Perioperative Duloxetine to Improve Postoperative Recovery After Abdominal Hysterectomy: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Study.

BACKGROUND: Postsurgical quality of recovery is worse in female than that in male patients. Duloxetine has been used successfully for the treatment of chronic pain conditions, but its use for preventing acute postoperative pain has been limited to a single previous study. More importantly, the effect of preoperative duloxetine on global postoperative quality of recovery has yet to be evaluated. The main objective of the current investigation was to evaluate the effect of perioperative duloxetine on postoperative quality of recovery in women undergoing abdominal hysterectomy. METHODS: The study was a prospective, randomized, placebo-controlled, double-blinded trial. Female patients undergoing abdominal hysterectomy were randomized to receive duloxetine (60 mg orally 2 hours before surgery and 24 hours after surgery) or an identical placebo pill. The primary outcome was the quality of recovery-40 score at 24 hours. Secondary outcomes included opioid consumption and postoperative pain scores. A P value <0.05 was used to reject type I error. RESULTS: Seventy patients were recruited, and 63 completed the study. The median difference (95% confidence interval) in global recovery scores (quality of recovery-40) at 24 hours after surgery between the duloxetine and the placebo group was 9 (4-20) (P < 0.001). Total opioid consumption was reduced at 24 hours in the duloxetine group compared with the placebo group, median (interquartile range) of 1 (0-5) mg IV morphine compared with 5.5 (0.5-9) mg IV morphine (P = 0.004). Nausea, vomiting, and time to postanesthesia care unit discharge were not significantly reduced in the duloxetine group compared with placebo. CONCLUSIONS: Duloxetine improves postoperative quality of recovery after abdominal hysterectomy. In addition, duloxetine reduces postoperative opioid consumption, even in the presence of a robust multimodal analgesic strategy. Duloxetine seems to be a viable pharmacologic strategy to improve postoperative quality of recovery in female patients undergoing abdominal hysterectomy.

The effect of neuraxial versus general anesthesia techniques on postoperative quality of recovery and analgesia after abdominal hysterectomy: a prospective, randomized, controlled trial.

BACKGROUND: Patients undergoing abdominal hysterectomy often have significant postoperative pain despite the use of concurrent multimodal pain strategies. Neuraxial anesthesia has opioid-sparing effects and may provide better postoperative recovery to patients when compared with general anesthesia. Our main objective in this study was to compare the effects of neuraxial and general anesthesia on postoperative quality of recovery after abdominal hysterectomy. METHODS: The study was a prospective, randomized, controlled clinical trial. Seventy healthy females were recruited and randomized to a general anesthesia or neuraxial technique as their primary anesthetic regimen. The primary outcome was the global quality of recovery-40 questionnaire (QoR-40) at 24 hours after the surgical procedure. Other data collected included postoperative pain scores and opioid consumption. Data were analyzed using the Mann-Whitney U test, Fisher's exact test, and linear regression. A P value <0.05 was considered statistically significant. RESULTS: The median difference (95% confidence interval [CI]) in the global QoR-40 score at 24 hours between the neuraxial and general anesthesia groups was 17 (11 to 21.5) (P < 0.001). Patients in the neuraxial anesthesia group had better quality of recovery scores in all the QoR-40 subcomponents than did the general anesthesia group (all P < 0.005). The median difference in global QoR-40 scores at 48 hours between the neuraxial anesthesia and the general anesthesia groups was 8 (6-10) (P < 0.001). Postoperative opioid consumption and pain scores were higher in the general anesthesia group than in the neuraxial anesthesia group. There was an inverse linear relationship between opioid consumption and postoperative quality of recovery at 24 hours, r(2) = 0.67 (P < 0.0001, 95% CI of 0.77 to 0.51), and at 48 hours, r(2) = 0.58 (P < 0.0001, 95% CI of 0.72 to 0.42). CONCLUSION: Neuraxial anesthesia provides better quality of recovery than does general anesthesia for patients undergoing abdominal hysterectomy. The opioid-sparing effects of neuraxial anesthesia were associated with a better quality of recovery in patients after the surgical procedure. In the absence of contraindications, neuraxial anesthesia seems to be a better anesthetic plan for those patients.

Intravenous and subcutaneous tramadol for inguinal herniorrhaphy: comparative study.

BACKGROUND AND OBJECTIVES: Inguinal herniorrhaphy is one of the most common surgeries in men. Neuroaxis block is the anesthetic technique used more often and in the majority of the cases the patient is ready to be discharged from the hospital a few hours after the procedure, as long as satisfactory analgesia is present and nausea and vomiting are absent. Tramadol is an analgesic drug that can be used in postoperative analgesia, but it has important side effects, such as nausea and vomiting whose incidence can range from 0% to 50%. The objective of the present study was to compare the incidence of nausea and vomiting and the quality of postoperative analgesia of subcutaneous and intravenous tramadol in patients undergoing inguinal herniorrhaphy. METHODS: This is a prospective study with 30 patients undergoing inguinal herniorrhaphy. Patients were divided into two groups: Group C (n = 15) received 1.5 mg.kg⁻¹ of subcutaneous Tramadol, and Group V (n = 15) received 1.5 mg.kg⁻¹ of intravenous Tramadol. All patients underwent continuous epidural anesthesia with 0.5% levobupivacaine. Anthropometric data, quality of analgesia, and the development of postoperative nausea and vomiting in the first eight hours were recorded. RESULTS: Statistically significant differences were not observed between both groups for anthropometric data, quality of analgesia, and the development of nausea and vomiting. CONCLUSIONS: The present study demonstrates the absence of statistically significant differences regarding the incidence of nausea and vomiting and quality of analgesia when using intravenous and subcutaneous Tramadol.

Anesthetic strategy for cesarean section in a patient with factor XI deficiency. Case report.

BACKGROUND AND OBJECTIVES: Factor XI deficiency is a rare hematologic disorder. Hemophilia C (factor XI deficiency) affects both genders and it is usually asymptomatic, manifesting only as postoperative hemorrhage. It is an autosomal recessive, homozygous or heterozygous, disorder, and its severity depends on the levels of factor XI. The objective of this report was to present the anesthetic strategy in a patient with hemophilia C. CASE REPORT: This is a 32 years old female, gravida 1/para 0, on the 39th week of pregnancy, scheduled for elective cesarean section. Physical and laboratorial exams did not show any abnormalities. According to the recommendations of the hematologist, on the day of the procedure, the patient was given promethazine, 25 mg, hydrocortisone, 500 mg, due to prior transfusion reaction, and plasma, 10 mL x kg(-1) for a total of 700 mL. Two hours later, the patient underwent subarachnoid block under routine monitoring. Ringer's lactate, 2000 mL, was administered for hydration. The anesthetic-surgical procedure proceeded without intercurrences. Postoperatively, the patient was doing well when, on the 3rd PO day, fresh frozen plasma (FFP), 10 mL x kg(-1), was administered to prevent late postoperative bleeding. CONCLUSIONS: The objective of this report was to present the anesthetic protocol for patients with hemophilia C and to alert for the need of investigation in patients with a history of postoperative bleeding, when a coagulation study should e be done before any invasive procedure and, in the case of prolonged aPTT, one should investigate the presence of factor XI deficiency.