Summary

Background and objective: This study was designed to determine if subhypnotic propofol reduces postoperative behavioural disturbances in children undergoing sevoflurane induction compared with intravenous propofol induction for elective adenoidectomy and tonsillectomy. Methods: Following Ethics Committee approval and parental informed consent, ASA I–II, 120 children (2–10 yr) were recruited. Parents were not allowed to accompany their child. Unpremedicated children were randomly allocated to groups receiving inhalation induction with sevoflurane, 2–2.5 mg kg−1 intravenous propofol induction or inhalation induction with sevoflurane followed by subhypnotic dose of propofol (1 mg kg−1). Anaesthesia was maintained with 2–4% sevoflurane, O2 and N2O. Anxiety on arrival to operating theatre, at anaesthesia induction and 30 min after emergence was assessed. Parents completed a state–trait anxiety inventory test preoperatively and a post hospitalization behaviour questionnaire a week later to assess children's postoperative behavioural disturbances. Kruskal–Wallis test, Wilcoxon signed rank sum test, Bonferroni's test, Paired t-test, t-test, Pearson and Spearman's rank correlation test, χ2-test were used for statistical analysis. Results: The anxiety level at induction was high in all groups (P < 0.05). There was no difference between groups in respect to anxiety at other measurement times. A relation between preoperative anxiety level and postoperative behavioural disturbances was determined (P < 0.05). Some behavioural disturbances as nightmare/night fear and desire of sleeping with parents were rarely seen in intravenous propofol induction group (P < 0.05). Conclusion: Addition of subhypnotic dose of propofol to sevoflurane induction did not reduce the incidence of postoperative behavioural disturbances.

Summary

Background and objectives: Postoperative pain is a common problem following ambulatory breast augmentation surgery. This study was performed to compare standard of care (oral analgesics) with patient-controlled incisional regional analgesia (PCRA) for postoperative pain management at home for 48 h. A second aim was to compare the analgesic efficacy of ropivacaine 0.25% vs. 0.5%. Methods: Surgery was performed under local anaesthesia and monitored anesthesia care. Sixty adults (ASA 1–2) were randomized to one of two groups. Patients in Group PCRA could self-administer ropivacaine 0.25% 10 mL in the left breast and ropivacaine 0.5% in the right breast. Patients in Group T (tablets) received our standard of care treatment, i.e. oral paracetamol 1 g four times a day and oral ibuprofen 500 mg three times a day. Parameters measured included: analgesic requirements (in post-anesthesia care unit, PACU and post-discharge), pain intensity (visual analogue scale), patient satisfaction, global analgesia, side-effects, and quality of recovery. Results: Pain scores were significantly lower in Group PCRA compared to Group T at all time periods (P < 0.05). No differences were found in pain scores between the right and left breasts. Significantly more patients in Group T requested analgesics in the recovery unit (27 vs. 7; P = 0.001) and also at home (20 vs. 11; P < 0.02). More patients in the tablet group had nausea and vomiting (10 vs. 3; P < 0.05). Global analgesia on day 2 was significantly better in PCRA group; however, patient satisfaction was similar in both groups. More patients in the tablet group had sleep disturbance and woke up at night due to pain. Conclusions: Pain relief after ambulatory breast augmentation is superior with incisional PCRA when compared to oral analgesic combination of paracetamol and ibuprofen. Incisional PCRA was associated with minimal side-effects and less sleep disturbance. There was no difference in the analgesic efficacy between ropivacaine 0.25% and 0.5%.

Summary

Background and objective: In order to identify parameters predicting intensive care unit mortality in patients transferred to a specialized tertiary centre because of progressive acute respiratory distress syndrome, an observational pilot study was carried out involving 94 patients. Methods and Results: Forty-one patients (43.6%) died. Survival was defined as intensive care unit discharge. Survivors were younger (32.0 ± 11.8 vs. 39.1 ± 12.4 yr, P = 0.008), at admission they had a lower acute physiology and chronic health evaluation (APACHE) II score (21.7 ± 5.4 vs. 25.4 ± 5.2, P = 0.0009), higher PaO2/FiO2 (122 ± 79 vs. 79 ± 42 mmHg, P = 0.002), lower positive end-expiratory pressure (10.6 ± 3.1 vs. 12.5 ± 3.7 cmH2O, P = 0.02) and a lower Murray score (2.8 ± 0.63 vs. 3.0 ± 0.62, P = 0.04). No differences were observed for tidal volumes and peak inspiratory pressures. Days of hospitalization and mechanical ventilation prior to transferral were not related to survival. Multivariate analysis of variables assessed on admission detected only differences for age (P = 0.014) and APACHE II (P = 0.005). Odds ratio was 1.06 (95% confidence interval (CI): 1.013–1.119) for age and 1.21 (CI: 1.059–1.381) for APACHE II. Multivariate analysis of changes in respiratory parameters, APACHE II and Murray score during the first 3 days after transferral revealed a significant difference only for positive end-expiratory pressure (P < 0.008). Corresponding odds ratio was 2.40 (CI: 1.25–4.58) for an increase of 1 cmH2O/24 h. Conclusion: Age-related mortality in this small, but highly selected group of patients with established ARDS increased early in life even in a population with an overall mean age of 35.1 yr. APACHE II was the only clinical predictor for mortality on admission. The need for a substantial increase in positive end-expiratory pressure after transferral markedly reduced the chance to survive.

