Preoperative carbohydrate drink in fast-track primary total knee arthroplasty: a randomized controlled trial of 168 patients.

A key component in fast-track total knee arthroplasty (TKA) is early mobilization. Preoperative fasting might cause orthostatic hypotension and -intolerance which both can interfere with early mobilization. It was hypothesized that consuming a carbohydrate drink 2-3 hours prior to surgery is a viable option to reduce orthostatic hypotension, and as a result, improve rehabilitation. In this randomized controlled trial, all consecutive unilateral primary TKA patients were reviewed for eligibility. Exclusion criteria were American Society of Anesthesiologists (ASA) class above 3, older than 80 years of age, Diabetes Mellitus, and an insufficient comment of Dutch language. Patients were distributed in two groups. The control group was allowed to eat till 6 hours and drink clear fluids till 2 hours before surgery (standard treatment). The intervention group consumed, additionally to the standard treatment, a carbohydrate drink 2-3 hours before surgery. Blood pressure was measured both lying and standing as a measure for orthostatic hypotension during first time postoperative mobilization on day of surgery. A total of 168 patients were included. Prevalence of orthostatic hypotension in the control- and intervention group was 24 patients (34%) and 14 patients (19%) respectively, (p=0.05). Prevalence of orthostatic intolerance was 13 patients (19%) in the control group and 9 patients (13%) in the intervention group (p=0.32). No drink related adverse events occurred. In conclusion, taking a carbohydrate drink 2-3 hours before TKA significantly lowers the number of patients with orthostatic hypotension in early mobilization. However, the clinical relevance of the carbohydrate drink has to be studied further.

Waterijs na een operatie vermindert opiaatbehoefte.

OBJECTIVE To evaluate the effect of an ice-lolly on acute postoperative pain. DESIGN Randomised prospective intervention study. METHOD A total of 100 patients scheduled for an elective laparoscopic cholecystectomy were recruited to participate in the study. Patients were randomised to receive either an ice-lolly or no treatment after arrival at the post-anaesthesia care unit. The analgesic requirements (opioid and non-opioid), pain scores, and the presence of nausea and vomiting were registered on the post- anaesthesia care unit and ward during the first 24 hours after surgery. This study is registered in the Nederlands Trial Register under number NTR5335. RESULTS In the post-anaesthesia care unit, pain scores did not differ between patients who received an ice-lolly and those who did not. The opioid requirements of patients who had consumed an ice-lolly were significantly lower than those of the patients who had not (cumulative piritramide dose: 4.9 (SD 4.2) with ice-lolly vs. 6.6 (SD 4.0) without ice-lolly mg; P = 0.04). Furthermore, patients who did not receive an ice-lolly required more additional pain relief with non-opioid analgesics than patients who had been given an ice- lolly (31% vs. 10%; P = 0.01). Combining all administered opioid and non-opioid analgesics into one analgesic composite score showed that patients who received an ice-lolly required significantly fewer analgesics in the post-anaesthesia care unit than patients who had not been given an ice-lolly (2.2 (SD 1.7) vs. 2.9 (SD 1.8); P = 0.03). No differences between the groups in pain scores or use of analgesics were observed on the ward in the first 24 hours postoperatively. CONCLUSION The postoperative consumption of an ice-lolly reduces postoperative opioid and non-opioid analgesic requirements in the post- anaesthesia care unit. Conflict of interest and financial support: none declared.

No effect of the infiltration of local anaesthetic for total hip arthroplasty using an anterior approach: a randomised placebo controlled trial.

Only limited data are available regarding the infiltration of local anaesthetic for total hip arthroplasty (THA), and no studies were performed for THA using the anterior approach. In this prospective, randomised placebo-controlled study we investigated the effect of both standard and reverse infiltration of local anaesthetic in combination with the anterior approach for THA. The primary endpoint was the mean numeric rating score for pain four hours post-operatively. In addition, we recorded the length of hospital stay, the operating time, the destination of the patient at discharge, the use of pain medication, the occurrence of side effects and pain scores at various times post-operatively. Between November 2012 and January 2014, 75 patients were included in the study. They were randomised into three groups: standard infiltration of local anaesthetic, reversed infiltration of local anaesthetic, and placebo. There was no difference in mean numeric rating score for pain four hours post-operatively (p = 0.87). There were significantly more side effects at one and eight hours post-operatively in the placebo group (p = 0.02; p = 0.03), but this did not influence the mobilisation of the patients. There were no differences in all other outcomes between the groups. We found no clinically relevant effect when the infiltration of local anaesthetic with ropivacaine and epinephrine was used in a multimodal pain protocol for THA using the anterior approach.

Intrathecal baclofen for dystonia of complex regional pain syndrome.

