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Continuous Spinal Anesthesia/Analgesia for Perioperative Management of Morbidly Obese Patients Undergoing Laparotomy for Gastroplastic Surgery
Abstract
The authors determined prospectively the safety of continuous spinal anesthesia combined with general anesthesia and the efficacy of postoperative pain relief with continuous spinal analgesia for morbidly obese patients undergoing vertical banded gastroplasty.
27 patients (13 men, 14 women) with a mean body mass index (BMI) of 50.4 +/- 7.8 and several co-morbidities were studied. All patients were anesthetized with the same anesthetic regimen, which included midazolam, fentanyl, propofol, muscle relaxants, nitrous oxide, isoflurane and intrathecal bupivacaine. Postoperative pain relief was provided for 5 days and all patients received the same regimen, which included intrathecal bupivacaine, fentanyl and intravenous tenoxicam. The intrathecal analgesic regimen was administered continuously through a pump which had the facility of providing bolus doses when requested in predetermined lockout intervals. Intra-operative monitoring included hemodynamic and respiratory parameters. Additional postoperative monitoring included respiratory rate, degree of sedation, sensory level of anesthesia, motor response and intensity of pain.
Intraoperative anesthetic technique was safe and provided satisfactory results in the immediate postoperative period. Furthermore, the postoperative analgesia regimen provided effective analgesia in all patients. The mean doses of fentanyl and bupivacaine infused intrathecally for the first 24 postoperative hours were 14.1 +/- 2.0 microg.h(1) and 0.7 +/- 0.1 mg.h(1) respectively, while the requirements of analgesia decreased progressively with time. The technique provided effective analgesia with low pain scores, which was reflected by ease in mobilizing and performing physical exercises with the physiotherapist. Only minor complications related to anesthesia and analgesia were encountered.
To our knowledge, this technique of anesthesia and postoperative analgesia has not been described before in morbidly obese patients. This regimen merits further controlled trials to establish its place in the perioperative management of morbidly obese patients.
... Seven patients required additional sedation with intermittent bolus of propofol for intraoperative discomfort. Reasons include anxiety (1). bowel loops adherent to the anterior abdominal wall (4) and pre-existing abdominal pain with tight rectus abdominis muscle (2). ...
Continuous Spinal Anaesthesia is a recognized technique for providing anaesthesia
for various surgical procedures. It may be an alternative to general anaesthesia in
high-risk elderly patients requiring emergency laparotomy. The objective was to evaluate
the benefits of continuous spinal anaesthesia in providing effective anaesthesia for
emergency laparotomy, in enhancing recovery after major abdominal surgery and in reducing
length of stay in the intensive care unit in high-risk elderly patients. Prospective
service evaluation was performed at a tertiary care university hospital. High-risk elderly
patients were offered both general anaesthesia and continuous spinal anaesthesia.
An 18-gauge macro catheter was inserted into the intrathecal space through a 16-gauge
Tuohy needle. Sedation was maintained with remifentanil. Prophylactic anti-emetics
were administered. Blood pressure was maintained with an infusion of metaraminol.
Over a 27-month period, 25 high risk elderly patients were offered continuous spinal
anaesthesia and general anaesthesia for emergency laparotomy. Twenty-one patients
opted for continuous spinal anaesthesia. Three patients required conversion to general
anaesthesia. In the remaining 18 patients, continuous spinal anaesthesia provided adequate
anaesthesia for major bowel surgery. Mean length of stay in level 2 care was
1.6 days. 30-day mortality was 14%. None of the patients reported post dural puncture
headache. There were no neurological complications.
Emergency laparotomy carries well-recognised intra and postoperative risks
and in the elderly cohort, these risks are significant and probably life threatening. Continuous
spinal anaesthesia is a well-established technique that may offer some reduction
of both intra and postoperative risks with an improved immediate recovery from
major emergency surgery.
... Only a few studies addressed other analgesic regimens such as i.m. opioids [13,17], wound infiltration with bupivacaine combined with i.v. PCA opioids [10,[18][19][20], and even intrathecal PCA [21]. Fewer studies examined the use of thoracic epidural analgesia using either bolus morphine analgesia [6,17,22] or other opioid combinations supplemented with bupivacaine [6,10] or bupivacaine alone [23] . ...
Background
Insufficient data exist regarding postoperative thoracic epidural analgesia for morbidly obese patients undergoing open bariatric surgery. This study evaluated the effectiveness of morphine loading in a postoperative thoracic epidural analgesic regimen of patient-controlled epidural analgesia (PCEA) with levobupivacaine combined with continuously administered epidural morphine in this patient group.
Methods
In this prospective randomized controlled trial, 48 superobese patients (body mass index of ≥50 kg/m2) undergoing open bariatric surgery were randomly allocated to three groups of 16 patients each. Postoperatively, all groups received a continuous epidural morphine infusion of 0.2 mg/h with 0.1 % levobupivacaine via PCEA. Group A did not receive intraoperative epidural morphine loading, while groups B and C received an intraoperative 1- and 2-mg morphine bolus, respectively. Levobupivacaine consumption via PCEA (primary outcome), pain scores at rest and on cough, the time to return of bowel function and ambulation, and arterial blood gas levels (secondary outcomes) were recorded.
Results
The increase in perioperative morphine administration (groups B and C) led to a significantly prolonged return to normal bowel function and delayed ambulation (P
... In the absence of convincing evidence that the spinal micro-catheter itself was the cause of the cauda equina syndrome, and as the availability of small bore microcatheters increased, CSA continued to be used in clinical practice outside of the USA. CSA has been used in medically complicated patients undergoing cardiac, vascular, [8][9][10][11][12] orthopaedic, 13,14 and general surgery [15][16][17] as well as in patients with respiratory failure. 18 Many authors advocate general anaesthesia with or without epidural analgesia as first choice in fit patients undergoing abdominal procedures. ...
Continuous spinal anaesthesia (CSA) for laparotomy was described more than 100 years ago. Recent literature on CSA suggests that this technique can be used as a sole anaesthetic technique for laparotomy especially in patients with severe cardio-respiratory disease who would otherwise be considered unlikely to tolerate general anaesthesia or where general anaesthesia could result in a prolonged stay in the intensive care unit. This article describes how to use the technique of CSA in high risks patients undergoing laparotomy, potential problems that might be encountered and how they can be treated and prevented.
... No abnormalities of arterial oxygen saturation or vital signs were reported. Drowsiness was the most common adverse event; only one [64]. These patients received post-operative analgesia by intrathecal bolus on request. ...
An increasing number of obese patients are undergoing surgery, particularly bariatric and orthopaedic surgery. The physiological differences between obese and normal-weight subjects may modify not only anaesthetic requirements during surgery but also post-operative analgesic management, raising a number of challenges in a critical period. In this review, we analyse studies of post-operative pain management with opioids in obese subjects. We discuss the genetic factors common to pain and obesity and the factors potentially modifying opioid pharmacokinetics and pharmacodynamics in obese patients, and we analyse the overall efficacy and safety of opioids for pain management during the post-operative period in obese patients. Both modifications to surgical methods and additional analgesic treatments to decrease the requirement for opioids may improve early rehabilitation and quality of care and reduce adverse effects in obese patients.