Summary

Background and objective: To evaluate and compare the effect of two clinically available central nervous system stimulants, namely doxapram and aminophylline on arousal from sevoflurane anaesthesia and bispectral index. Methods: This randomized, double-blind, placebo-controlled, prospective study was conducted in 90 adult females, ASA I–II, scheduled for elective lower abdominal surgeries at Taipei Medical University Hospital. At 5 min before the completion of surgery, under sevoflurane anaesthesia, patients were divided into three groups to receive doxapram 1 mg kg−1, aminophylline 2 mg kg−1 or saline placebo intravenous. Standard vital signs, end-tidal CO2, end-expiratory sevoflurane concentration, bispectral index and neuromuscular blockade were measured plus clinical parameters of recovery from general anaesthesia. Results: Compared with the control group, patients receiving doxapram or aminophylline showed a similarly faster recovery from sevoflurane anaesthesia correlated with increase in bispectral index. Conclusion: Intravenous administration of doxapram 1 mg kg−1 or aminophylline 2 mg kg−1 hastened the early recovery from sevoflurane anaesthesia. The arousal effect of aminophylline and doxapram appears to be similar.

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Background: In this prospective, randomized, double-blind, controlled study, we investigated the sensory, motor and analgesic block characteristics of S(+) ketamine, fentanyl and saline given intrathecally (IT) in addition to 0.5% plain bupivacaine (10 mg) for spinal analgesia. Methods: Ninety ASA I or II adult patients undergoing Caesarean section were randomly allocated to receive 1.0 mL of 0.9% saline in Group S (n = 30), 0.05 mg kg−1 of S(+) ketamine (1.0 mL) in Group K (n =30) or 25 μg (1.0 mL) of fentanyl in Group F (n =30) following 10 mg of plain bupivacaine 0.5% IT. We recorded onset and duration of sensory and motor block, time to reach the maximal dermatomal level of sensory block and duration of spinal analgesia. Results: The onset time of sensory and motor block was significantly shorter in Groups K and F than in Group S (P < 0.014). Their duration was significantly longer in Group F than in Groups K and S (P < 0.009). The time to reach the maximal dermatomal level of sensory block was significantly shorter in Groups K and F than in Group S (P < 0.001). The duration of spinal analgesia was significantly longer in Group F than in Groups K and S (P < 0.001). Conclusion: In patients undergoing Caesarean section with spinal analgesia, the addition of S(+) ketamine (0.05 mg kg−1) IT to 10 mg of spinal plain bupivacaine (0.5%) led to rapid onset of both sensory and motor blockade and enhanced the segmental spread of spinal block without prolonging the duration of spinal analgesia, whereas fentanyl provided prolonged analgesia.

Summary

Background and objectives: This study was designed to quantify the additional postoperative analgesic efficacy of a single dose of ketoprofen in patients undergoing thyroid surgery using two different intraoperative analgesic regimens. Methods: One hundred and twenty patients were randomly assigned to one of four groups: intraoperative fentanyl or remifentanil with or without ketoprofen (n = 30 for each group). Intravenous ketoprofen (1.5 mg kg−1) or saline was administered 45 min before the end of surgery. Pain scores, opioid demand and length of stay in the postanaesthesia care unit were assessed in a blinded manner. Results: Patients receiving intraoperative fentanyl with saline had significantly lower visual analogue scale pain scores in the postanaesthesia care unit compared with those receiving intraoperative remifentanil with saline (55 ± 10 mm vs. 80 ± 18 mm, P < 0.05) and they stayed shorter in the postanaesthesia care unit (86 ± 24 min vs. 126 ± 37 min). In conjunction with intraoperative fentanyl, ketoprofen significantly decreased postoperative pain scores (40 ± 10 mm, P < 0.05 compared with fentanyl alone) and opioid demand (4 of 30 patients vs. 14 of 30 patients compared with fentanyl alone, P < 0.05). Patients receiving intraoperative remifentanil had no additional analgesic benefit with ketoprofen. Conclusion: After thyroid surgery, patients receiving intraoperative fentanyl had lower pain scores and needed less rescue analgesia compared with patients receiving intraoperative remifentanil. The adjunction of ketoprofen further improved analgesia in patients who received intraoperative fentanyl only.

