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BACKGROUND AND AIMS: The quadratus lumborum block (QLB) provides regional analgesia of the anterior abdominal wall, theoretically matching the postoperative pain after postbariatric standard full abdominoplasty. We investigated the effectiveness of a QLB as an addition to the current multimodal analgesia regimen in postbariatric patients treated with standard full abdominoplasty. METHODS: Randomized, placebo-controlled, triple blinded study (n = 50). All patients received perioperative paracetamol and intraoperative local anesthetic infiltration. QLB was administered bilaterally before induction of general anesthesia with 2 × 20 mL of either ropivacaine 3.75 mg/mL (n = 25) or placebo (saline 9 mg/mL) (n = 25). Patients received intravenous patient controlled opioid analgesia postoperatively. The primary endpoint was opioid use during the first 24 postoperative hours. Secondary endpoints were acute and chronic postoperative pain, postoperative nausea and vomiting, and other side effects. RESULTS: Patient characteristics were similar between groups. The primary endpoint in morphine equivalent units was similar between groups during the first 24 h with mean (SD) of 26 (25) vs. 33 (33) mg (p = 0.44) in the ropivacaine and placebo group, respectively. The observed effect was smaller, and SD larger than assumed in the sample size estimation. Linear mixed effects modeling indicated a minimal inter-group difference. No differences were found for secondary endpoints. CONCLUSIONS: The QLB did not provide significant additional benefit in terms of reduced opioid requirements or secondary endpoints when administered as part of a multimodal pain regimen to postbariatric patients undergoing standard full abdominoplasty. A minimal difference of little clinical importance the first 12 postoperative hours may have been missed. IMPLICATIONS: Including the QLB in the current multimodal pain regimen cannot be recommended based on these findings. The study does not preclude QLB use in individual cases where the multimodal regimen is inadequate or contraindicated. The effectiveness of the QLB for supraumbilical pain remains undocumented.
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Background and objective Perioperative low-dose ketamine has been useful for postoperative analgesia. In this study we wanted to assess the analgesic effect and possible side-effects of perioperative low-dose S (+) ketamine when added to a regime of non-opioid multimodal pain prophylaxis. Methods Seventy-seven patients scheduled for haemorrhoidectomy were enrolled in this randomized, double-blind, controlled study. They received oral paracetamol 1-2 g, total intravenous anaesthesia, intravenous 8 mg dexamethasone, 30 mg ketorolac and local infiltration with bupivacaine/epinephrine. Patients randomized to S (+) ketamine received an intravenous bolus dose of 0.35 mg kg-1 S (+) ketamine before start of surgery followed by continuous infusion of 5 µg kg-1 min-1 until 2 min after end of surgery. Patients in the placebo group got isotonic saline (bolus and infusion). BISTM monitoring was used. Pain intensity and side-effects were assessed by blinded nursing staff during PACU stay and by phone 1, 7 and 90 days after surgery. Results In patients randomized to S (+) ketamine emergence from anaesthesia was significantly longer (13.1 min vs. 9.3 min; p < 0.001). BIS values were significantly higher during anaesthesia (maximal value during surgery: 62 vs. 57; p = 0.01) and when opening eyes (81 vs. 70, p < 0.001). Pain scores (NRS and VAS) did not differ significantly between groups. Conclusions The addition of perioperative S (+) ketamine for postoperative analgesia after haemorrhoidectomy on top of multimodal non-opioid pain prophylaxis does not seem to be warranted, due to delayed emergence and recovery, more side-effects, altered BIS readings and absence of additive analgesic effect.
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PURPOSE OF REVIEW: We describe the different possible anaesthetic techniques for an emergency caesarean section. To choose the right method of anaesthesia may have major implications for mother, child and all involved personnel. The major controversy is whether one have other or better alternatives or both than general anaesthesia, with a rapid sequence induction technique, when the foetus is compromised. RECENT FINDINGS: Recently published studies indicate that a top-up of a well functioning labour epidural is as fast as general anaesthesia, and that the top-up can be performed during preparation and transport. Spinal anaesthesia, when performed by skilled anaesthetists, is as fast or almost as fast as general anaesthesia with a very low failure rate. Combined spinal/epidural may have advantages, especially in high-risk cardiac patients, but is too time-consuming. General anaesthesia still seems to be the method of choice for most anaesthetists in extremely urgent settings. The major disadvantage with general anaesthesia is the risk of failure and the dramatic consequences of a 'cannot intubate, cannot ventilate' situation. Awareness is another concern, and the incidence varies from 0.26 to 1% in recent literature. SUMMARY: Regional anaesthesia techniques such as a single-shot spinal or a top-up of a well functioning labour epidural analgesia are good alternatives to general anaesthesia in an emergency caesarean setting.