... The benefits of a 'combined-technique' for normal-weight patients have been reviewed elsewhere, 2 and its utility has been demonstrated for morbidly obese patients undergoing open bariatric procedures. 48 Neuraxial anaesthesia with local anaesthetics, with or without opioids, provides an excellent means of reducing parenteral opioid requirements, especially in obese patients with OSA, who may be sensitive to the respiratory depressant effects of these drugs. There has been some success using 'pumps' for continuous infusion of local anaesthetics intraperitoneally, subfascially and subcutaneously as part of a multimodal approach for postoperative analgesia. ...
Obesity is associated with a number of anaesthetic-related risks. Regional anaesthesia offers many potential advantages for the obese surgical patient. Advantages include a reduction in systemic opioid requirements and their associated side effects, and possible avoidance of general anaesthesia in select circumstances, with a lower rate of complications. Historically, performing regional anaesthesia procedures in the obese has presented challenges due to difficulty in identifying surface landmarks and availability of appropriate equipment. Ultrasound guidance may aid the regional anaesthesia practitioner with direct visualisation of underlying anatomic structures and real-time needle direction. Further research is needed to determine optimal regional anaesthesia techniques, local anaesthetic dosage and perioperative outcomes in obese patients.
... Unfortunately some technical problems arose [27][28][29][30]. However, despite controversy, CSA has been used in complicated patients undergoing cardiac and vascular surgery [4,[31][32][33][34][35], orthopaedic surgery [36,37], general surgery [38][39][40][41] and in patients with respiratory failure [42]. ...
Extended spinal anaesthesia using a spinal micro-catheter was used as a primary method of anaesthesia for elective colorectal cancer surgery in 68 high risk patients over a 14-year period in our institution. The technique was also useful in eight elective and 13 emergency abdominal surgeries. All patients suffered from severe chronic obstructive airway disease requiring multiple inhalers and drugs (ASA III). Thirty nine of these patients also suffered from angina, myocardial infarction, diabetes and other systemic diseases (ASA IV). Surgery included right hemicolectomy, left hemicolectomy, total colectomy, sigmoid colectomy, Hartman's resection, anterior resection of rectum, abdominoperineal resection, cholecystectomy (open and laparoscopic) and obstructed inguinal hernia requiring laparotomy. Spinal anaesthesia was performed under strict aseptic conditions with a 22 gauge spinal needle with a mixture consisting of 2.75ml of 0.5% heavy bupivacaine and 0.25ml of fentanyl (25microg). This was followed by placement of a spinal micro-catheter and the duration of anaesthesia was extended by intermittent injection of 0.5% isobaric bupivacaine. Brief hypotension occurred in 12.4% of patients during the establishment of anaesthetic block height to T6-7 and was duly treated with intravenous administration of fluid and ephedrine hydrochloride. Good anaesthesia resulted in all patients except for brief discomfort in some patients during hemicolectomy surgery possibly due to the dissection and traction on the peritoneum causing irritation to the diaphragm. The use of sedation was avoided. General anaesthesia was administered in one patient and this patient required postoperative ventilation and cardiovascular support in the Intensive Care Unit. The spinal micro-catheter was removed at the end of surgery. Postoperative pain relief was obtained by administering intravenous morphine through a patient controlled analgesia machine in the critical care ward area (High Dependency Unit). There was a low incidence of minor postoperative side effects such as nausea (14.6%), vomiting (7.9%), minor post dural puncture headache (5.6%) and pruritus (5.6%). We conclude that spinal anaesthesia with a micro-catheter may be used as a primary method of anaesthesia for colorectal cancer surgery and other major abdominal surgery in high-risk patients for whom general anaesthesia would be associated with higher morbidity and mortality.
According to the latest estimates of the World Health Organization, more than 1 billion people in the world are overweight. In economically developed countries, the proportion of the population with overweight reaches almost 50 %, of which 30 % are obese. In Russia, on average, 30 % of people of working age are obese and 25 % are overweight. Despite the significant economic costs for the prevention and treatment of obesity, mortality at the age of 20–35 with morbid obesity exceeds the average statistical 12 times, mainly from cardiovascular complications. The guidelines provides principles of perioperative management of patients with obesity.
Increasing numbers of patients with morbid obesity are presenting for surgery, and their acute pain management requires an evidence-based clinical update. The objective of this study was to complete a literature review for acute pain management in morbid obesity and provide an evidence-based clinical update with recommendations. Using standardized search terms, in March 2015, we completed a literature search to determine evidence for different acute pain pharmacologic modalities in morbid obesity. For each modality, the highest level of evidence was ascertained, and recommendations for each pharmacologic modality are presented. Though overall evidence is limited to few well-conducted clinical trials, mostly related to weight loss surgery, multimodal analgesia with a step-wise, severity-based, opioid-sparing approach appears to improve acute pain management in morbid obesity. The perioperative use of nonopioid adjuvants appears to offer further improvements in patient safety and outcomes. Further research into standardization of pain assessments and implementation of acute pain management protocols is required.
Patients undergoing bariatric surgery present many anesthetic challenges. In this chapter, we discuss various aspects of anesthetic management in this patient population. Predictors of difficult mask ventilation and difficult intubation, techniques to optimize preoxygenation, airway equipment, and criteria for extubation are addressed. Intraoperative monitoring, ventilation strategies, patient positioning, and injury prevention are also discussed. Morbid obesity affects the pharmacokinetics and pharmacodynamics of various anesthetic drugs, including induction agents, opioids, and muscle relaxants, requiring dosage adjustment. We introduce a multimodal pain management strategy to improve pain control and reduce side effects. Morbidly obese patients have a higher risk of postoperative respiratory complications, necessitating extra attention to postoperative management and disposition planning from the postoperative anesthesia care unit.
Perioperative management of geriatric patients requires a working knowledge of changes associated with aging and the physiology of surgery and anaesthesia. Using this information, patient can be managed intraoperatively efficient and safe. The choice of appropriate technique and the optimisation of existing intercurrent therapies as well will help to avoid haemodynamic changes caused by spinal anaesthesia.
Regional anesthesia may have potential advantages compared to general anesthesia for select surgical procedures in obese patients. Even when general anesthesia is necessary, the addition of a regional anesthesia technique for postoperative analgesia may decrease requirements for supplemental systemic analgesics and therefore reduce the incidence of opioid-induced side effects. This may be particularly beneficial in obese patients with obstructive sleep apnea (OSA) syndrome. However, obese patients present technical challenges to the anesthesia practitioner due to unfamiliar surface anatomy and difficulty assuming positions optimal for procedural performance. Surface ultrasound is emerging as a useful tool for regional anesthesia in obese patients for pre-procedural scanning to establish the site for needle insertion and target location or for real-time needle guidance.