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Background and objective: In the perivascular sheath of the brachial plexus, the volume of anaesthetic solution determines the quality of anaesthetic cover. Fibrous septa may divide the perivascular space into compartments, leading to inadequate diffusion of the anaesthetic solution. The aim of our study was to obtain good anaesthesia and less complications using high volume of low concentration anaesthetic solution, overcoming the obstacle of the septa with a double approach to the scalene sheath. Methods: Sixty patients scheduled for shoulder capsuloplasty received both Winnie interscalene brachial plexus block and Pippa proximal cranial needle approach. The patients were randomly assigned to two groups. A constant dose of local anaesthetic was administered to each group: Group I (30 patients) received high volume (60 mL of anaesthetic solution) and Group II (30 patients) received low volume of solution (30 mL of anaesthetic solution). Sensory and motor block in the upper limb and complications were evaluated. Results: In all the patients the quality of anaesthesia obtained at the surgical site was excellent. In Group I also the areas supplied by the medial cutaneous nerves of the arm and forearm, ulnar, median and radial nerves were blocked (P < 0.002). Complications were only observed in Group II and consisted of bradycardia and hypotension (66% of the patients) and phrenic nerve paresis (27% of the patients). Conclusions: The lower concentration of the anaesthetic solution avoids complications while increased volume provides good analgesic cover. The combination of the Winnie interscalene plexus block and the Pippa proximal cranial needle approach should contribute to fill up the scalene sheath overcoming the septa obstacles.

Summary

Background: The local anaesthetic prilocaine has a low systemic toxicity mainly because of a high absorption in the lung and a large volume of distribution and thus is associated with a lower risk of neurological or cardiac side-effects. However, the major disadvantage is the formation of methaemoglobin by its metabolite o-toluidine. This prospective observational study was performed to identify factors that are associated with increased prilocaine-induced methaemoglobinaemia. Patients and methods: One Hundred and sixty two patients undergoing major knee surgery under general anaesthesia combined with peripheral nerve blocks (femoral nerve block, combined femoral/sciatic nerve block or lumbar plexus block) received a single bolus injection of 300 or 400 mg prilocaine about 30 min before surgery via a catheter. The proper placement was verified using nerve stimulation via a stimulating catheter. Three hours after prilocaine injection, venous blood samples were drawn and methaemoglobin levels were measured by standard photometric technique. Data was subjected to a stepwise multiple regression analysis. Results: The mean methaemoglobin for all patients was 2.7% (range: 0.9–15.4%). A higher dose of prilocaine and younger age were the most important predictive factors for higher methaemoglobin formation. Female sex and to a lesser extent the use of high-concentration/low-volume prilocaine also increased methaemoglobin levels. These four factors of the model explain 36% of the total variance. Other investigated factors, including the patient’s height, weight, body mass index, the site of catheter insertion, the anaesthetist’s judgement concerning the difficulty of catheter placement, duration of catheter placement or an inadvertent puncture of a venous or arterial vessel, had no significant impact on the concentration of methaemoglobin. Conclusion: The use of prilocaine for regional block is safe, since the older patients who might be more susceptible to suffer from clinical symptoms of methaemoglobinaemia usually form less methaemoglobin. However, since prediction of high methaemoglobin levels is difficult, anaesthesiologists performing regional blocks in patients who might be jeopardized by a decreased oxygen transport capacity should avoid high doses of prilocaine.

