The beneficial effects of preperitoneal catheter analgesia following colon and rectal resections: a prospective, randomized, double-blind, placebo-controlled study.

BACKGROUND: Preperitoneal catheter analgesia following abdominal surgery has attracted interest in the last decade. We conducted this study to evaluate the benefits of preperitoneal catheter analgesia in managing pain after abdominal colon and rectal resections. METHODS: A total of 50 patients undergoing colon and rectal resections for benign and malignant diseases received analgesic medicines via an epidural catheter placed just prior to surgery and a preperitoneal catheter placed at the end of the surgical procedure. Patients were instructed to use the epidural patient-controlled analgesia (PCA) device freely and were randomized into two groups after obtaining the approval of the Institutional Review Board: Group A received 10 ml of levobupivacaine twice a day postoperatively via preperitoneal catheter and group B received only 10 ml of saline. Demographics, surgical characteristics, pain scores recorded four days following surgery, analgesic volume used from the epidural PCA, clinical outcomes (length of stay, time to first bowel movement, time to first passage of gas or stool, time to first oral intake) and respiratory function test results (preoperative vs. postoperative) were compared. RESULTS: There were no significant differences in demographics or surgical characteristics between both groups. Pain scores were similar. Clinical outcomes and respiratory functions were comparable. The use of analgesic volume via epidural catheter was significantly lower in group A than in group B (P = 0.032). CONCLUSIONS: Preperitoneal catheter analgesia significantly decreased the need for epidural drug consumption and proved to be a beneficial adjunct for postoperative pain management of patients who underwent colon and rectal resections.

The effect of local anaesthetic on post-operative pain with wound instillation via a catheter for paediatric orthopaedic extremity surgery.

PURPOSE: We aimed to investigate the effects on post-operative pain of local anaesthetic administration via a catheter placed into the operation site in patients who were undergoing upper and lower extremity paediatric orthopaedic surgery. METHODS: In this randomised, double-blind and placebo study, 40 ASA I-II patients aged between 1 and 12 years were randomly allocated into two groups: study group (Group S: 0.2 ml/kg, 0.5% bupivacaine, n = 20) and control group (Group C: 0.2 ml/kg, serum physiologic, n = 20). Before the fascia was closed by the surgical team, the solution previously prepared by the chief nurse was injected into the subfascial soft tissue with the syringe as the "injected dose" of serum physiologic or bupivacaine. After the closure, 0.2 ml/kg (1 mg/kg) bupivacaine or saline was instillated as the "first instillated dose" into the surgical area via the catheter. Pain scores were recorded at 0, 1, 2, 4, 8, 12, 24 and 48 h post-operatively. Patients were administered 0.75 mg/kg meperidine intramuscularly post-operatively to equalise the pain scores. RESULTS: No statistically significant difference was found between Group S and Group C in terms of demographic and other data and pain scores in the post-anaesthesia care unit, while a statistically significant decrease was found at 2, 4, 8, 12, 24 and 48 h in Group S and at 1, 2 and 4 h in Group C based on pain scores in the post-anaesthesia care unit (P < 0.05). A statistically significant decreasing pain score was found at 4, 8, 12, 24 and 48 h in Group S (P < 0.05). CONCLUSION: The local anaesthetic administered via a catheter implanted in the surgical field may provide long-term and efficient post-operative analgesia.

The effectiveness of local anesthetics in preventing postoperative adhesions in rat models.

BACKGROUND: Intra-abdominal adhesions are fibrous bands that develop after abdominal surgery or inflammation and cause significant surgical morbidity and mortality. In this study, the effectiveness of lidocaine, prilocaine and bupivacaine in preventing experimental intra-abdominal adhesions in rats was studied. METHODS: After obtaining the approval of our local institutional review board, 50 female Wistar-Albino rats weighing 250-320 g underwent laparotomy via a standard 5-cm midline incision under intramuscular anesthesia with ketamine (40 mg/kg) and xylazine (10 mg/kg). The cecal serosa and adjacent abdominal wall were superficially injured using sterile gauze. The laparotomy incision was closed after irrigation of the peritoneal cavity with the following: 5 ml saline in Group II, (the sham group), 7 mg/kg prilocaine in Group III, 3 mg/kg lidocaine in Group IV or 2 mg/kg bupivacaine in Group V. No irrigation was performed in Group I rats (the control group). After laparotomy closure, all rats were allowed to wake spontaneously. Two weeks after the initial experimental procedure, all rats underwent a second laparotomy, and adhesions were scored using the Linsky scale. RESULTS: The adhesion quantity and quality were comparable among all groups (P > 0.05); however, adhesion severity scores were significantly lower in the prilocaine and bupivacaine groups vs. the other groups (P < 0.05). CONCLUSIONS: Prilocaine and bupivacaine were found to decrease the severity of intra-peritoneal adhesions.