Dystonia in complex regional pain syndrome (CRPS) responds poorly to treatment. Intrathecal baclofen (ITB) may improve this type of dystonia, but information on its efficacy and safety is limited. A single-blind, placebo-run-in, dose-escalation study was carried out in 42 CRPS patients to evaluate whether dystonia responds to ITB. Thirty-six of the 38 patients, who met the responder criteria received a pump for continuous ITB administration, and were followed up for 12 months to assess long-term efficacy and safety (open-label study). Primary outcome measures were global dystonia severity (both studies) and dystonia-related functional limitations (open-label study). The dose-escalation study showed a dose-effect of baclofen on dystonia severity in 31 patients in doses up to 450 microg/day. One patient did not respond to treatment in the dose-escalation study and three patients dropped out. Thirty-six patients entered the open-label study. Intention-to-treat analysis revealed a substantial improvement in patient and assessor-rated dystonia scores, pain, disability and quality-of-life (Qol) at 12 months. The response in the dose-escalation study did not predict the response to ITB in the open-label study. Eighty-nine adverse events occurred in 26 patients and were related to baclofen (n=19), pump/catheter system defects (n=52), or could not be specified (n=18). The pump was explanted in six patients during the follow-up phase. Dystonia, pain, disability and Qol all improved on ITB and remained efficacious over a period of one year. However, ITB is associated with a high complication rate in this patient group, and methods to improve patient selection and catheter-pump integrity are warranted.

Iontophoretic administration of S(+)-ketamine in patients with intractable central pain: a placebo-controlled trial.

The efficacy of 50 and 75 mg S(+)-ketamine administered daily by an iontophoresis-assisted transdermal drug delivery system was tested against placebo in a randomized, double-blind design in 33 patients with central neuropathic pain. At baseline and 1 week after the start of treatment subjects were evaluated with standard measures of efficacy: pain intensity measured by visual analog scale (VAS), health status (Pain Disability Index and EQ-5D) and quality of life (SF-36). Safety assessment included incidence and intensity of adverse events. No significant differences in pain scores (VAS) were observed between the ketamine groups and placebo during the course of the trial. Corrected for baseline levels, daily 50 mg S(+)-ketamine did not improve patient's health status or quality of life compared with placebo treatment. However, daily 75 mg S(+)-ketamine showed significant improvements on the Pain Disability Index, on the EQ-5D, and on the SF-36 except for the role-physical functioning and general health perception. Iontophoretic administration of S(+)-ketamine was well tolerated with a low incidence of adverse events (mild and transient in nature, resolving spontaneously). Iontophoretic administration of S(+)-ketamine was not more effective than placebo treatment in reducing pain scores in patients with severe central neuropathic pain. However, iontophoretic administration of 75 mg S(+)-ketamine improved the health status and the quality of life in these patients.

Interrater reliability of diagnosing complex regional pain syndrome type I.

BACKGROUND: Diagnosis of complex regional pain syndrome type I (CRPS I) is based on clinical observation of symptoms. As little information is available on the reliability of CRPS I diagnosis, we evaluated the agreement between therapists with regard to the presence and severity of CRPS I and its symptoms. METHODS: The interrater reliability was evaluated in 37 presumed CRPS I patients by three observers; one consultant anesthesiologist and two resident anesthesiologists. Patients were assessed on the basis of Veldman's CRPS criteria. RESULTS: The interrater reliability for diagnosing CRPS I was good for the majority of observer combinations. The percentage of agreement for the absence or presence of CRPS I was good (88%-100%). Cohen's Kappa's ranged from 0.60 to 0.86. The agreement for the mean symptom score ranged from 70.2% to 88.6%; Kappa's were lower and showed more variation. Interrater reliability for assessment of the severity of CRPS I and its symptoms was poor. Factors influencing the interrater reliability were symptom type, individual observers and sample population. CONCLUSION: Diagnosing CRPS I can be performed on the basis of clinical observation. Further assessment of severity of CRPS I and its symptoms should be performed with reliable and valid measurement instruments.

Radiofrequency treatment in The Netherlands.

A national enquiry was developed by the Pain Control Department of the Dutch Society of Anesthesiology (NVA) in co-operation with the National Organisation for Quality Assurance in Hospitals (CBO). A questionnaire for retrospective collection of invasive pain control data was sent to all (147) Dutch hospitals as part of the "Quality Assurance of Anesthesiological Pain Control Study" which took place from 1991 to 1997. The questionnaire related to the organisation of pain departments, availability of personnel, material and space facilities, use of treatment protocols, type and number of procedures carried out in cancer and non-cancer pain management during a 1 year period (1990-1991). The response rate to the enquiry was 98 per cent; this high response rate was important to evaluate the status of anesthesiological pain control in The Netherlands. During the study period 92 per cent of the respondents carried out 9,700 invasive cancer pain procedures; 85 per cent of the respondents were active in the field of chronic non-cancer pain control and were responsible for approximately 63,000 procedures.

Failure to demonstrate unconscious perception during balanced anaesthesia by postoperative motor response.

Eighty patients undergoing a standardized balanced anaesthesia were randomly assigned to either a suggestion group (N = 38) or a control group (N = 42), in a double-blind design. Anaesthesia was maintained with nitrous oxide, enflurane and fentanyl. Patients in the suggestion group were played seaside sounds, interrupted by statements of the importance of touching the ear during a postoperative visit, by means of a prerecorded audiotape and headphones. Tapes containing these suggestions were played from 30 min after the first incision, for a duration of 15 min. Patients in the control group were only played seaside sounds. There were no significant differences between the groups in either the number of patients touching their ears postoperatively or the number and duration of ear touches.