Preoperative versus intraoperative antiemetic strategies in patients undergoing laparoscopic cholecystectomy: A randomised double-blind study.

BACKGROUND: Previous studies have determined ondansetron's efficacy in preventing and treating postoperative nausea and vomiting (PONV). However, evidence regarding the timing of drug administration in relation to the surgical procedure remains vague. OBJECTIVE: To compare the preoperative and intraoperative administration of ondansetron on the incidence of PONV. DESIGN: Single-centred, randomised, double-blind trial. Patients were recruited between November 2018 and April 2021. Follow-up for PONV and retching was up to 24 h. SETTING: Aretaieio University Hospital, Greece. PATIENTS: A total of 121 patients undergoing elective laparoscopic cholecystectomy gave written consent. INTERVENTIONS: Patients were randomly allocated to the preoperative or the intraoperative group. The preoperative group received 4 mg of ondansetron dissolved in 100 ml of 0.9% saline 1 hour before induction of anaesthesia and 100 ml of 0.9% saline 30 min before end of surgery. The intraoperative group received 100 ml of 0.9% saline 1 h before induction of anaesthesia and 4 mg of ondansetron dissolved in 100 ml of 0.9% saline 30 min before end of surgery. MAIN OUTCOME MEASURES: The primary outcome was the incidence of nausea and/or vomiting combined at 24 h. RESULTS: No difference was found between the two groups regarding either the incidence of nausea and vomiting at 24 h (1.7% for the preoperative group versus 5.3% for the intraoperative group, P  = 0.31) or the incidence of nausea, vomiting and retching combined (5.3% for the preoperative group versus 10.5% for the intraoperative group, P  = 0.30). There was no difference between the groups in the pain intensity at rest or with coughing in the post anaesthesia care unit, at 4, 8 and 24 h postoperatively ( P  = 0.961, 0.929, 0.748 and 0.883 at rest, and 0.974, 0.220, 0.235 and 0.317 with coughing, respectively). CONCLUSION: Under the current study design, we found no difference in the incidence of PONV between the administration of ondansetron 1 h before induction of anaesthesia and the intraoperative administration of ondansetron 30 min before the end of surgery. TRIAL REGISTRATION: ClinicalTrials.gov NCT03023306.

Acute and Chronic Pain after Cesarean Delivery under Subarachnoid Anaesthesia. Is Postoperative Analgesia Adequate? A Cohort Observational Study.

Objectives: Uncontrolled pain after cesarean delivery is associated with women's dissatisfaction and limited ability to take care of the neonate. Materials and methods:This prospective observational study included 173 women scheduled for elective cesarean delivery under spinal anesthesia. Postoperative analgesia included subcutaneous morphine 0.1 mg/kg in the post-anesthesia care unit, followed by intravenous paracetamol 1000 mg every eight hours and intravenous diclofenac 75 mg every 12 hours in the ward. Subcutaneous morphine was repeated on demand. Pain intensity at rest, pain intensity after movement and cumulative morphine consumption were recorded at 2, 4, 8, and 24 hours postoperatively. Acute pain intensity was assessed on a 100 mm visual analogue scale (VAS, score 0-100 mm). Three and six months postoperatively, women were interviewed by phone for the presence of persisting pain, abnormal sensation in the wound area and analgesic consumption. Results:Our results showed that 24 hours postoperatively the mean dose of morphine was 16±7.1 mg and VAS scores at rest and after movement were 23±17.3 mm and 40±20.9 mm, respectively. The mean VAS scores at rest remained below 31 mm at all times, while after movement they were over 40 mm at both four and eight hours postoperatively (45±23.8 mm and 43±23.2 mm, respectively). Three months postoperatively, 15% of women reported the presence of continuous or intermittent pain, 72% loss of sensation or numbness at the site of surgery and 32% occasional analgesic consumption at home. Six months after surgery, 5% of women reported pain, 44% loss of sensation or numbness in the wound area and none of them (0%) consumed analgesics due to persistent post-cesarean delivery pain. Conclusion:Based on the above-mentioned findings, we concluded that the amount of morphine consumed in the ward was low and possibly inadequate to alleviate early post-cesarean delivery pain. The overall incidence of persisting pain was low and consistent with previous studies.

Impact of Altmetrics in evaluation of scientific journals, research outputs and scientists' careers: Views of editors of high impact anaesthesia, critical care and pain medicine journals.

