Multimodal prevention of pain, nausea and vomiting after breast cancer surgery.

BACKGROUND: Despite many one- or two-modal attempts to relieve postoperative nausea and vomiting (PONV) and pain, postoperative issues following breast cancer surgery remain a substantial problem. Therefore, the aim of this explorative, hypothesis-generating study was to evaluate the effect of a multimodal, opiate-sparing, evidence-based regimen for prevention of PONV and pain. METHODS: Two hundred consecutive patients scheduled for breast cancer surgery were included. The prevention regimen included a package consisting of preoperative paracetamol, dextromethorphan, celecoxib, gabapentin, dexamethasone, total intravenous anaesthesia and intraoperative ondansetron. The patients were prospectively scored according to PONV, pain during rest and mobilization and major side effects. RESULTS: Of 200 consecutive breast cancer patients, 191 received the full package. During the first 36 postoperative hours, 79.1% reported no PONV at all and only 3.7% reported severe PONV. At rest, 69.6% reported no or light pain and 3.1% reported severe pain, with corresponding values of 59.7% and 8.9% during arm mobilization. Mean postoperative morphine consumption was 2.2 mg. The only significant side effect was transient dizziness. CONCLUSION: A multimodal, opiate-sparing regimen to prevent pain and PONV seems to be more effective than one- or two-component regimens on PONV and pain after breast cancer surgery, a result which calls for large-scale multi-center or randomized studies.

Scandinavian clinical practice guidelines on general anaesthesia for emergency situations.

Emergency patients need special considerations and the number and severity of complications from general anaesthesia can be higher than during scheduled procedures. Guidelines are therefore needed. The Clinical Practice Committee of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine appointed a working group to develop guidelines based on literature searches to assess evidence, and a consensus meeting was held. Consensus opinion was used in the many topics where high-grade evidence was unavailable. The recommendations include the following: anaesthesia for emergency patients should be given by, or under very close supervision by, experienced anaesthesiologists. Problems with the airway and the circulation must be anticipated. The risk of aspiration must be judged for each patient. Pre-operative gastric emptying is rarely indicated. For pre-oxygenation, either tidal volume breathing for 3 min or eight deep breaths over 60 s and oxygen flow 10 l/min should be used. Pre-oxygenation in the obese patients should be performed in the head-up position. The use of cricoid pressure is not considered mandatory, but can be used on individual judgement. The hypnotic drug has a minor influence on intubation conditions, and should be chosen on other grounds. Ketamine should be considered in haemodynamically compromised patients. Opioids may be used to reduce the stress response following intubation. For optimal intubation conditions, succinylcholine 1-1.5 mg/kg is preferred. Outside the operation room, rapid sequence intubation is also considered the safest method. For all patients, precautions to avoid aspiration and other complications must also be considered at the end of anaesthesia.

One-thousand consecutive inguinal hernia repairs under unmonitored local anesthesia.

UNLABELLED: To evaluate the feasibility and safety of unmonitored local anesthesia (ULA) for elective open inguinal hernia repair, we made a prospective, consecutive data collection from 1000 operations on primary and recurrent hernias. Follow-up consisted of a questionnaire 1 mo after surgery and retrieval from the electronic patient data management system. In 921 ASA Group I and II and 79 ASA Group III and IV patients, the median age was 60 yr (range, 18-95 yr). ULA was converted to general anesthesia in 5 of 1000 cases, and 961 patients were discharged on the day of surgery after 95 min (median; interquartile range, 75-150); 29 patients had complications requiring surgical intervention. Within the first month, three patients died of causes unrelated to hernia surgery, and six had cardiovascular or respiratory events. The questionnaire was returned by 940 patients; 124 were dissatisfied with local anesthesia, day-case setup, or both, primarily because of intraoperative pain (n = 74; 7.8%). We conclude that open inguinal hernia repair can be conducted under ULA, regardless of comorbidity, with a small rate of deviation from day-case setup and minimal morbidity. It provides a safe alternative to other anesthetic techniques with an acceptable rate of satisfaction, but intraoperative pain relief needs improvement. IMPLICATIONS: Inguinal hernia repair can be safely performed under unmonitored local anesthesia with infrequent postoperative morbidity and acceptable satisfaction, but intraoperative pain may be a problem.