This chapter reviews the use of regional anesthesia techniques in obese patients. The most extensive experience with regional anesthetic techniques in obese patients is with neuraxial anesthesia. Obese patients require less local anesthetic than their normal counterparts to achieve a similar sensory level. For a lumbar approach for either an epidural or spinal anesthetic, a cooperative patient can be asked to identify the "midpoint of your body". The incidence of complications with epidural anesthesia increases with increasing weight. As with epidural anesthesia, obesity is an important factor influencing spinal anesthesia. Neuraxial anesthesia is often used in combination with general anesthesia during surgery to reduce the amount of inhalational and intravenous agents. All peripheral nerve blocks were performed using a nerve stimulator technique. Overweight and obese patients should not be excluded from undergoing regional anesthesia in the ambulatory setting.
Introduction: Currently, the majority of bariatric operations are performed laparoscopically. Laparoscopic surgery provokes less nociceptive stimulation than similar operations performed with an open incision. Accordingly, post-operative analgesia for acceptable pain control is different for laparoscopic compared to open operations. Although laparoscopy is the preferred technique for bariatric surgery, in some cases (e.g., reoperation, previous abdominal surgery, lack of experience in laparoscopy) an open midline abdominal incision is necessary. MO patients may also need surgery for other conditions occurring more frequently in this population such as endometrial, prostate, or colon cancer. Following open operations, the greater physical insult promotes a higher intensity of post-operative pain and an increased surgical-stress response. More aggressive modalities of post-operative analgesia are usually necessary in these circumstances. All MO patients need to become mobile as soon as possible after any surgery. Post-operative activity can be influenced by the level of pain following surgery. Adequate pain relief allowing the patients to cough, to take deep breaths, and to sit and to walk as early as possible may reduce the incidence of serious complications. On the other hand, the amount of opioids necessary to provide efficient dynamic analgesia (acceptable pain relief with cough and ambulation) can result in opioid-related, dose-dependent side effects, including nausea, vomiting, sedation, prolonged ileus, and, especially, respiratory depression.
La prise en charge opératoire des patients atteints d’obésité est de plus en plus fréquente dans nos blocs opératoires. L’anesthésiste doit tenir compte des spécificités liées à l’obésité et ses répercussions, notamment cardiorespiratoires. Certains risques particuliers pouvant survenir au cours de l’anesthésie générale peuvent être directement en rapport avec l’obésité. Les techniques d’anesthésie et/ou d’analgésie locorégionale, en évitant le recours à l’anesthésie générale, offrent un certain nombre d’avantages dans ce contexte. Cependant, elles nécessitent une connaissance parfaite et présentent également plusieurs points à risque directement en rapport avec l’obésité. L’objectif de cette revue est de discuter les points clés de l’anesthésie locorégionale réalisée pour la prise en charge périopératoire du patient obèse.
Abstract
The number of procedures schedules for obese patients increases regularly. The anesthesiologist has to take into account the obese-related characteristics, first of all the cardiorespiratory ones. Some specific risks that occurred during general anesthesia may be directly in relation with obesity. By avoiding general anesthesia, most of regional anesthesia/analgesia techniques present some advantages in this context. However, skill and experience are key point to avoid some complications. The goal of this review is to discuss specific points of regional anesthesia performed in obese patient.
Morbidly obese patients due to high incidence of obstructive sleep apnea (OSA) are predisposed to opioid induced airway obstruction and thus frontline high ceiling analgesics (opioids) have concerns based on safety in their liberal use. Although surgical techniques over the last two decades have seen a paradigm shift from open to laparoscopic procedures for morbidly obese patients; optimally titrated yet safe analgesic management still remains a challenge. The present review sums up the analgesic options available for management of morbidly obese patients undergoing surgery. We highlight the utility of multimodal approach for analgesia with combinations of agents to decrease opioids requirements. Pre-emptive analgesia may be additionally used to improve the efficacy of postoperative pain relief while allowing further reductions in opioid requirements.
Basically regional anaesthesia offers a lot of advantages compared with general anaesthesia for obese patients, e.g. avoiding airway manipulation and systemic application of opioids. Although anesthesiologists are increasingly faced with obesity, regional anaesthesia poses a challenge because of missing landmarks, increased depth of nerval structures and difficulties in positioning these patients. While obesity is not associated with an increased risk for severe complications in regional anaesthesia, a higher failure rate can be observed because of difficulties in performing the blocks. Ultrasound guidance may be an important aid but it is associated with specific phenomena caused by obesity. Further studies are needed to optimize regional anaesthesia techniques and dosing of local anaesthetics avoiding block failures as well to improve the patients' safety and outcome.
© Georg Thieme Verlag Stuttgart · New York.
In obese patients, concomitant use of clonidine and ketamine might be suitable to reduce the doses and minimize the undesired side effects of anesthetic and analgesic drugs. In this study, we evaluated the perioperative effects of administration of clonidine and ketamine in morbidly obese patients undergoing weight loss surgery at a university hospital in Rome, Italy.
A total of 50 morbidly obese patients undergoing open biliopancreatic diversion for weight loss surgery were enrolled. The patients were randomly allocated into a study group (n = 23) receiving a slow infusion of ketamine-clonidine before anesthesia induction and a control group (n = 27) who received standard anesthesia. The hemodynamic profile, intraoperative end-tidal sevoflurane and opioid consumption, tracheal extubation time, Aldrete score, postoperative pain assessment by visual analog scale, and analgesic requirements were recorded.
The patients in the study group required less end-tidal sevoflurane, lower total doses of fentanyl (3.8 +/- 0.3 gamma/kg actual body weight versus 5.0 +/- 0.2 gamma/kg actual body weight, respectively; P <.05) and had a shorter time to extubation (15.1 +/- 5 min versus 28.2 +/- 6 min, P <.05). The Aldrete score was significantly better in the postanesthesia care unit in the study group. The study group consumed less tramadol than did the control group (138 +/- 57 mg versus 252 +/- 78 mg, P <.05) and had a lower visual analog scale score postoperatively during the first 6 hours.
The preoperative administration of low doses of ketamine and clonidine at induction appears to provide early extubation and diminished postoperative analgesic requirements in morbidly obese patients undergoing open bariatric surgery.
The amount of excess weight which must be lost in order to cure or to improve disorders associated with obesity remains unknown. This study was designed to compare super obese and morbidly obese patients in terms of weight reduction following VBG and to investigate the effects of postoperative weight changes to preexisting co-morbidities.
125 patients underwent VBG. Group A consisted of 80 morbidly obese patients (64%) and group B consisted of 45 super obese patients (36%). Preoperative examination was planned to identify and determine the severity of any disorders associated with obesity, that the patients may have had. Following VBG, all patients were followed-up at regular time periods, for at least 2 and up to 4 years. The progress of preexisting co-morbidities was evaluated and carefully recorded.