BACKGROUND AND AIMS: Altmetrics represent the attention of an article drawn from social and mainstream media. The aim of this survey was to investigate the views of editors of high-impact journals on the Altmetric Attention Score (AAS), the number derived from an automated algorithm including a weighted count of mainstream news and social media sources. METHODS: A questionnaire related to the AAS was sent to the editors of high-impact journals, namely Anaesthesia, Critical Care Medicine (CCM) and Pain Medicine (PM). Eleven questions were related to the possible benefits and flaws of Altmetrics. RESULTS: Of the 1,381 editors asked, 126 answered. The overall answers showed that 76% of the editors were familiar with Altmetrics, 28% knew how AAS is calculated, 12% believed that AAS should replace traditional bibliometrics, 34% favoured AAS for journal ranking, 40% believed that AAS should be used to assess an article, 44% felt that AAS should be included in researchers' curriculum vitae and 22% felt that it should be considered for grants. Sixty-two percent of editors believed that AAS is vulnerable to manipulations, 60% proposed improvement and 16% abandonment. Positive answers were similar across the fields, except for journal ranking. Fifty-four percent of editors of the CCM journals favoured journal ranking using AAS versus 28% and 26% editors of anaesthesia and PM journals (P = 0.025 and P = 0.006, respectively). CONCLUSION: A high percentage of editors believed that AAS should be used to assess scholarly output and that it should be included in the researchers' curriculum vitae. Sixty percent of responders supported the improvement of AAS.

Addition of 100 mg of Tramadol to 40 mL of 0.5% Ropivacaine for Interscalene Brachial Plexus Block Improves Postoperative Analgesia in Patients Undergoing Shoulder Surgeries as Compared to Ropivacaine Alone-A Randomized Controlled Study.

Background and objectives: Brachial plexus block is commonly used in shoulder surgery, as it provides satisfactory surgical conditions and adequate postoperative pain control. However, there are contradictory reports regarding the addition of tramadol to the injected regional anesthetic solution. We performed a prospective randomized study to evaluate the effectiveness of tramadol as an adjuvant to ropivacaine during interscalene brachial plexus block and assess its impact on the opioid consumption and the early postoperative pain in patients that underwent shoulder surgery. Materials and Methods: Eighty patients scheduled for elective shoulder surgery and anesthesia via interscalene brachial plexus block were randomly divided into two groups. In group A (n = 40), a solution of 40 mL of ropivacaine 0.5% and 2 mL (100 mg) of tramadol was administered during the brachial plexus block, while in group B (n = 40), a solution of 40 mL of ropivacaine 0.5% and 2 mL NaCl 0.9% (placebo) was administered. The effectiveness and duration of sensory and motor blocks were recorded in both groups. The sensory block was assessed recording the loss of sensation to pin prick test over the skin distribution of the axillary, radial, and musculocutaneous nerves. The motor block was assessed using the modified 3-point Bromage score (0-2 points). Cumulative morphine consumption and pain, using the Visual Analog Scale (VAS), were evaluated in both groups at 2, 4, 8, and 24 h after surgery. Results: Sensory block onset was achieved earlier in group A than in group B (5.21 ± 3.15 minutes (min) vs. 7.1 ± 4.51 min, p = 0.029). The motor block onset was similar between the two groups (13.08 ± 6.23 min vs. 13.28 ± 6.59 min; p = 0.932). The duration of the sensory block was longer in group A as compared to group B (13 ± 2.3 h vs. 12 ± 2.8 h; p = 0.013). The duration of the motor block did not present any difference between the groups (10 ± 2.2 h vs. 10 ± 2.8 h; p = 0.308). Differences in morphine administration were not significant at 2, 4, and 8 h, however, morphine consumption was found to be decreased in group A 24 h postoperatively A (p = 0.04). The values of VAS were similar at 2, 4, and 8 h, however, they were lower in group A at 24 h (p < 0.013). Conclusions: Combined regional administration of tramadol and ropivacaine during interscalene brachial plexus block improves the time of onset and the duration of the sensory block, while it is associated with reduced morphine consumption during the first 24 h after shoulder surgery.

Acupuncture and Acupressure Applied on the Extra-1 (Yintang) Acupoint in Healthy Volunteers Do Not Affect Regional Cerebral Blood Flow as Assessed by the Pulsatility Index: A Cohort Observational Study.