Quality assessment of 26,304 herniorrhaphies in Denmark: a prospective nationwide study.

BACKGROUND: Groin hernia repair is one of the most frequent operations, but there is no consensus about surgical or anaesthetic technique. Furthermore, no nationwide studies have been done. Our aim was to investigate outcome results of groin hernia surgery to improve quality of treatment. METHODS: We prospectively recorded 26304 groin hernia repairs done in Denmark from Jan 1, 1998, to June 30, 2000, in a nationwide Danish hernia database. FINDINGS: 93% of all groin herniorrhaphies done in Denmark in the 30 months of the study were recorded in the database. Kaplan-Meier estimates of reoperation rates 30 months after anterior mesh repair and laparoscopic repair were significantly lower than after sutured posterior wall repairs in primary inguinal hernia (2.2% and 2.6% vs 4.4%; p<0.0001). Reoperation rates were also lower with anterior mesh repair (6.1%; p<0.0001) and laparoscopic repair (3.4%; p<0.0001) than with sutured posterior wall repair (10.6%) after recurrent hernia. Use of Lichtenstein mesh repair increased from 33% in January, 1998, to 62% in June, 2000, whereas use of laparoscopic repair remained constant at about 5%. Kaplan-Meier estimates of reoperation rates were 2.8% in the first 15 months and 1.6% in the second (p=0.03). For elective repairs, only 59% of patients were treated on an outpatient basis, and only 18% had local anaesthesia. INTERPRETATION: Mesh repairs have a lower reoperation rate than conventional open repairs. Systematic prospective recording of treatment and outcome variables in a national clinical database improved the overall quality of surgical care. However, there is a large potential for cost savings and more efficient patient care with extended use of mesh techniques, outpatient surgery, and local anaesthesia.

Feasibility of local infiltration anaesthesia for recurrent groin hernia repair.

OBJECTIVE: To describe the the feasibility of and patients' satisfaction with day case repair of recurrent inguinal hernias under unmonitored local anaesthesia. DESIGN: Prospective study. SETTING: Public service university hospital, Denmark. SUBJECTS: All patients with a reducible recurrent inguinal or femoral hernia unselectedly referred for elective repair during the 4-year period 1 September 1994 to 31 August 1998. INTERVENTIONS: Data were collected prospectively and consecutively from standardised, detailed files, a questionnaire 4 weeks postoperatively, and the Copenhagen Hospitals electronic patient data management system. MAIN OUTCOME MEASURES: Feasibility of local anaesthesia in the day case setting, patient satisfaction and morbidity. RESULTS: 215 consecutive operations for recurrent hernias were performed under unmonitored local anaesthesia. No conversion to general anaesthesia took place and no patients developed urinary retention. After 207 operations, the patients were discharged on the day of operation (96%), and the median time from the end of operation to discharge was 90 minutes (IQR 75-140). After 6 operations (3%), patients had complications that required surgical intervention. The 4-week questionnaire was returned after 208 operations (97%). 30 patients were dissatisfied, mainly because of intraoperative pain (17 patients, 8%). No mortality or cardiopulmonary morbidity was recorded during the first 30 days postoperatively. CONCLUSIONS: Open day-case repair of recurrent inguinal hernias can safely be conducted under unmonitored local anaesthesia with minimal morbidity. Intraoperative pain is the main topic that requires improvement.

Prospective study of chronic pain after groin hernia repair.

