to demonstrate an (additive) analgesic or opioid sparing effect of ketamine 10 mg h-1 i.v. combined with epidural bupivacaine at 0-24 h, or epidural morphine at 24-48 h after renal surgery. (+info)