Objective: Acupressure applied on the Extra-1 (Yintang) point decreases bispectral index (BIS) values and stress in healthy volunteers. The current authors hypothesized that acupressure and/or acupuncture could alter regional cerebral oxygenation as expressed by middle cerebral-artery velocity. This study was conducted to test that hypothesis. Materials and Methods: After giving written informed consent, healthy volunteers received, randomly, (1) acupressure on the Extra-1 (Yintang) point, (2) acupressure on a sham point lying 2 cm over the lateral end of the right eyebrow, (3) no acupressure, or (4) modified manual acupuncture on the Extra-1 (Yintang) point. Each intervention lasted 10 minutes, except for acupuncture, which lasted for 20 minutes. The flow velocity of the left middle cerebral artery-as expressed by the Pulsatility Index (PI), heart rate (HR), and hemoglobin oxygen saturation (SpO2)-was recorded before each intervention, every 2 minutes during the intervention, and 10 and 70 minutes after the end of the intervention. A 2-MHz hand-held probe of a transcranial Doppler system (Companion II Micro TCD Nikolet Biomedical Inc., Madison, WI) was used to isolate the left middle cerebral artery via a transtemporal approach. Results: There was no difference among the four interventions at any timepoint in PI (P = 0.431; F = 0.929), HR (P = 0.948; F = 0.121), and SpO2 (P = 0.708; F = 0.465), as well as in systolic arterial pressure (P = 0.857; F = 0.255) or diastolic arterial pressure (P = 0.991; F = 0.036). Conclusions: There were no changes in PI measurements when acupuncture or acupressure was applied on the Extra-1 (Yintang) point once and for a limited time duration.

Measurements of oxygen saturation of brain, liver and heart areas in the supine and sitting position using near infrared spectrophotometry.

BACKGROUND AND AIMS: Regional oxygen saturation (rSO2) monitoring of the brain by near-infrared spectroscopy (NIRS) has been mainly used during carotid endarterectomy. The present study was conducted in volunteers and investigates the rSO2 values of the brain, heart and liver tissue as assessed by NIRS in the supine and the sitting position. METHODS: After obtaining written informed consent from forty-nine healthy volunteers, rSO2 values were recorded in the heart and liver areas in the supine and the sitting position, while simultaneously the rSO2 values of the brain. RESULTS: The rSO2 brain values in the supine and the sitting position were 69 ± 6.0 and 66 ± 6.1 respectively (p = 0.0001). The rSO2 values in the supine and the sitting position were 76 ± 10.5 and 79 ± 6.7 for the heart (p > 0.05) and 85 ± 6.8 and 82 ± 7.2 for the liver, (p = 0.007). Heart rSO2 values were higher than the brain rSO2 values in both the supine (76 ± 10.4 versus 69 ± 6.6; p = 0.0001) and the sitting position (79 ± 6.7 versus 66 ± 6.1; p = 0.0001). The liver rSO2 values were also higher than the brain rSO2 values in the supine (85 ± 6.8 versus 69 ± 6.0; p = 0.0001) and in the sitting position (82 ± 7.2 versus 66 ± 5.7; p = 0.0001). Arterial blood pressure and arterial oxygen saturation (SpO2) did not differ between the two positions but the heart rate was higher in the sitting position (p = 0.030). CONCLUSIONS: We conclude that brain and liver (but not heart) rSO2 values are higher in the supine than sitting position. Additionally, NIRS may be used to assess oxygenation of the heart and liver.

Physiological and operative severity score for the enumeration of mortality and morbidity scoring systems for assessment of patient outcome and impact of surgeons' and anesthesiologists' performance in hepatopancreaticobiliary surgery.

CONTEXT: The physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) is a scoring system used to predict morbidity and mortality. AIMS: We compared the physiological and operative risk, the expected morbidity and mortality, and the observed postoperative mortality among patients operated by different surgeons and anesthetized by different anesthesiologists. SETTINGS AND DESIGN: This was a retrospective, single center study. SUBJECTS AND METHODS: The anesthetic records of 159 patients who underwent hepatopancreaticobiliary surgery were analyzed for the physiological and operative severity, POSSUM morbidity, POSSUM and Portsmouth POSSUM (P-POSSUM) mortality scoring systems, observed mortality in 30-days, 3, 6, and 12 months postoperatively, duration of surgery, and units of packed red blood cells (PRBC) transfused. These variables were compared among patients operated by five different surgeons and anesthetized by seven different anesthesiologists. STATISTICAL ANALYSIS: One-way analysis of variance was used for normally and Kruskal-Wallis test for nonnormally distributed responses. Differences in percentages of postoperative mortality were assessed by Chi-squared test. RESULTS: The physiological severity, POSSUM morbidity, POSSUM and P-POSSUM mortality scores, and observed mortality at 1, 3, 6, and 12 months postoperatively did not differ among patients operated by different surgeons and anesthetized by different anesthesiologists. Duration of surgery (P < 0.001), PRBC units transfused (P = 0.002), and operative severity (P = 0.001) differed significantly among patients operated by different surgeons. CONCLUSIONS: The physiological severity score, POSSUM and P-POSSUM scores did not differ among patients operated by different surgeons and anesthetized by different anesthesiologists. The different operative severity scores did not influence the observed mortality in the postoperative period.