BACKGROUND: The aim was to provide a detailed description of any residual pain 1 year after elective day-case open groin hernia repair under local anaesthesia. METHODS: This was a prospective consecutive case series study by questionnaire of 500 consecutive operations in 466 unselected adult patients 1 year after surgery. Pain was scored (none, mild, moderate or severe) at rest, while coughing and during mobilization, and compared with similar data collected 1 and 4 weeks after operation. RESULTS: Some 419 questionnaires were returned (response rate 93 per cent); 20 patients had died within the year and 30 data sets from patients who had a subsequent operation during the study were excluded. Eighty patients (19 per cent) reported some degree of pain, and 25 (6 per cent) had moderate or severe pain. Pain restricted daily function in 24 patients (6 per cent). The incidence of moderate or severe pain was higher after repair of recurrent than primary hernias (14 versus 3 per cent; P < 0.001). The risk of developing moderate or severe pain was increased in patients who had a high pain score 1 week after operation (9 versus 3 per cent; P < 0.05) and also in patients who had moderate or severe pain 4 weeks after operation (24 versus 3 per cent; P < 0.001). CONCLUSION: Chronic pain is a significant problem after open groin hernia repair. It may be worse after surgery for a recurrent hernia and may be predicted by the intensity of early postoperative pain.

Combined epidural-spinal opioid-free anaesthesia and analgesia for hysterectomy.

Postoperative nausea and vomiting (PONV) are major problems after gynaecological surgery. We studied 40 patients undergoing total abdominal hysterectomy, allocated randomly to receive opioid-free epidural-spinal anaesthesia or general anaesthesia with continuous epidural bupivacaine 15 mg h-1 or continuous bupivacaine 10 mg h-1 with epidural morphine 0.2 mg h-1, respectively, for postoperative analgesia. Nausea, vomiting, pain and bowel function were scored on 4-point scales for 3 days. Patients undergoing general anaesthesia had significantly higher nausea and vomiting scores (P < 0.01) but significantly lower pain scores during rest (P < 0.05) and mobilization (P < 0.01). More patients undergoing general anaesthesia received antiemetics (13 vs five; P < 0.05), but fewer received supplementary opioids on the ward (eight vs 16; P < 0.05). We conclude that opioid-free epidural-spinal anaesthesia for hysterectomy caused less PONV, but with less effective analgesia compared with general anaesthesia with postoperative continuous epidural morphine and bupivacaine.

Multi-regional local anesthetic infiltration during laparoscopic cholecystectomy in patients receiving prophylactic multi-modal analgesia: a randomized, double-blinded, placebo-controlled study.

UNLABELLED: Pain is the dominant complaint after laparoscopic cholecystectomy. No study has examined the combined effects of a somato-visceral blockade during laparoscopic cholecystectomy. Therefore, we investigated the effects of a somato-visceral local anesthetic blockade on pain and nausea in patients undergoing elective laparoscopic cholecystectomy. In addition, all patients received multi-modal prophylactic analgesic treatment. Fifty-eight patients were randomized to receive a total of 286 mg (66 mL) ropivacaine or 66 mL saline via periportal and intraperitoneal infiltration. During the first 3 postoperative h, the use of morphine and antiemetics was registered, and pain and nausea were rated hourly. Daily pain intensity, pain localization, and supplemental analgesic consumption were registered the first postoperative week. Ropivacaine reduced overall pain the first two hours and incisional pain for the first three postoperative hours (P < 0.01) but had no apparent effects on intraabdominal or shoulder pain. During the first 3 postoperative h, morphine requirements were lower (P < 0.05), and nausea was reduced in the ropivacaine group (P < 0.05). Throughout the first postoperative week, incisional pain dominated over other pain localizations in both groups (P < 0.01). We conclude that the somato-visceral local anesthetic blockade reduced overall pain during the first 2 postoperative h, and nausea, morphine requirements, and incisional pain were reduced during the first 3 postoperative h in patients receiving prophylactic multi-modal analgesic treatment. IMPLICATIONS: A combination of incisional and intraabdominal local anesthetic treatment reduced incisional pain but had no effect on deep intraabdominal pain or shoulder pain in patients receiving multimodal prophylactic analgesia after laparoscopic cholecystectomy. Incisional pain dominated during the first postoperative week. Incisional infiltration of local anesthetics is recommended in patients undergoing laparoscopic cholecystectomy.