Effects of adding epinephrine plus fentanyl to low-dose lidocaine for spinal anesthesia in outpatient knee arthroscopy.

BACKGROUND: This study investigated whether addition of 15 microg epinephrine plus 25 microg fentanyl to lidocaine spinal anesthesia for outpatient knee arthroscopy makes it possible to use a subanesthetic lidocaine dose. The aim was to assess the quality of anesthesia and the suitability of this protocol for outpatient knee arthroscopy. METHODS: Seventy-five outpatients scheduled for knee arthroscopy were randomly assigned to one of three spinal anesthetic protocols: Group L10F25 received 10 mg of lidocaine plus 25 micro g fentanyl; Group L10F25E15 received 10 mg of lidocaine plus 25 microg fentanyl plus 15 microg epinephrine; and Group L20F25 received 20 microg lidocaine plus 25 microg fentanyl. Tourniquet pain and surgical pain were assessed using a visual analog scale. If spinal anesthesia was inadequate despite supplementary intravenous analgesia and sedation, the patient was converted to general anesthesia. Recovery times and side-effects in the early postoperative period were recorded. RESULTS: The highest level of sensory block was above the T12 dermatome in all patients. Compared with the other groups, significantly more patients in Group L10F25 converted to general anesthesia. Group L10F25 had a significantly higher mean surgical pain score than the other groups. The mean tourniquet pain score was significantly higher in Group L20F25 than Group L10F25E15. Group L10F25E15 had a significantly shorter time to discharge than the other groups. Post-operative nausea and vomiting and drowsiness were more frequent in Group L10F25 than in the other groups. CONCLUSION: The combination of 10 mg lidocaine and 25 microg fentanyl plus 15 microg epinephrine provides adequate spinal anesthesia and has favorable recovery characteristics for outpatient knee arthroscopy.

Comparison of the catheter-technique psoas compartment block and the epidural block for analgesia in partial hip replacement surgery.

BACKGROUND: The aim of this study was to compare the intra- and postoperative analgesia provided by the catheter-technique psoas compartment block and the epidural block in hip-fractured patients. We also compared hemodynamic stability, motor blockade, ease of performing the technique, and complications. METHODS: Thirty patients who underwent partial hip replacement surgery were included in this prospective single-blind study. Subjects were randomly assigned to Group E (n=15; general anesthesia plus epidural block with 15 ml of 0.5% bupivacaine) or Group P (n=15; general anesthesia plus psoas compartment block with 30 ml of 0.5% bupivacaine). Hemodynamic parameters were recorded at 10-min intervals intraoperatively. Regional anesthesia procedure time, number of attempts at block, intraoperative blood loss, and need for supplemental fentanyl and/or ephedrine were noted. Postoperatively, a patient-controlled analgesia device delivered an infusion and boluses of bupivacaine/fentanyl. Pain, motor blockade, ambulation time, patient satisfaction with analgesia, and complications were recorded postsurgery. RESULTS: The epidural required significantly more attempts than the psoas block, thus procedure time was longer in this group. Group E also showed significantly greater drops in mean arterial blood pressure from baseline at 30, 40 and 50 min after the start of general anesthesia. Significantly more Group E patients required epinephrine supplementation. The groups were similar regarding pain scores (at rest and on movement) and patient satisfaction, but Group E had higher motor blockade scores, longer ambulation time, and significantly more complications. CONCLUSION: The continuous psoas compartment block provides excellent intraoperative and postoperative analgesia with a low incidence of complications for partial hip replacement surgery

A clinical comparison of psoas compartment and inguinal paravascular blocks combined with sciatic nerve block.