Among the 80 patients of Group A, there were 240 total co-morbidities (3 per patient), and in group B there were 196 co-morbidities (4.35 per patient) preoperatively. Dyspnea during fatigue and arthritis were found at statistically higher incidence in the super obese category. At the end of the second postoperative year, greater weight loss in terms of number kilograms was seen in patients in group B, but these patients did not reach a BMI lower than 35, while patients in group A had mean BMI below 30. In group A, 66% of the co-morbidities completely resolved, 19% significantly diminished and 15% remain unchanged. In group B, the respective percentages were 53%, 27.5% and 19.5%. However, after weight reduction by VBG a significant number of co-morbidities remain in the super obese patients (92 or 2.044 per/patient), and this is believed to be due to the greater remaining excess weight.
Reduction of body weight by VBG is associated with resolution or improvement of a significant number of the obesity-associated disorders. However, super obese patients remain obese after surgery, and this results in two-fold higher remaining morbidity.
To identify the factors predicting morbidity and mortality in patients undergoing bariatric surgery for morbid obesity in our hospital.
Sixty bariatric surgery patients whose body mass indexes (BMI) exceeded 35 kg.m-2 were studied retrospectively. We examined the incidence of associated disease, the perioperative period, type of surgery, anesthetic technique, postoperative analgesia and the incidence of major complications.
Fifty-one women and 9 men (mean age 43.33 +/- 10.25 years, mean BMI 46.41 +/- 6.04 kg/m-2) were studied. The incidences of high blood pressure (55%) and obstructive sleep apnea syndrome (40%) were high. Nine patients (15%) were physical status (ASA) I, 18 (30%) were ASA II, 27 (45%) were ASA III and 6 (10%) were ASA IV. Major complications developed in 3 cases (5%) in the first 24 h and in 8 (13.33%) in the first 7 days. The mortality rate was 0% among ASA I and II patients, 3.7% (1 death) among ASA III patients, and 33.33% (2 deaths) among ASA IV patients. All who died were men. The only factor that predicted morbidity in the first week after surgery was BMI. Both morbidity in the first 24 h and mortality were associated with greater underlying disease in our patients undergoing bariatric surgery.
Major complications of bariatric surgery occurred in 18.3% of our patients and mortality was 5%. Physical status was a prognostic factor for both early (24 h) postoperative morbidity and mortality in our morbidly obese patients, whereas BMI was related to morbidity during the first week after surgery.
ccording to the National Institutes of Health, obesity is a major health problem with clearly established health implications, including an in- creased risk for coronary artery disease, hypertension, dyslipidemia, diabetes mellitus, gallbladder disease, degenerative joint disease, obstructive sleep apnea, and socioeconomic and psychosocial impairment (1). The risk of developing one or more of these obesity- related conditions is based on body mass index (BMI), with 25-30 kg/m2 being low risk and 40 kg/m2 being very high risk (2). The prevalence of obesity in the 18- to 29-yr-old group increased from 12% in 1991 to 18.9% in 1999 (3). Bariatric surgery encompasses a variety of surgical weight loss procedures used to treat morbid obesity. Obesity is clinically expressed in terms of BMI or Quetelet's index (4), which is derived by dividing weight by the square of height to estimate the degree of obesity. Thus, BMI body weight (kg)/height2 (m2). Morbid obesity is a BMI more than 35 kg/m2, and super morbid obesity is BMI more than 55 kg/m2. The indications for surgical treatment of severe obe- sity, as outlined in the 1991 National Institutes of Health Consensus Development Conference Panel, in- clude an absolute BMI more than 40 kg/m2 or BMI more than 35 kg/m2 in combination with life- threatening cardiopulmonary problems or severe dia- betes mellitus (1). Patients seeking surgical weight loss must have proven attempts at medically supervised weight loss. Documentation of loss of 5% to 10% excess body weight or weight gain after at least 6 mo of diet modification, exercise, and medical therapy or nonim- provement in comorbid conditions during this period indicates failure. Studies have shown that weight loss of 5%-10% of initial body weight improves glucose intolerance and Type II diabetes, hypertension, and dyslipidemia (5-7). The average expenditure is approximately $7000 per year per patient on weight loss programs and equip- ment. Unfortunately, long-term weight loss is the ex- ception, and most patients regain weight, sometimes more than they initially lost.
Technical improvements of laparoscopic bariatric procedures are important to minimize operative time and increase safety and simplicity.
A modification is described of the "classic" Mason-MacLean vertical banded gastroplasty (VBG), performed by laparoscopy, with wedge resection of the gastric fundus, thus avoiding the time-consuming and technically difficult gastro-gastrostomy window.
The technique used was simple and safe, and required less operative time than the "classic" method, without serious intra- or postoperative complications. Weight loss in 18 patients who underwent the modified laparoscopic VBG and were followed-up for 1 year was equal to that achieved in patients who underwent open VBG at our Institution. Gastro-gastric fistula was not observed in upper GI barium studies performed 12 months postoperatively.
The modified technique is preferable when lap-VBG is indicated for surgical treatment of morbidly obese patients.
Obesity causes structural changes to the heart that may influence its function. Furthermore, morbid obesity is associated with an acquired prolongation of the QTc interval that may lead to potentially hazardous arrhythmias. The present study investigated the effect of body weight loss following vertical banded gastroplasty (VBG) on the QTc interval.
17 morbidly obese patients, scheduled for elective VBG, were studied before the operation and 8-10 months postoperatively, when each patient had achieved a weight loss of >/= 25% of the preoperative body weight.
15 patients achieved significant body weight loss of >/= 25% within the first 8-10 postoperative months (P <0.001). This weight loss, corresponding to an excess weight loss of 48.7% and a mean body mass index (BMI) reduction from 49.7 kg/m2 to 36.6 kg/m2, was followed by significant shortening of the QTc interval from 428 msec to 393 msec (P <0.001).
The significant postoperative weight loss following VBG was accompanied by shortening of the QTc interval. This effect is expected to reduce the incidence of fatal conditions associated with the long QT syndrome, such as malignant ventricular arrhythmias and sudden death, and therefore improve morbidity and mortality.
Early and uneventful postoperative recovery of morbidly obese patients remains a challenge for anesthesiologists. BIS monitoring is useful in providing fast recovery.
We describe the anesthetic management of 23 morbidly obese patients who underwent elective open Roux-en-Y gastric bypass (RYGBP) for morbid obesity. Thoracic epidural analgesia combined with light general anesthesia with propofol and nitrous oxide adjusted to keep the bispectral index (BIS) around 60 was performed. Intraoperative hemodynamic stability, early and intermediate recovery and patient satisfaction were assessed.
The cardiovascular variables were fairly stable during surgery. Times to spontaneous respiration, response to orders, tube removal and orientation were 4 +/- 3, 6 +/- 2, 8 +/-3, and 13 +/- 7 respectively. Times until the patients were able to sit unassisted, stand unassisted and walk freely without assistance were 319 +/- 25, 803 +/- 78, 1070 +/- 75 respectively (values expressed as min, mean +/- se).
Propofol-nitrous oxide anesthesia adjusted to keep BIS around 60, combined with thoracic epidural analgesia, seems to be effective in providing predictable and uneventful recovery to patients submitted to elective RYGBP.
To develop evidence-based recommendations that optimize the safety and efficacy of perioperative anesthetic care and pain management in weight loss surgery (WLS) patients.