Combined field block and i.p. instillation of ropivacaine for pain management after laparoscopic sterilization.

We have studied the effect of ropivacaine for combined port site and mesosalpinx infiltration, and peritoneal instillation on pain, nausea and vomiting after laparoscopic sterilization, in a double-blind, placebo-controlled study in 80 patients. The total dose of ropivacaine was 285 mg. All patients received intra- and postoperative NSAID in fixed doses. Abdominal and shoulder pain, nausea and vomiting were recorded during the first 8 h after operation and in a diary for 3 days. In the ropivacaine group, abdominal pain scores were lower during the first 4 h (P < 0.00001), additional use of morphine was less (P < 0.001) and fewer patients had nausea or vomiting during the first 72 h (five vs 14; P < 0.05). There were no signs of local anaesthetic toxicity.

Short convalescence after inguinal herniorrhaphy with standardised recommendations: duration and reasons for delayed return to work.

OBJECTIVE: To provide a detailed description of post-herniorrhaphy convalescence. DESIGN: Prospective, descriptive, consecutive questionnaire case series. SETTING: Public university hospital, Denmark. PATIENTS: 100 consecutive patients treated for inguinal hernia. INTERVENTION: Elective open inguinal herniorrhaphy under local anaesthesia. One day convalescence for light/moderate and three weeks for strenuous physical activity was recommended. MAIN OUTCOME MEASURE: Duration of absence from work or main recreational activity. RESULTS: Overall median absence (including the day of operation) was 6 days (interquartile range 1-16). For unemployed patients it was 1 day (0-7), for patients with a light or moderate workload 6 days (3-12), and for those with a heavy workload 25 days (21-37). Among the 64 patients, who did not follow the recommendations, pain was contributory in 33 and advice from the general practitioner in 12. Pain was the main cause of impairment of activities of daily living. CONCLUSION: Well-defined recommendations for convalescence may, together with improved management of postoperative pain, shorten convalescence; they are essential in the evaluation of effects of different surgical techniques of herniorrhaphy on convalescence.

Pain after primary inguinal herniorrhaphy: influence of surgical technique.

BACKGROUND: Pain is an important problem after ambulatory hernia repair. To assess the influence of the surgical technique on postoperative pain, two separate randomized, patient-blinded, controlled trials were performed in men with an indirect inguinal hernia. STUDY DESIGN: In study A, 48 patients with an internal inguinal ring smaller than 1.5 cm were randomly allocated to either simple extirpation of the hernial sac or extirpation plus annulorrhaphy. In study B, 84 patients with an internal inguinal ring wider than 1.5 cm were randomly allocated to extirpation plus annulorrhaphy or extirpation plus Lichtenstein mesh repair (modified). All operations were performed under unmonitored local anesthesia with standardized perioperative analgesia using methadone and tenoxicam. Pain was scored daily for the first postoperative week and after 4 weeks on a four-point verbal-rank scale (no, light, moderate, or severe pain) during rest, while coughing, and during mobilization (rising to the sitting position). Use of supplementary analgesics (paracetamol) was recorded. Cumulative daily pain scores for the first postoperative week and the number of patients who used supplementary analgesics were the main outcome measures. RESULTS: There were no significant differences in cumulative pain scores or use of supplementary analgesics between the treatment groups in either study. Cumulative pain scores were significantly higher during coughing and mobilization than during rest in both studies. CONCLUSIONS: Choice of surgical technique for open repair of a primary indirect inguinal hernia has no influence on postoperative pain.

Pain after groin hernia repair.