Differences in Pain Perception Between Men and Women of Reproductive Age: A Laser-Evoked Potentials Study.

Objective: We investigated differences in pain perception between men and women of reproductive age by using Laser-Evoked Potentials (LEPs). Design, Setting, Subjects: Forty-four right-handed healthy volunteers (19 males/25 females), aged 30­40 years were studied. A CO2 laser generated three series of 10 thermal pulses (4.5 W) on the radial aspect of the dorsum of the left hand. A recording montage for late LEPs was used, and the potentials of each series of stimuli were averaged to calculate mean latency and amplitude for each subject. Volunteers scored verbally pain intensity (Numerical rating scale [NRS]; 0­10). Three series of 10 numbers were averaged for calculation of mean NRS score. Methods: LEP peak-to-peak amplitude, latency, and NRS scoring were compared between genders, and correlations between LEP amplitude/latency and NRS scores were assessed. Results: Data from 44 subjects were analyzed. LEP amplitudes differed significantly (P < 0.001) between men (24.2 ± 6.0 µV) and women (38.9 ± 15.28 µV), while no difference was found for latency (156.5 ± 8.6 versus 160.4 ± 19.8 ms, P = 0.42) or NRS score (2.6 ± 1.5 versus 2.4 ± 1.4, P = 0.63), respectively. Menstrual cycle phase did not influence LEP parameters (P = 0.59 for amplitude and P = 0.69 for latency) or NRS score (P = 0.95). No significant correlation was found between latency or amplitude and NRS score (P = 0.43 and P = 0.90, respectively). Conclusions: Our results demonstrate a significant gender-related difference in LEP amplitudes with lower mean values in men, while no difference was found in LEP latencies or in subjective pain ratings. Further research is required to clarify the clinical significance of the above experimental findings.

Sugammadex at both high and low doses does not affect the depth of anesthesia or hemodynamics: a randomized double blind trial.

Previous studies have shown that sugammadex decreases the anesthetic depth when administered to reverse the neuromuscular blockade produced by rocuronium/vecuronium. The aim of the present study was to investigate the effect of sugammadex alone on anesthetic depth and hemodynamics. Sixty patients scheduled for abdominal surgery participated in the study. Anesthesia was induced with thiopental/fentanyl and maintained with N2O/oxygen and sevoflurane concentrations adjusted to maintain Entropy and Bispectral Index (BIS) values between 40 and 50. Cis-atracurium 0.2 mg/kg was administered for neuromuscular blockade which was monitored with a TOF-Watch® SX acceleromyograph. State entropy (SE), response entropy (RE), Bispectral Index (BIS), systolic (SAP) and diastolic blood pressure (DAP), heart rate (HR), SpO2, end-tidal CO2 and sevoflurane concentrations were recorded every 3 min intraoperatively. Sugammadex 2 mg/kg (Group-2), 4 mg/kg (Group-4) or 16 mg/kg (Group-16) was given intravenously when a count of two responses of the train-of-four (TOF) or a post-tetanic count (PTC) 1-3 appeared or when no response at all (PTC = 0) was observed, respectively. The overall SE values, thus the primary outcome of the study, were 44 ± 11, 43 ± 10 and 43 ± 11 for Group-2, Group-4 and Group-16, respectively (p = 0.812). Also, the secondary endpoints, namely RE, BIS, SAP and DAP, HR and SpO2 did not differ between the three groups. Comparisons between Group-2 versus Group-4, Group-2 versus Group-16 and Group-4 versus Group-16 showed no differences (p > 0.05) for all the studied variables. Sugammadex alone at low, medium or high clinical doses has no effect on anesthetic depth as assessed by Entropy and BIS or on hemodynamics.