This Task Group examined the scientific literature on anesthetic perioperative care and pain management published in MEDLINE from January 1994 to March 2004. We also reviewed additional data from other sources (e.g., book chapters). The search yielded 195 abstracts, of which 35 references were reviewed in detail. Task Group consensus was used to provide recommendations when evidence in the literature was insufficient.
We developed anesthesia practice and patient safety advisory recommendations for preoperative evaluation, intraoperative management, and postoperative care and pain management of WLS patients. We also provided suggestions related to medical error reduction and systems improvements, credentialing, and future research.
Obesity-related comorbidities including obstructive sleep apnea place WLS patients at increased risk for complications perioperatively. Regarding perioperative safety and outcomes, conclusive evidence beyond the accepted standard of care in the reviewed literature is limited. Few reports specifically address the perioperative needs of severely obese patients. In this advisory, we synthesize current knowledge and make best practice recommendations for perioperative care and pain management in WLS patients. These recommendations require periodic review as further medical knowledge and evidence evolve.
Intragastric balloon placement in association with diet for weight reduction is steadily gaining popularity. However, long-term follow-up studies on the effect of this method in maintaining weight loss are lacking. This study evaluated the long-term outcome following balloon removal in morbidly obese patients who had selected this method for weight loss.
140 morbidly obese patients who refused bariatric surgery because of fear of complications and mortality, underwent intragastric balloon placement and were followed over a 6- to 30-month period (mean 18.3 months) after balloon extraction. The 34 males and 106 females, with median age 38 years (range 16-62), median weight 122 kg (range 85-203), median BMI 42.3 kg/m(2) (range 35-61.3) and median excess weight (EW) 59 kg (range 29-132), received a Bioenterics Intragastric Balloon (BIB). Excess weight loss (EWL) > or =25% when the BIB was removed was considered a success. Weight fluctuations and any further interventional therapy requested by the patients after balloon removal were recorded.
100 patients (71.4%) lost > or =25% of their EW on balloon extraction and were categorized as successes, while 40 patients (28.6%) did not achieve that weight loss and were categorized as failures of the method. During the follow-up period, 44 of the originally successful patients (31.4%) regained weight and were categorized as recurrences, while the remaining 56 patients (40%) maintained their EWL of > or =25% and were considered long-term successes. During follow-up, 45 patients (32.1%) requested and underwent bariatric surgery for their morbid obesity (21 Adjustable Gastric Band, 11 Laparoscopic Sleeve Gastrectomy, 13 Laparoscopic Gastric Bypass). Of these, 13 (32.5%) were from the group of 40 patients categorized as failures on BIB removal, 28 (63.6%) were from the group of 44 patients whose obesity recurred, and 4 (7.1%) were from the 56 patents who although they maintained successful weight loss requested further weight reduction.
The BIB served as a first step and a smooth introduction to bariatric surgery for morbidly obese patients who initially refused surgical intervention. The incidence of surgical intervention was double in patients who initially experienced the benefits of weight loss and then had obesity recurrence, compared with patients in whom the method failed. Indeed, a significant number of patients were assisted in their efforts to lose and maintain an acceptable weight loss over a 6- to 30-month follow-up period.
Development of new drugs and special techniques, as well as changes in health care organization have markedly influenced the use of spinal block and its indications. The present review overviews recent developments in local anesthetic drugs, side effects and special techniques for intrathecal anesthesia.
Severe complications after spinal anesthesia are acceptably rare. The cardiovascular effects associated with sympathetic block are more frequent but may successfully be treated with volume expansion and administration of vasoactive drugs while the multimodal approach to prevention of such side effects can also reduce the incidence. Based on recent magnetic resonance imaging studies the volume of cerebrospinal fluid at the lumbosacral level is the main determinant of the effects produced by intrathecal injection of local anesthetic solutions. Unfortunately, it is not possible to estimate the volume of cerebrospinal fluid at the lumbosacral region in clinical practice, but it is clear that the total dose of local anesthetic injected into the subarachnoid space is the primary determinant of both therapeutic and unwanted effects of spinal anesthesia. There is overwhelming evidence of the potential risk for neurological dysfunction associated with spinal lidocaine. This evidence is even more relevant in outpatients, in whom lidocaine is primarily indicated. On the other hand, several studies have demonstrated the efficacy and safety of using small doses of long-acting agents, such as bupivacaine or ropivacaine, to produce a short spinal block. The addition of small doses of opioids further helps to minimize the dose of local anesthetic solution required, without affecting the recovery profile from spinal block. The extensive use of pencil-point designs for spinal needles, and the availability of needles of very small size have allowed a significant reduction in the incidence of postdural puncture headache.
The changes in health care organization observed during the past few years have forced us to change the indications for and clinical uses of intrathecal anesthesia techniques in accordance with the changing needs of surgery. The development of new drugs and special techniques for spinal anesthesia will further improve the clinical use of this old but trusted technique.
The potential advantages of regional anesthesia include minimal airway intervention, less cardiopulmonary depression, excellent postoperative analgesia, less postoperative nausea and vomiting, and shorter recovery room and hospital stays. These concerns are particularly important for the obese surgical patient. This review discusses the application of regional anesthetic techniques in obesity. Further clinical studies are needed to fill the knowledge gap about regional anesthesia and outcome in obese and morbidly obese patients.
In a randomised double-blind study, 45 patients, scheduled for major orthopaedic surgery under continuous spinal anaesthesia, received for relief of postoperative pain patient-controlled analgesia with either sufentanil 2 micrograms.ml-1, bupivacaine 0.0625% or a mixture of both by the intrathecal route. The mean (SD) consumption of sufentanil and bupivacaine during the first 12 h was 65.5 (27.1) micrograms and 18.2 (4.8) mg, respectively. Combining bupivacaine and sufentanil reduced the consumption of both to approximately 40% as compared to the administration of each component separately. Pain relief was very good in all subjects, although this was obtained faster with the combined regimen. Moreover, more patients in this group remained completely painfree during the entire observation period (p < 0.05). The incidence of hypotension was low and not significantly different when the plain bupivacaine group was compared with the two other groups. Nausea and vomiting were significantly more frequently observed in both groups treated with sufentanil. Motor block was not a major problem and was noticed during the first 2 h of treatment only. Tachyphylaxis did not occur. It was concluded that the groups receiving plain bupivacaine and sufentanil alone experienced pain relief of good quality. The use of a mixture, however, accelerated the onset of analgesia, improved the analgesic quality and reduced the doses for both components by 60% but at the expense of a higher incidence of nausea and vomiting.