BACKGROUND: The purpose of the study was to provide a detailed description of postoperative pain after elective day-case open inguinal hernia repair under local anaesthesia. METHODS: This was a prospective consecutive case series study. After 500 hernia operations in 466 unselected patients aged 18-90 years, pain was scored (none, light, moderate or severe) at rest, while coughing and during mobilization, daily for the first postoperative week and after 4 weeks. Pain scores were added together over the first postoperative week. RESULTS: On days 1, 6 and 28, 66, 33 and 11 per cent respectively had moderate or severe pain while coughing or mobilizing. Total pain scores were higher while coughing or mobilizing than at rest (P < 0.001). Younger patients had higher total pain scores than older patients while coughing or mobilizing (P0< 0.01), but not at rest. No significant differences were found between types of surgery or hernia. CONCLUSION: Pain remained a problem despite the pre-emptive use of opioids, non-steroidal anti-inflammatory drugs and local anaesthesia, irrespective of surgical technique.

Cryoanalgesia: effect on postherniorrhaphy pain.

UNLABELLED: Cryoanalgesia versus sham treatment was applied to the ilioinguinal and iliohypogastric nerves after mesh repair of an inguinal hernia under local anesthesia in 48 male patients in a prospective, randomized, and observer- and patient-blinded trial. Pain was scored daily during rest, while coughing, and during mobilization to the sitting position for 1 wk and weekly for 8 wk on a four-point verbal rank scale. Use of supplementary analgesics and sensory disturbances were recorded. Assessments were made for allodynia, hyperalgesia, and mechanical pain detection thresholds 8 wk postoperatively. Cumulative pain scores for the first postoperative week were equal in the two groups, as was the use of analgesics. Eight weeks postoperatively, three cases of hyperalgesia to pinprick were detected in the cryoanalgesia group, and 10 patients in the cryoanalgesia group versus 5 in the sham-treatment group reported disturbed sensibility. We conclude that cryoanalgesia of the iliohypogastrical and ilioinguinal nerve does not decrease postherniorrhaphy pain. IMPLICATIONS: Does freezing of sensory nerves in the groin reduce pain after hernia repair? Extreme cold (-60 degrees C) was applied in a double-blind, randomized study. No difference in pain scores was found. Sensory disturbances were seen in treatment and control patients. Freezing cannot be recommended for pain relief after hernia repair.

[Ambulatory laparoscopic cholecystectomy. Feasibility and convalescence]. / Ambulant laparoskopisk kolecystektomi. Gennemførlighed og rekonvalescens.

UNLABELLED: The purpose was to describe feasibility of and convalescence after laparoscopic cholecystectomy in a day case set up in this prospective, open, and descriptive study. Fifty consecutive patients referred for elective cholecystectomy participated. An overnight stay was planned for 13 patients, (12 because they lived alone, one because of pulmonary disease ASA III). The operation was in all cases performed under combined epidural-general anaesthesia. The primary issues were duration of hospital stay, reasons for delayed discharge, frequencies of nausea and vomiting, as well as duration of convalescence and reasons for postponement of return to work or recreational activities. Twenty-six patients (of 37 candidates for day case surgery) were discharged on the day of surgery and 16 on the first postoperative day. Eleven patients had nausea, and three vomited during the first three postoperative hours. Pain was the most common contributory reason for overnight stay (17 patients, eight of these being planned day-case patients who stayed overnight). The patients were recommended to resume work and recreational activities after 48 hours, but 35 patients did not observe this recommendation. The median number of days off work or recreational activity was four days (2-8), including the day of surgery. Pain was the most common contributory reason (19 patients). CONCLUSIONS: Laparoscopic cholecystectomy can be performed as an outpatient operation in more than half of all patients, in approximately 70% of patients not living alone, and with only 15% of the patients requiring more than one over-night stay. Postoperative pain is the primary reason for both delayed discharge and prolonged convalescence. Up to one week's duration of convalescence is recommended.

The feasibility, safety and cost of infiltration anaesthesia for hernia repair. Hvidovre Hospital Hernia Group.