Ropivacaine, Interleukin-6 and Tumor Necrosis Factor Alpha Plasma Levels during Intermittent Epidural and Continuous Wound Infusion of Ropivacaine for Analgesia after Hysterectomy or Myomectomy: An Observational Study.

BACKGROUND/AIMS: The concentration-time profile of the long-acting local anesthetic ropivacaine after epidural (EP) administration at fixed time intervals or continuous subcutaneous (SC) infusion has not been fully evaluated. The objective of this work was to determine total plasma concentrations of ropivacaine and changes in cytokine interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-α) levels during EP and SC. METHODS: In this prospective randomized controlled trial, 18 patients undergoing abdominal hysterectomy or myomectomy were randomly selected to receive ropivacaine either every 6 h via an EP catheter or by continuous wound infusion along the skin incision, after a bolus dose, for 48 h. Total plasma ropivacaine concentrations were measured before the bolus and 2, 4, 8, 24, 48, and 50 h after the bolus using high-performance liquid chromatography-UV and IL-6 and TNF-α levels were measured at 0, 8 and 24 h with ELISA and analyzed statistically. RESULTS: During EP, mean ± SD ropivacaine concentrations were relatively stable up to 50 h postoperatively, that is, 239 ± 89 ng/ml, while during SC, initial concentrations between 2 and 8 h were comparatively lower (101.5 ± 42.9 ng/ml) than 24-50 h concentrations (437.1 ± 206 ng/ml). An increase in IL-6 levels was noted between 0 and 24 h during EP and SC, but TNF-α levels increased slightly, between 0 and 24 h, only during EP. CONCLUSION: Ropivacaine plasma concentrations with both EP and SC were found to be safe throughout the administration time interval. IL-6 levels increased during the same time interval, while TNF levels varied only slightly.

A meta-analysis to determine the effect of pharmacological and non-pharmacological treatments on fibromyalgia symptoms comprising OMERACT-10 response criteria.

Fibromyalgia is characterized by widespread pain, sleep problems, fatigue, functional impairment, psychological distress, and cognitive dysfunction. The objective of this meta-analysis is to synthesize the available data on the effectiveness of pharmacological and non-pharmacological interventions across all domains included in the Outcome Measures in Rheumatology Clinical Trials (OMERACT-10) fibromyalgia response definitions, and to examine response based on these definitions. We searched Cochrane, PubMed, Scopus, and the reference lists of articles for randomized controlled trials of any drug formulation or non-pharmacological intervention used for fibromyalgia treatment. We extracted efficacy data regarding pain, sleep, physical function, fatigue, anxiety, depression, and cognition. The available data were insufficient to draw definite conclusions regarding response. Indirect evidence indicates that it may be expected with the use of serotonin noradrenaline reuptake inhibitors (SNRIs), noradrenaline reuptake inhibitors (NRIs), and multidisciplinary treatment.

Perioperative Continuous Ropivacaine Wound Infusion in Laparoscopic Cholecystectomy: A Randomized Controlled Double-blind Trial.

Wound infusion with local anesthetics has been used for postoperative pain relief with variable results. This randomized, controlled, double-blind clinical trial examines the effect of ropivacaine infusion on pain after laparoscopic cholecystectomy. A total of 110 patients were randomly assigned to 2 groups. After induction of anesthesia a 75-mm catheter was inserted subcutaneously and connected to an elastomeric pump containing either 0.75% ropivacaine (ropivacaine group) or normal saline (control group) for 24 hours postoperatively. Before skin closure, each hole was infiltrated with 2 mL of 0.75% ropivacaine or normal saline according to randomization. Pain at rest, pain during cough, and analgesic consumption were recorded in the postanesthesia care unit and at 2, 4, 8, 24, and 48 hours postoperatively. Analgesic requirements and pain scores were recorded 1 and 3 months after surgery. The ropivacaine group reported less pain during cough (P=0.044) in the postanesthesia care unit (P=0.017) and 4 hours postoperatively (P=0.038). Ropivacaine wound infusion had no effect on late and chronic pain.

Pretreatment with nitrous oxide enhances induction of anesthesia with sevoflurane: A randomized controlled trial.