Objectives: There are several advantages of continuous spinal anaesthesia via micro-catheter in high risk patients. Since the development of these catheters a few authors have reported on cauda equina syndromes caused by repeated injections or continuous infusion of local anaesthetics (LA) (1), which could expose the cauda equina to concentration of LA that may be neurotoxic (1). The dextrose added to comercialy formulated LA and the time of exposure may also contribute to neurotoxic effects. This study evaluated the neurotoxic effect of various concentrations of lidocaine, bupivacaine and dextrose on the reversibility of nerve conduction block in isolated bovine caudal nerves in vitro. Methods: The reversibility of conduction blockade was studied in isolated cauda nerves from fresh bovine cadavers (n=10, respectively). The nerves were first exposed for 30min to lidocaine 5% or bupivacaine 0.5% (isobaric or hyperbaric or 7.5% dextrose) or diluted solutions containing LA down to 0.5% or 0.05%, respectivley. After exposure the nerves were washed in artificial cerebrospinal fluid (ACSF) for up to 4h. Every hour the peak amplitudes of compound action potential (CAP) from the large myelinated axons were measured using supramaximal stimulation (0.2 ms, 5-10 m A). Concentrations of LA lower than the ones that produce irreversible block after 30min were continued for 60 and 90 min exposures. Nerves exposed only to ACSF served as controls. Results: The CAPs after LA exposure were normalized by their initial values and divided into three groups: 75% CAP was considered to be the threshold for "recovered", 75-25% for "injured" and below 25% for "dead" nerves, all from measurements made after 3-4h wash in ACSF. concentration-dependent data (in %) Lidocaine recovered injured dead Bupivacaine recovered injured dead 2.5% iso (1:1) 56 44 0 2.5% iso (1:1) 90 10 0 3.3% iso (2:1) 62 26 12 3.3% iso (2:1) 90 10 0 5% iso (pure) 11 22 69 5% iso (pure) 86 14 0 2.5% hyper (1:1) 78 12 10 2.5% hyper (1:1) 87 13 0 3.3% hyper (2:1) 27 45 28 3.3% hyper (2:1) 85 15 0 5% hyper (pure) 10 0 90 5% hyper (pure) 52 23 25 time-dependent data (in %) Lidocain isobar recovery injured dead Bupivacain recovery injured dead 0.83% iso 60 min 66 17 17 0.083% iso 60 min 100 0 0 0.83% iso 90 min 56 22 22 0.083% iso 90 min 83 17 0 1.66% iso 60 min 32 33 35 0.166% iso 60 min 68 32 0 1.66% iso 90 min 16 0 84 0.166% iso 90 min 59 41 0 0.83% hyper 30 min 100 0 0 0.083% hyper 30 min 100 0 P 0.83% hyper 60 min 49 51 0 0.083% hyper 60 min 100 0 0 0.83% hyper 90 min 0 100 0 0.083% hyper 90 min 68 32 0 1.66% hyper 30 min 85 0 15 0.166% hyper 30 min 100 0 0 1.66% hyper 60 min 20 80 0 0.166% hyper 60 min 81 19 0 1.66% hyper 90 min 0 0 100 0.166% hyper 90 min 53 47 0 Discussion: These data indicate that cauda equina syndrome occuring after spinal anesthesia could be due to the neurotoxic effect of high concentration of LA. Lidocaine is more toxic than equipotent bupivacaine, and in the hypertonic solution toxicity is greater. Solutions of more than 2,5% hyperbaric lidocaine or 5% isobaric lidocaine for 30min cause an irreversible block in isolated mammalien cauda nerves.
SummaryA randomised, double-blind study of patients after upper abdominal surgery was undertaken to assess the analgesic efficacy of ketorolac tromethamine, a new, parenteral non-steroidal anti-inflammatory agent. Postoperatively, patients received a 24-hour intramuscular infusion of either saline (n = 20), ketorolac 1.5 mg/hour (n = 21) or ketorolac 3.0 mg/hour (n = 20). Cumulative morphine requirements were measured using a patient-controlled analgesia system which delivered intravenous increments of morphine on demand. Pain was assessed by visual analogue scores. Arterial blood gas analyses were performed pre-operatively and on the first postoperative day.Patients who received low and high dose ketorolac infusions required less morphine than the control group (p < 0.05 and p = 0.06, respectively). This was associated with significantly lower pain scores. Patients who received the higher ketorolac dose had significantly less postoperative increase in arterial carbon dioxide tensions than controls. This study suggests that ketorolac tromethamine is a useful analgesic drug with significant morphine sparing properties.
Small diameter intrathecal catheters potentially combine the certainty of intrathecal injection and the advantage of repeatability, without the risk of a high incidence of headache after dural puncture. We report problems placing such catheters.
This retrospective study compared continuous spinal anaesthesia with continuous epidural anaesthesia for lower limb orthopaedic surgery in the elderly. The anaesthetic records of 457 patients who received continuous spinal anaesthesia and 274 who received continuous epidural anaesthesia over a 5-year period were analysed. The patients who had continuous spinal anaesthesia were at a higher anaesthetic risk (ASA 3-4, 76% as compared with 37%, p less than 0.001), but the incidence of failures was significantly lower (1.7%, as compared with 9%, p less than 0.001) and fewer patients showed a decrease in mean arterial pressure of more than 30% (44%, as compared with 65%, p less than 0.001) and (or) received vasopressors (65%, as compared with 77%, p less than 0.01). Our data show continuous spinal anaesthesia to be more reliable and to provide better cardiovascular stability.
Although obese patients represent a high risk group and reports document the occurrence of sudden unexplained deaths in the early postoperative period, no data exist to delineate the existence, extent or duration of hypoxemia in obese subjects. Twenty adults undergoing jejunoileal bypass for morbid exogenous obesity, with a mean weight of 144.0 +/- 24.7 kg and a mean age of 34.1 +/- 8.3 years, were studied. While breathing room air, arterial blood was collected from each patient, placed in ice and analyzed within ten minutes. A preoperative sample was taken; then samples were analyzed two hours postoperatively and on postoperative days one through five. Preoperatively in the obese patients there was a significant reduction in arterial oxygen tension, mean 75.1 +/- 11.1 mm Hg, as against 92.4 +/- 4.0 mm Hg in control patients matched for age. There was also a difference in the slope of the regression equation of PaO(2) vs. age; the regression coefficient being significantly greater in the obese group (0.9 vs. 0.46). Postoperatively there was a further fall in PaO(2). Decrease in mean PaO(2) in the obese group in mm Hg averaged -9.2 two hours postoperatively (p < 0.001), -15.0 on day one (p < 0.001), -15.5 on day two (p < 0.001), -11.7 on day three (p < 0.001) and -5.1 on day four (p < 0.01). PaCO(2) was not significantly different from the preoperative control. Base excess was elevated on days two, three and four; 3.1 mEq/ L(p. < .001), 3.6 mEq/L(p < .001) and 1.9 mEq/L(p <.05) respectively. Our findings indicate that in obese patients: 1) Preoperatively the fall in PaO(2) with increasing age is greater than in control subjects; 2) Starting with a low basal PaO(2) during postoperative days one through four, the fall in CaO(2) often reaches dangerous levels; and 3) Elevation of blood buffer on days two, three and four can further depress respiration at a time when the PaO(2) has been shown to be at its lowest levels. This hypoventilation due to metabolic alkalosis can further accentuate the already existent hypoxemia. Because of these findings, we suggest careful monitoring of arterial blood gases in obese patients and the administration of oxygen and appropriate electrolyte solutions postoperatively to reduce the increased morbidity and mortality.