Data from 400 consecutive elective ambulatory operations for inguinal hernia under unmonitored local anaesthesia with limited pre-operative testing were prospectively obtained by the use of standardised files and questionnaires to assess the feasibility, patient satisfaction and potential cost reductions for such a technique. The median age of the patients was 59 years, and 29 operations were performed in ASA group III patients. The median postoperative hospital stay was 85 min. Conversion to general anaesthesia was necessary only in two cases, and nine patients needed overnight admission. One week postoperative morbidity was low with one case of transient cerebral ischaemia and one case of pneumonia, but no case of urinary retention. On follow-up, 88% were satisfied with the procedure, including unmonitored local anaesthesia. The cost reduction was at least 160 Pounds per patient compared with general/regional anaesthesia. We conclude that elective inguinal herniorrhaphy may be performed routinely under unmonitored local anaesthesia with a low postoperative morbidity, a high satisfaction rate and significant cost reductions.

[Recommendations for convalescence after hernia surgery. A questionnaire study]. / Rekonvalescensanbefalinger efter herniekirurgi. En enqueteundersøgelse.

To determine differences in recommendations for convalescence after inguinal herniorrhaphy, a questionnaire was mailed to 294 general practitioners in the Copenhagen area. Sixty-two percent returned the questionnaire. After primary hernia repair a period of 1-12 weeks off work was recommended (mean 2.6, 4.1 and 7.8 weeks in patients with light, moderate or heavy work load, respectively). After repair for recurrent hernia 1-24 weeks off work were recommended (mean 3.5, 5.4 and 8.3 weeks in patients with light, moderate or heavy work load, respectively). Restrictions in lifting (> 5 kg) were recommended for 1-16 weeks, mean 6.1 and 7.4 weeks after primary and recurrent repair, respectively. It is concluded that there is a need for propagation of new data regarding shortened convalescence after herniorrhaphy in order to maximise the advantages of new surgical and analgesic techniques.

[Organization and results of ambulatory surgery for inguinal hernia]. / Organisation og resultater af ambulant kirurgi for hernia inguinalis.

The results of a reorganization of surgery for inguinal hernias within a department of surgical gastroenterology were assessed concerning staff simplifications, feasibility, patient satisfaction, safety, complications and resources. Five hundred consecutive, elective, open operations for unilateral reducible inguinal hernias were performed in 466 patients under local anaesthesia in an ambulatory setup. One hundred and fourteen of the operations were for a recurrent hernia. The median age was 60 years (44-74 years as 25% and 75% quartiles). Two of the operations were converted to general anaesthesia. The patients were discharged 85 min (median) post-operatively, but 12 patients were not discharged on the same day. Bleeding or wound infections in need of treatment were seen postoperatively in 1.6% and 1.6%, respectively. All patients were given a postoperative questionnaires with a response rate of 95%, 89% of the respondents were satisfied with the whole procedure, 11% were dissatisfied. A reorganization of surgery for inguinal hernias to a standardized ambulatory setup induced staff simplifications and saved resources with a preserved high patient satisfaction, safety and a low complication rate.

[Recurrence of inguinal hernia: ambulatory surgery under local anesthesia]. / Recidiv af ingvinalhernie: ambulant operation i lokal anaestesi.

In order to assess the feasibility of repair of a recurrent inguinal hernia in unmonitored local anaesthesia in an ambulatory set-up pain scores and data on patient satisfaction were obtained from 76 unselected patients after 79 consecutive operations. Median age was 63 years, and 25%- and 75% quartiles were 49 and 72 years respectively. All operations were conducted in local anesthesia. Three patients stayed in hospital overnight after the operation. Pain: After one, six and 28 days 27, 14 og 7% respectively had severe pain during function (cough and/or rising). Satisfaction: 82% were satisfied with ambulatory surgery in local anaesthesia, 82% were satisfied with the analgesic therapy (tenoxicam and methadone), but one third needed supplementary analgesics during the first week (acetaminophen was recommended). It is concluded, that ambulatory repair of a recurrent inguinal hernia in unmonitored local anaesthesia is a safe and cost effective alternative to operation in general or spinal anaesthesia.