The extent of inguinal paravascular blockade and psoas compartment blockade with sciatic nerve block was evaluated in 60 patients. Volumes of 30 ml and 20 ml 0.35% bupivacaine with 1/200,000 epinephrine were injected for lumbar plexus and sciatic nerve block, respectively. Complete lumbar plexus blockade was achieved in 73% of the group who were treated with the psoas compartment technique and 43% of the group who were treated with the inguinal paravascular technique. Sensory blockade of the femoral, lateral femoral cutaneous and obturator nerves was obtained in 100%, 97% and 77% of the patients in the psoas compartment group, and 93%, 63% and 47% of the patients in the inguinal paravascular group, respectively. Sensory blockade of the lateral femoral cutaneous and obturator nerves was more rapid with psoas compartment block. The study suggests that the psoas compartment block is effective in blocking the femoral, lateral femoral cutaneous and obturator nerves, but the inguinal paravascular block is only effective in blocking the femoral nerve.

Comparison of the efficacy of 2 mg versus 5 mg tropisetron in the management of post-operative nausea and vomiting.

A randomized, double-blind, placebo-controlled study was carried out to investigate the efficacy of 2 mg versus 5 mg tropisetron in the prevention of post-operative nausea and vomiting. Patients between 22 and 64 years old who were undergoing surgery under general anaesthesia and who had been classified according to the American Society of Anesthesiologists criteria with physical status I or II were included in this trial. Sixty female patients were recruited and divided into three groups (n = 20 in each group). Patients in group 1 received saline solution as control, whereas in groups 2 and 3, 2 mg or 5 mg tropisetron, respectively, was administered intravenously as a single dose during the induction of anaesthesia. The number of patients vomiting within the first 2 h following the operation was significantly less in groups 2 and 3 compared with that in group 1 (one of 20 for each of the groups 2 and 3 versus 12 of 20 in group 1). Three patients required rescue anti-emetic medication in each of the groups 2 and 3. In conclusion, 2 mg tropisetron appears to be equally as efficacious as 5 mg in preventing post-operative nausea and vomiting.

Vasopressin, renin, and adrenocorticotropic hormone levels during the resuscitation of hemorrhagic shock in dogs.

Hemorrhage is a potent stimulus for the release of vasopressin (VP), renin, and adrenocorticotropic hormone (ACTH). The goal of this study was to analyze changes in plasma VP, renin, and ACTH levels during hemorrhagic shock and resuscitation with two different solutions: hypertonic acetate dextran (HAD) and lactated Ringer's (LR) solution. Eight randomized dogs were shocked by removing 37 +/- 9 mL/kg of blood while maintaining the mean arterial pressure (MAP) at 45 +/- 5 mmHg for 1 h. Test solutions were randomized and infused as needed with the hemorrhaged blood to restore the MAP and cardiac index to baseline. Blood samples for hormone analyses were taken in baseline, shock, and resuscitation periods. For each experiment, all hormone levels increased in the postshock period and then returned to baseline values after resuscitation with both solutions. VP and renin levels rapidly returned to baseline values after resuscitation in the LR dogs compared with the HAD dogs (p < 0.05). By contrast, there was no significant difference in ACTH levels between the two solutions. High-volume infusion with LR achieves more rapid restoration than small-volume infusion with HAD for VP and renin levels.

Complications of 1303 central venous cannulations.

Central venous catheterization (CVC), now a common procedure, has several major complications. We assessed their incidence in a prospective study of 1303 cannulations done in the intensive care unit or operating theatre. Chest radiographs were obtained to verify proper catheter placement and to detect pneumothorax. Complications were arterial puncture in 68 (5.2%) patients, arrhythmias in 21 (1.6%), cardiopulmonary arrest in 1 (0.1%), and pneumothorax in 5 (0.5%). The tip of the CVC was incorrectly located in 149 (11.2%). The chest radiograph was a valuable method for detecting complications of central venous catheterization.

The myocardium and brain SPECT findings in organophosphate poisoning.