Seventy morbidly obese patients presented for upper abdominal surgery; 17% had pre-existing cardiovascular disease and 23% pre-existing respiratory disease. Twenty-eight patients received general anaesthesia, plus narcotic analgesia postoperatively, and 42 general anaesthesia plus thoracic epidural analgesia intra- and postoperatively. Aspects of anaesthetic management are discussed and compared with previous similar reports. Doses of local anaesthetic for induction of epidural analgesia were less than those for the non-obese but doses of local anaesthetic for maintenance of epidural analgesia were similar to those in non-obese patients. Patients who had thoracic epidural analgesia required less volatile anaesthesia than the group who had general anaesthesia and narcotic analgesics. Postoperative respiratory complications were more common in patients with pre-existing cardiovascular and respiratory disease, and occurred less frequently in patients who had thoracic epidural analgesia.
Two groups of morbidly obese patients undergoing a gastric stapling procedure were compared. Patients in group I received 5 mg of morphine through a lumbar epidural catheter immediately after the surgical procedure while group II patients were treated conventionally with parenterally administered morphine. In group I less narcotics were needed and patients were able to walk earlier than in group II. Length of hospital stay, time to removal of the nasogastric tube and postoperative pulmonary function were not significantly different between groups. Two patients in group I and one patient in group II had generalized pruritus, and in one study patient bradypnea developed in association with the epidural administration of morphine. It is concluded that morbidly obese patients can benefit from epidurally administered morphine and that this form of therapy has a role in the management of these patients.
This double-blind, placebo-controlled study investigated the efficacy of intermittent doses of intrathecal fentanyl in 30
patients undergoing thoracotomy. They were allocated randomly to three groups, two of which had microspinal catheters inserted
into the lumbar subarachnoid space at the end of surgery; the third group acted as a control. Intrathecal fentanyl or 0.9%
saline was administered through the catheters and all patients received morphine using a patient-controlled analgesia (PCA)
system. Pain scores, morphine consumption and peak expiratory flow rates (PEFR) were recorded on an hourly basis. Intrathecal
fentanyl resulted in a faster onset of analgesia (mean visual analogue scale (VAS) score at 1 h = 0.9 compared with 6.3 (95%
confidence intervals for the difference -6.8, -4.0) for the other groups; P < 0.001) and significantly lower pain scores at
rest, on cough and on movement. PEFR values were consistently higher in the intrathecal fentanyl group. There were no cases
of early or delayed respiratory depression.
A prospective study was undertaken in an elderly population undergoing orthopedic surgery to specifically study the feasibility of continuous spinal anesthesia (CSA). In a university hospital, 14 residents and 5 junior staff, using an 18-gauge needle and a 20-gauge catheter, performed 76 and 24 consecutive CSAs, respectively. There was an overall failure rate of 6%, all occurring in the residents' group. The causes affecting the success of CSA were inability to identify the subarachnoid space in 5/6 cases (all lumbar punctures were performed using the midline approach) and, in one case, inability to thread the catheter. The six failed CSAs were ultimately performed successfully by one of the senior authors. All surgeries were successfully performed with CSA, without requiring general anesthesia or intravenous narcotic supplementation. Anesthesia was initiated with isobaric bupivacaine in 94/100 cases. In 18% of patients, inadequate anesthesia prompted modifications of the local anesthetic solutions (i.e., type, baricity, total dosage) before surgery. One case of minor neurologic complication was observed, but no postspinal headache occurred. In conclusion, our findings led us to pursue CSA with large-bore equipment in an elderly population; furthermore, we believe that teaching the earlier use of alternative approaches other than the midline approach could further reduce our failure rate.
Continuation of intrathecal anesthesia into the postoperative period has been limited by important safety concerns. Principal among these has been the assumption that extended intrathecal therapy leads to spinal (epidural and intrathecal) space infections. To address the role of extended intrathecal catheter therapy as a cause of infections, we cultured all intrathecal catheters used to provide postoperative analgesia.
All intrathecal catheters were inserted in the operating room using sterile technique. The catheters were used either for the duration of the patients stay in the intensive care unit or until they were no longer judged to provide a therapeutic advantage. They were removed without skin preparation. The distal 2-3 cm of the catheters was cultured using semiquantitative culture methods. Results were divided into four groups: group 1, negative culture results; group 2, ten or fewer colonies of growth; group 3, more than 10 colonies on initial plates and/or growth from broth cultures; and group 4, any bacterial growth, along with evidence of local or central nervous system infections.
Cultures were obtained from 139 patients with a mean indwelling catheter time of 66.1 h. Group 1 (102 patients) had a mean indwelling duration of 55 h. Group 2 (26 patients) and group 3 (11 patients) had significantly longer indwelling duration (83.2 h P = .0023, 129.6 h P = < .0001, respectively) than group 1. Cultures of cerebrospinal fluid obtained simultaneously with catheter cultures in 9 cases (5 in group 2 and 4 in group 3) showed no growth. No patient had evidence of local or central nervous system infection. Difficulty of catheter placement (number of attempts made and the number of levels explored), antibiotic administration, the composition of the postoperative infusions and the number of catheter breaks in the postoperative period were similar in each group. With the exception of two catheters in group 3, (cultured at 49 and 54 h), significant bacterial growth (more than ten colonies) was observed only after more than 96 h of indwelling duration.
Application of semiquantitative culture methods assisted in explaining the results seen in group 2 as secondary to contamination of the catheter that occurred on removal. Higher numbers of bacteria (group 3) may define a population at increased risk for infectious complications. The results of this study do not absolutely resolve the issue of infectious risk associated with postoperative intrathecal catheter use, nor do they define a safe period beyond which the risk of continued catheter use would be unacceptable. However, it appears that limited periods of use (96 h or less) is not associated with either frequent local or spinal infections. Semiquantitative culture methods may help identify individuals (with catheter cultures yielding more than ten colonies) at increased risk for infectious complications and in need of closer observation.
We hypothesized that intrathecal fentanyl infusion would provide excellent analgesia, require lower doses than necessary for the epidural or intravenous route of administration, and reduce the incidence and/or severity of side effects. Accordingly, we studied 12 patients during 48 h after thoracotomy (three pneumonectomies, six lobectomies, and three multiple resections of metastases or pleural surgery). The mean dose of fentanyl infused intrathecally was 0.81 +/- 0.26 microgram.kg-1 x h-1, and plasma fentanyl concentrations ranged between 0.49 +/- 0.19 and 0.72 +/- 0.34 ng/ml. Four patients needed a supplementary bolus of intrathecal fentanyl. Pain scores decreased below 30/100 within 1 h when measured at rest but required 24 h to decrease to the same level during coughing. Pulmonary function tests returned to approximately 50% of preoperative values within 1 h of fentanyl infusion. Mean respiratory rates averaged 19 +/- 4, and no episode of apnea was detected. Pruritus, nausea, and headache occurred, respectively, in four, one, and zero patients. Excessive pressure in the infusion system occurred frequently, limiting fentanyl infusion in two patients. All catheters were removed intact; however, one broke outside of the patient's back. This study demonstrates that intrathecal fentanyl infusion can safely provide rapid and intense analgesia but that current 32-gauge intrathecal catheters are not well suited for prolonged postoperative use.