BACKGROUND AND AIMS: Inhalation anesthesia with sevoflurane may be enhanced by several drugs or techniques. The aim of the present study was to investigate the effect of nitrous oxide (N2O) pretreatment on the speed of anesthesia induction with sevoflurane. MATERIAL AND METHODS: Eighty patients scheduled for hysteroscopy under general anesthesia were randomly assigned to inhale for 10 min before induction 50% N2O in oxygen or air via a facemask. Anesthesia was induced with 7-8% sevoflurane in oxygen via a facemask. Bispectral index (BIS), end-tidal carbon dioxide (EtCO2) tidal volume, respiratory rate, oxygen saturation (SpO2), and heart rate were recorded every minute during the 10 min pretreatment periods and every 30 s during the first 300 s of induction with sevoflurane. During induction of anesthesia inspired and end-tidal sevoflurane concentrations were also recorded. RESULTS: During the 10 min of inspired 50% N2O or air BIS, EtCO2, tidal volume, respiratory rate and heart rate values did not differ between the two groups except for the SpO2, which was higher in the N2O group (P < 0.001). During induction of anesthesia the N2O group exhibited lower BIS values (P = 0.001), being significant at 60-150 s (P < 0.001, P < 0.001, P = 0.002, P = 0.014) as well as at 270 s (P = 0.004). EtCO2 and tidal volume were consistently lower in the N2O group (P = 0.001, P = 0.041 respectively) and respiratory rate was higher (P = 0.007). CONCLUSION: Our results show that pretreatment of the patients with 50% N2O for 10 min enhances the speed of induction with sevoflurane as assessed by the BIS monitoring.

Deep sedation for endoscopic cholangiopancreatography with or without pre or intraprocedural opioids: A double-blind randomised controlled trial.

BACKGROUND: Propofol alone or combined with opioids is considered the drug of choice for sedation during endoscopic retrograde cholangiopancreatography (ERCP). OBJECTIVE: To investigate the effect of pre or intraprocedural opioids on propofol requirement during deep sedation for ERCP, and on recovery, pain and cognitive function postoperatively. DESIGN: Three-arm, double-blinded randomised controlled trial. SETTING: Aretaieio University Hospital, February 2011 to July 2013. PATIENTS: One hundred and eighty adults aged between 45 and 75 years. INTERVENTIONS: Deep sedation with propofol (target bispectral index 40 to 70) was performed. In the remifentanil group (R), patients received intranasal placebo before ERCP, and remifentanil 0.1 ml kg(-1) h(-1) (concentration 10 µg ml(-1)) during ERCP. In the fentanyl group (F), patients received intranasal fentanyl 200 µg before ERCP and placebo during ERCP. In the placebo group (P), patients received intranasal placebo before ERCP and placebo during ERCP. MAIN OUTCOME MEASURES: The primary outcome was total propofol requirement. Secondary outcomes were recovery [assessed using the Ramsay Sedation Scale score and Observer's Assessment of Alertness/Sedation Score (OAAS)] at 30 min; postoperative pain [assessed using a visual analogue pain scale (VAS; 0 to 100 mm)]; and cognitive function [assessed using a MiniMental state test (max. 25 points) 30 min before and 30 min after ERCP]. RESULTS: Fifty-seven patients were included in group R, 59 in group F and 57 in group P. Propofol requirements for deep sedation were similar in all groups (13 mg kg(-1); P = 0.97). Ramsay Sedation Scale scores and OAAS scores were similar in all groups (P = 0.18 and P = 0.55, respectively). Postoperative median pain VAS differed among the groups (P = 0.007): 10 in group R, 0 in group F, five in group P. Cognitive function was high pre and postprocedure (median MiniMental state test 23 to 24) and not different among the groups. CONCLUSION: The addition of pre or intraprocedural opioids had no effect on propofol requirement for deep sedation, but patients who received fentanyl had less minor pain. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01304342.

Intermittent epidural vs continuous wound infusion of ropivacaine for acute and chronic pain control after hysterectomy or myomectomy: a randomized controlled trial.