A case of organophosphate poisoning is presented by using Tc-99m HMPAO (hexamethyl propylenamine oxime) brain SPECT (single photon emission computer tomography) and Tc-99m Sestamibi myocardial SPECT findings in the acute recovery and delayed phases. On the 4th day, brain SPECT imaging showed the perfusion defects in the left parietal lobe of the brain. On the 5th day myocardium scintigraphy also revealed the anterolateral wall perfusion defect. The myocardial defect became more prominent but brain defect was smaller than before, on the 19th day of the therapy. Two months later, on the third examinations of the brain and myocardium, their imagings were both normal.

Brain involvement in organophosphate poisoning.

Organophosphate poisonings cause substantial morbidity and mortality worldwide; however, the neurological effects have not been clearly established. We have studied cerebral perfusion to investigate neurotoxic effects. Clinical effects, plasma cholinesterase activity, and brain single photon emission computerization tomography (SPECT) data were investigated in 16 patients with organophosphate poisonings. The subjects were from an adult intensive care unit in a university hospital. Cholinesterase activity in plasma was determined upon admission and then every day in the morning. Brain SPECT studies were performed during the first week, at the end of therapy, and 3 months after discharge. Patients were classified into 3 groups using a modified Namba classification: latent poisoning (Group A); mild and moderate poisoning (Group B); or severe poisoning (Group C). None of the 6 patients in Group A showed any symptoms; 3 patients in Group B had muscarinic and nicotinic effects; 5 patients in Group C had muscarinic, nicotinic, and central nervous system symptoms. The average plasma cholinesterase for Groups A, B, and C were 54.16 +/- 9.10, 42.2 +/- 12.02, and 13 +/- 4.84 U/ml, respectively (normal range of plasma cholinesterase is 40-80 U/ml). Only 1 patient from Group A required treatment with oxime; 2 patients from Group B and all patients in Group C were given oxime, atropine sulfate, and mechanical ventilation. In the brain SPECT studies, the patients in Group A showed fewer perfusion defect areas than did Group B and C patients. All cases showed perfusion defects especially in the parietal lobe. In addition, perfusion improvement took more time for Group C than for the other groups. The intensive care unit stays of Group C were statistically longer than for Groups A and B. We concluded that brain SPECT is a highly sensitive diagnostic method, together with clinical symptoms and plasma cholinesterase activity, for monitoring the clinical prognosis of organophosphate poisonings.

Anti-emetic efficacy of tropisetron and metoclopramide.

Post-operative vomiting, especially in ambulatory surgical patients, remains a troublesome problem. This placebo-controlled, randomized, prospective double-blind trial was designed to evaluate the efficacy of two prophylactic anti-emetic regimens on post-operative vomiting in 1-day thyroid surgery. Altogether 60 elective surgical patients were followed for 4 h post-operatively. All patients were American Society of Anesthesiologists physical status of I or II and aged between 22 and 60 years: group 1 was saline control; in groups 2 and 3, metoclopramide (0.2 mg/kg) or tropisetron (5 mg) was administered, respectively, as an intravenous single dose during induction. Patients were pre-medicated. A standardized anaesthetic technique consisting of thiopentone-succinylcholine for induction and fentanyl-nitrous oxide-halothane-pancuronium for maintenance of anaesthesia was used. A 'rescue' anti-emetic was provided in case of continued vomiting or at the patient's request. Anti-emetic inefficacy was defined as request for rescue anti-emetic and/or vomiting episode during the first 4 h post-operation. The number of patients vomiting was 12/20 (60%), 10/20 (50%) and 1/20 (5%) within the first 2 h post-operation in groups 1, 2 and 3, respectively (P > 0.05 for groups 1 and 2; P < 0.01 for groups 2 and 3; P < 0.001 for groups 1 and 3). In group 2, three patients required rescue medication during the first 2 h post-operation, but no significant difference was observed between groups 2 and 3 (P > 0.05). None of the cases in any of the groups needed any rescue medication during post-operative 2-4 h. It is concluded that tropisetron is a highly effective anti-emetic drug in the prophylaxis of post-operative vomiting.

Acute organophosphate poisoning--Tc-99m HMPAO SPECT imaging of the brain. A report of two cases.

Two cases of organophosphate poisoning are presented along with Tc-99m HMPAO brain SPECT findings in the acute and delayed phases. Perfusion defects were more prominent at the onset of poisoning in both cases.