ABSTRACT
Laparoscopic fundoplication is surgical treatment of choice for gastroesophageal reflux disease. The primary objective of our study was to determine the incidence and severity of intraoperative and postoperative [up to 48 hours after surgery] complications in laparoscopic Nissen fundoplication. We retrospectively analyzed case files and anesthesia charts of patients operated for this surgery from 2005 to 2011 and recorded the incidence and severity of intraoperative and postoperative [up to 48 hours after surgery] complications. 63 patients undergoing laparoscopic surgery for either a sliding [76%] or paraesophageal hiatus hernia [24%] were included in the study. Mean age was 41.6 +/- 13.3 years and mean surgical duration was 4.5 +/- 1.5 hours. Hypertension [28.5%], bradycardia [22.2%], high mean airway pressures [17.4%], desaturation [17.4%], arrhythmia [15.8%], bronchospasm [9.5%], pleural injury [6.3%] and subcutaneous emphysema [4.7%] were the main intraoperative complications. Abdominal pain [79%], radiological evidence of atelectasis [31.7%], breathlessness [22%], nausea and vomiting [20.6%], chest pain [9.5%] and pneumothorax [3%] were reported in early postoperative period. Pleural effusion [19%], pneumonia [3%], abdominal fluid collection [3%] and bed sore [1.5%] were seen in late postoperative period [after 24 hrs]. There was no mortality and the incidence of mild [grade 1], moderate [grade 2; grade 3] and severe complications [grade 4] was 31.5, 62.3 and 5.26% respectively. Injury to splenic artery, injury to stomach and difficult dissection due to adhesions was the reason for conversion to open surgery in three patients. Hypertension, bradycardia, higrrmean airway pressures and desaturation are the commonest intraoperative complications. Pneumothorax is common but clinically asymptomatic. Monitoring of airway pressure, KtCO2, SpO2 and intermittent chest auscultations is needed to detect it. Multimodal analgesia is needed for abdominal pain. Lung recruitment manoeuvers, chest physiotherapy and early mobilization are needed to prevent atelectasis, pleural effusion and pneumonia in the postoperative period
ABSTRACT
Magnesium has been used as an adjuvant by various routes, including intravenous, intrathecal, and epidural in different dosage regimens. The effect of single bolus dose of magnesium as an adjuvant to fentanyl for postoperative analgesia has not been studied. This prospective randomized controlled trial was done to evaluate the efficacy of single bolus administration of magnesium epidurally as an adjuvant to epidural fentanyl for postoperative analgesia in patients undergoing total hip replacement under combined spinal epidural anesthesia. Sixty patients received combined spinal-epidural anesthesia with 2 mL of 0.5% hyperbaric bupivacaine intrathecally. After the surgery, patients were randomized into Group F [epidural fentanyl [1 microg/kg] in 10 mL saline] and Group FM [epidural magnesium [75 mg] along with fentanyl [1 microg/kg] in 10 mL saline]. Supplementary analgesia was provided by 50 mg intravenous tramadol if Verbal Rating Score [VRS] > 4. Patient's first analgesic requirement and duration of analgesia were recorded. The duration of analgesia was significantly longer for Group FM, 340 +/- 28.8 min, compared with Group F, 164 +/- 17.1 min [P=0.001]. The frequency of rescue analgesics required in 24-h postoperative period in Group FM [2.3 +/- 0.5] was significantly less than that in Group F [4.3 +/- 0.5] [P=0.001]. VRS was significantly lower in Group FM up to 4 h in the postoperative period [P=0.001]. Bromage scale was statistically insignificant at all points of time. The administration of magnesium [75 mg] as an adjuvant to epidural fentanyl [1 microg/ kg] for postoperative analgesia results in significantly lower VRS with prolonged duration of analgesia as compared with epidural fentanyl [1 microg/kg] alone. Concomitant administration of magnesium also reduces the requirement of breakthrough analgesics with no increased incidence of side effects