Summary

Background and objectives: This study was designed to investigate whether single epidural droperidol or continuous epidural droperidol inhibit pruritus and postoperative nausea and vomiting induced by postoperative continuous epidural fentanyl administration, and to identify the optimal method of administering epidural droperidol. Methods: 120 ASA I–II patients undergoing subtotal gastrectomy with general anaesthesia combined with epidural anaesthesia were randomly allocated into three groups: control (no droperidol), single injection (droperidol 2.5 mg) and continuous group (droperidol 2.5 mg 2 day−1). Postoperatively the frequency and severity of pruritus and postoperative nausea and vomiting in all groups were compared during 48 h. Results: The frequency and severity of pruritus was significantly lower in both single injection and continuous groups than control group after epidural fentanyl administration (P < 0.05). The frequency and severity of postoperative nausea and vomiting was significantly lower in single injection group than control group after epidural fentanyl administration (P < 0.05). Conclusion: Epidural continuous droperidol is effective for reducing pruritus, and single epidural droperidol injection is effective for reducing pruritus and postoperative nausea and vomiting induced by postoperative continuous epidural fentanyl analgesia.

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Background and objective: Crystalloid haemodilution has been widely found to enhance coagulation onset, but the duration of this effect has never been documented. Methods: Twelve healthy, consenting volunteers had a rapid infusion of 14 mL kg−1 of normal (0.9%) saline. Blood samples were taken, prior to (control), and immediately after (30 min) the rapid saline infusion was completed (30 min). They were then repeated at regular intervals up to 120 min. Haematocrit/platelet counts were taken to determine the degree of dilution and thrombelastograms, with and without platelet antagonists (ReoPro, Abciximab), were measured in all samples. Antithrombin levels were selectively measured. Results: The haematocrit and platelet count showed a rapid dilutional decrease at 30 min (mean of −12.2% and −14.4%, respectively), with values returning towards baseline within 15 min after finishing the infusion. There was a significantly faster onset of coagulation (decrease in r-time) in the post-infusion sample (30 min) compared to control (P < 0.05), again returning towards normal as the dilution effect was reversed. Similar thrombelastograms findings were evident in the plasma factor only group (platelets inhibited by ReoPro). Antithrombin levels changed in keeping with the haemodilution effect (P < 0.0001). There was a linear relationship between antithrombin and thrombelastograms r-time (P = 0.012). Conclusion: The faster onset of coagulation brought on by haemodilution return towards normal as the dilutional effect is reversed. This effect is mediated through plasma clotting factors. Of interest is the significant inverse correlation of the onset of coagulation increasing as the antithrombin levels decreased with dilution.

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Background and objective: Quality of acute pain management is far from being satisfactory. These deficits are not caused by the complexity of the medical problem but by difficulties in organization and hospital structures, sand procedures. Continuous quality improvement is a recommended tool to overcome such difficulties and to increase quality in the long run. This study reports the implementation of benchmarking-based continuous quality improvement to improve postoperative pain management at a university hospital. Methods: A specialised pain nurse interviewed patients of three surgical departments on the first day after surgery, and continuously assessed process and outcome quality parameters. A multidisciplinary team of anaesthetists, surgeons, nurses and pharmacists implemented a regular procedure of data analysing and internal benchmarking. Results and suggested improvements were fed back to the healthcare teams. Results: From 1998 to 2002, 6756 patients were assessed. Average pain on ambulation and maximal pain were 3.7 ± 2.4 and 5.0 ± 2.5 (mean ± SD) on a 11-point numeric rating scale. Pain intensity at rest was 1.9 ± 1.8. Over time, pain intensity on ambulation decreased (P = 0.022) whereas maximal pain and pain at rest remained unchanged. There was an increase in the number of patients who received non-opioid analgesia (P < 0.001). Conclusions: A continuous quality improvement process could be established and is now successfully used in clinical routine. Cornerstones of this project were frequent assessments of process and outcome parameters, regular benchmarking and implementation of feedback mechanisms. Changes in organization of medical management and multidisciplinary teamwork seem to be more important than medical or technical aspects.

Summary

Introduction: We decided to investigate the pathogenesis of pulmonary ventilatory and radiographic abnormalities in patients after major vascular surgery. Patients and methods: Sixteen mechanically ventilated patients without heart failure were studied, within 3 h after major abdominal surgery. We measured extravascular lung water, intrathoracic, global end-diastolic and pulmonary blood volumes, 67Ga-transferrin pulmonary leak index and ventilatory and radiographic variables. The latter allowed computation of the lung injury score as a measure of lung injury. Results: The extravascular lung water was elevated (>7 mL kg−1) in 5 of 16 patients, while the pulmonary leak index was elevated in 11 patients and a supranormal extravascular lung water was associated with a high pulmonary leak index and higher extravascular lung water relative to intrathoracic blood volume or pulmonary blood volume. Patients were arbitrarily divided into those with a lung injury score >1 and ≤1, and only differed in the factors composing the score as well as in extravascular lung water divided by pulmonary blood volume. A lung injury score >1 was associated with a longer duration of mechanical ventilation. Conclusion: Our data suggest that mild, subclinical, pulmonary oedema is relatively common after major vascular surgery, mainly caused by increased pulmonary capillary permeability in the absence of overt heart failure. However, permeability oedema only partially contributes to postoperative lung injury score and need for mechanical ventilation, suggesting a major contribution by atelectasis.