OBJECTIVE: Adequate postoperative analgesia may enhance recovery. The efficacy of continuous wound infusion vs intermittent epidural ropivacaine for postoperative analgesia was investigated. DESIGN: Prospective randomized, observer blind trial. SETTING: Aretaieio University Hospital. SUBJECTS: Patients scheduled for open abdominal hysterectomy or myomectomy. METHODS: Patients received 10 mL of 0.75% ropivacaine along the skin incision before skin closure, followed by wound infusion 2 mL/hour of 0.375% ropivacaine or epidurally 10 mL of 0.75% ropivacaine in the beginning of surgery followed by 10 mL of 0.2% ropivacaine 6 hourly. The epidural injections or the wound infusion of ropivacaine lasted 48 hours. Rescue analgesia consisted of patient-controlled analgesia morphine up to 48 hours and acetaminophen/codeine tablets the next 24 hours. Analgesic consumption and visual analog scale pain at rest and during cough were assessed 2, 4, 8, 24, 48, and 72 hours postoperatively. One and three months later, patients were interviewed by phone for analgesic consumption at home and presence of pain. RESULTS: The subcutaneous group consumed more morphine during the first 2, 4, and 8 hours postoperatively (P < 0.001, P < 0.001, and P < 0.001, respectively). Subsequent morphine and acetaminophen/codeine requirements did not differ between the two groups. Pain intensity during cough was higher only 2 hours after surgery in the subcutaneous group (P = 0.002). Three months postoperatively, the two groups did not differ in the analgesic requirements and presence of persisting and/or burning pain. CONCLUSION: Based on our results, there is no clinical significant difference between the epidural ropivacaine and the subcutaneous ropivacaine group or a clear superiority to one management strategy.

The impact of two different transfusion strategies on patient immune response during major abdominal surgery: a preliminary report.

Blood transfusion is associated with well-known risks. We investigated the difference between a restrictive versus a liberal transfusion strategy on the immune response, as expressed by the production of inflammatory mediators, in patients subjected to major abdominal surgery procedures. Fifty-eight patients undergoing major abdominal surgery were randomized preoperatively to either a restrictive transfusion protocol or a liberal transfusion protocol (with transfusion if hemoglobin dropped below 7.7 g dL(-1) or 9.9 g dL(-1), respectively). In a subgroup of 20 patients randomly selected from the original allocation groups, blood was sampled for measurement of IL-6, IL-10, and TNFα. Postoperative levels of IL-10 were higher in the liberal transfusion group on the first postoperative day (49.82 ± 29.07 vs. 15.83 ± 13.22 pg mL(-1), P < 0.05). Peak postoperative IL-10 levels correlated with the units of blood transfused as well as the mean duration of storage and the storage time of the oldest unit transfused (r(2) = 0.38, P = 0.032, r(2) = 0.52, P = 0.007, and r(2) = 0.68, P<0.001, respectively). IL-10 levels were elevated in patients with a more liberal red blood cell transfusion strategy. The strength of the association between anti-inflammatory IL-10 and transfusion variables indicates that IL-10 may be an important factor in transfusion-associated immunomodulation. This trial is registered under ClinicalTrials.gov Identifier: NCT02020525.

Cesarean delivery under spinal anesthesia is associated with decreases in cerebral oxygen saturation as assessed by NIRS: an observational study.

OBJECTIVES: To investigate the effect of spinal anesthesia on cerebral rSO2 during elective cesarean delivery (CD). METHODS: Thirty-four women scheduled for elective CD under spinal anesthesia were recruited. In the operating room rSO2 of the left and right frontal area and right thigh was recorded using three disposable sensors. A combination of 1.8-2.0 ml of 0.75% ropivacaine plus 10 µg of fentanyl were injected intrathecally. Systolic and diastolic blood pressure, heart rate, SpO2 as well as rSO2 of the left and right forehead areas and right thigh were recorded before, 5, 10, and 25 to 50 minutes after spinal injection, after uterine incision and placenta delivery, and analyzed with ANOVA repeated measures. The study was approved by the Aretaieio Hospital Institutional Review Board and registered with ClinicalTrials.gov (ID: NCT01669135). RESULTS: The rSO2 left and right frontal area values decreased significantly from baseline (p=0.0001 and p=0.0001 respectively), with most remarkable decreases 5 and 10 minutes after spinal injection, from 65 (SD 8.7)% to 56 (SD 9.3)% and 56 (SD 9.5)% (p=0.0001 and p=0.0001) for the left and from 63 (SD 7.7)% to 55 (SD 9.3)% and 56 (SD 8.9)% (p=0,0001 and p=0.0001) for the right frontal area respectively. The rSO2 right thigh values increased significantly during the study period (p=0.0001). KEY LIMITATIONS: Contribution of extracranial circulation to the rSO2, lack of PaCO2 and cardiac output measurements. CONCLUSIONS: Women undergoing CD under spinal anesthesia may present decreases in cerebral rSO2. The clinical impact of these results remains to be determined.