We compared the hemodynamic stability after spinal anesthesia with two different dosing regimens in the elderly. Fifty patients, all older than 60 yr and scheduled for elective knee or hip surgery were assigned to two groups. After administration of 10 mL/kg of lactated Ringer's solution (RL) intravenously (i.v.) in the first group, we performed a continuous spinal anesthesia (CSA) by means of a 28-gauge catheter through which repetitive injections of 2.5-5 mg of plain bupivacaine 0.5% were given. In the other group, a single-dose spinal anesthesia (SS) with 20 mg of the same local anesthetic (LA) was carried out. Noninvasive mean arterial pressure (MAP), heart rate, and levels of analgesia were measured. To maintain MAP within 25% of initial value, the patients received additional i.v. fluids (RL) as first measure. When MAP could not be maintained despite hydration, incremental doses of ephedrine were given i.v. Six patients in the CSA group and 17 in the SS group developed a level of anesthesia higher than T6 (P < 0.01). In the SS group more fluid was needed (792 vs 388 ml) than in the CSA group (P < 0.01). Moreover, more patients of the SS group (11 vs 4) required ephedrine (P < 0.05). We conclude that CSA produces reliable and predictable analgesia for lower limb surgery with less need for correction of hemodynamic changes compared to SS.
Ketorolac is a nonsteroidal antiinflammatory agent with opioid-sparing properties. The effect of ketorolac on postoperative opioid analgesic requirement and surgical outcome was evaluated in 198 women after abdominal hysterectomy procedures using a double-blind protocol design.
Patients were randomly assigned to receive either 60 mg intravenous (2 ml) ketorolac, followed by 30 mg intravenously (in saline 20 ml) over 30 min every 6 h, or 2 ml intravenous saline, followed by saline 20 ml intravenously over 30 min every 6 h, for up to 72 h. The postoperative opioid analgesic requirement was assessed using a patient-controlled analgesia (PCA) device to self administer either morphine or meperidine. The authors also evaluated pain, sedation (or drowsiness), fatigue, quality of sleep, and postoperative side effects at 2-8-h intervals for up to 72 h after surgery.
Ketorolac decreased the PCA opioid usage on the night of operation and during the first postoperative day. Ketorolac also improved the quality of sleep during the first night after surgery. Although ketorolac- (vs. saline-) treated patients had a significantly shorter time to passage of bowel gas (50 +/- 24 h vs. 61 +/- 25 h), there were no clinically significant differences in the times to oral intake, unassisted ambulation, or hospital discharge. There were also no differences in the overall incidence of side effects in the ketorolac- (vs. saline-) treated patients. However, the use of ketorolac with opioid PCA was associated with a reduced need for antiemetic therapy on the postsurgical ward.
The authors conclude that the opioid-sparing effects of ketorolac contributed few clinically significant advantages after abdominal hysterectomy procedures.
Nonsteroidal antiinflammatory drugs (NSAIDs) decrease the postoperative requirements for opioid analgesic medication. To determine whether NSAIDs potentiate the respiratory effects of opioids, we studied the effects of ketoprofen (K), an NSAID, on respiratory depression induced by morphine (M) in volunteers. After ethics committee approval, 12 healthy male volunteers received infusions of K (1.5 mg/kg), M (0.1 mg/ kg), and KM (1.5 mg/kg + 0.1 mg/kg) in a double-blind, randomized, three-treatment, three-period cross-over trial. During the three sessions, CO2 rebreathing challenges for ventilatory and occlusion pressure responses to CO2 were performed immediately before and 10, 70, 130, 190, and 250 min after drug infusion over 10 min. Venous blood samples for plasma drug concentrations were withdrawn at the same times. Comparisons were made on slopes of ventilatory and occlusion pressure responses to CO2. Venous blood samples confirmed that morphine plasma concentrations were similar when subjects had received morphine alone and when they had received the combination of drugs. Morphine alone induced a respiratory depression with a decrease in both ventilatory and occlusion pressure responses to CO2. Ketoprofen alone did not produce any respiratory effects. The combination of drugs induced a decrease in ventilatory responses to CO2, but intergroup comparisons showed that this was significantly less marked than the decrease induced by morphine alone. In conclusion, for similar morphine plasma concentrations, respiratory depression was less marked with the combination of drugs than with morphine alone. Therefore, ketoprofen may reduce the respiratory depression induced by morphine.
Spinally and epidurally administered morphine is frequently associated with pruritus. Isolated case reports indicate that ondansetron may be effective in this context. This study aims to investigate the effectiveness of ondansetron to treat this side effect.
In a prospective, randomized, double-blind, placebo-controlled study, 100 patients with pruritus (> 4 on a visual analog scale, on which 0 represents no pruritus and 10 represents worst pruritus imaginable) after spinal or epidural administration of morphine, received either 8 mg ondansetron intravenously (ondansetron group) in 100 ml NaCl 0.9% or vehicle (placebo group). A decrease of more than 4 points on the visual analog scale 60 min after treatment was considered a success. Changes in levels of pain and sedation, hemodynamic values, and other side effects were checked regularly. The presence or absence of pruritus was assessed for the last time 24 h later.
The two groups were similar for demographic characteristics, the route of administration of morphine, and severity of pruritus at the beginning of the study. The ondansetron group showed a success rate of 70% versus 30% for the placebo group (P > 0.05). Among the successfully treated patients, three (9%) in the ondansetron group and six (40%) in the placebo group reported the recurrence of pruritus (P < 0.05). Among the successfully treated patients, none complained of residual pruritus 24 h later. No changes in pain or sedation levels were noted. Hemodynamic values remained stable, hemoglobin oxygen saturation did not decrease, and no other side effects were observed.
The administration of 8 mg ondansetron intravenously is an effective treatment for spinally or epidurally administered morphine-induced pruritus. In this clinical condition the treatment is safe and well tolerated.
In this prospective randomised study, pruritus and pain were evaluated in patients undergoing abdominal surgery during which epidural fentanyl was administered. All patients had an epidural catheter inserted at the time of surgery. Epidural fentanyl 100 micrograms was administered intra-operatively and infused at a concentration of 2 micrograms.ml-1 for 48 h postoperatively. All patients received a standard anaesthetic and, in addition, the study group had a 20 mg bolus of tenoxicam intravenously, intra-operatively. Patients receiving tenoxicam demonstrated significantly lower pruritus and pain scores at 30 min, 2, 4, 8 and 24 h postoperatively as well as reduced pethidine requirements for breakthrough pain in the first 24 h. In conclusion, tenoxicam 20 mg significantly reduces the incidence and severity of postoperative pruritus in patients who received peri-operative epidural fentanyl. In addition, it significantly reduces pain and further analgesic requirements postoperatively.