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Background and objectives: The primary objective of sedation in the critically ill patient is to achieve security and comfort. The routine use of standardized and validated sedation scales and monitors are needed. The Richmond agitation sedation scale has been used but some patients cannot be evaluated with subjective assessment tools such as the Richmond agitation sedation scale because they lack motor responsiveness due to therapeutic paralysis or because they are receiving deep sedation. We aimed to assess the correlation of bispectral index with Richmond agitation sedation scale during dexmedetomidine sedation and evaluate the use of the bispectral index in monitoring the levels of sedation in intensive care patients. Methods: This was a single centre, prospective, clinical study. Eleven mechanically-ventilated critically ill patients, aged 17–82 (50.09 ± 17.76; mean ± SD) yr, 3 males and 8 females, APACHE II score 12.63 ± 3.90, SOFA score 3.27 ± 1.73 were enrolled in the study. Patients received a dexmedetomidine infusion of 1 μg kg−1 over 10 min followed by a maintenance infusion of 0.5 μg kg−1 h−1 for 8 h. Sedation was assessed using the Richmond agitation sedation scale and bispectral index monitoring. Heart rate, blood pressure, respiratory rate and SPO2 were monitored. Wilcoxon signed rank sum test and Spearman's rank correlation analysis were used for statistical analysis. Results: The variation of Richmond agitation sedation scale score was between 0.9 and −1.7 bispectral index varied from 65 to 75. Significant correlations between Richmond agitation sedation scale and bispectral index values were found in this study. (r = 0.900; P = 0.0001) Conclusions: Richmond agitation sedation scale levels significantly correlated with bispectral index values during dexmedetomidine sedation in critically ill patients requiring mechanical ventilation in the intensive care unit.

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Background and objective: In small children, the placement of arterial catheters can be technically challenging for even the most experienced anaesthetist. We investigated whether ultrasound imaging would improve the success rate and reduce time demand and complications of radial artery cannulation. Method: In this prospective randomized study, we performed radial artery cannulation in 30 small children (age 40 ± 33 months) using two different techniques for localization of the vessel. In Group 1 (n = 15), the traditional palpation method was used, while in Group 2 (n = 15) cannulation was directed by vascular ultrasound imaging. In addition, we used ultrasound to determine the cross-sectional area of the radial artery with and without dorsiflexion. For statistical analysis, the non-parametric U-test for non-paired data and the Wilcoxon signed rank sum test for paired data were used. Differences were considered significant, when P < 0.05. Results: Ultrasound-guided puncture was successful in all children of Group 2 compared to only 12 of 15 (80%) children in Group 1. Fewer attempts with the imaging technique were required than with the traditional technique (20 vs. 34, P < 0.05). Dorsiflexion significantly reduced the mean cross-sectional area of the artery by 19%. Conclusion: The current pilot study suggests that ultrasound guidance is appropriate for radial artery catheter insertion, sharing many of the benefits of ultrasound-guided central vein catheter insertion.

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Background and objective: The optimal depth of insertion of left-sided double-lumen endobronchial tubes is strongly correlated with body height in average-sized adults. However, this relationship has not been studied in below average-sized adult patients. We investigated whether or not there is a clinically useful relationship in below average-sized adult patients. Methods: One hundred and ninety six consecutive adult patients undergoing thoracic surgery under one-lung anaesthesia (body height ≤ 155 cm) were included in this study. Left-sided double-lumen tubes were inserted under the guidance of a fibre-optic bronchoscope. Optimal depth was defined as the proximal surface of the bronchial cuff positioned just below the carina. Results: There was a statistically significant positive correlation between body height and the optimal depth of insertion (r = 0.61, P < 0.0001); however, the correlation coefficient was low. The actual optimal depth of insertion of one patient was even 4.5 cm shorter than that obtained from the equation. Conclusion: Although there was a statistically significant correlation between body height and the optimal depth of insertion of left sided double lumen tubes in adult patients of short stature (≤ 155 cm), clinical application of the equation is not warranted and these tubes should be inserted under direct vision with a fibre-optic bronchoscope.

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Background and objective: To evaluate the effects of sevoflurane and desflurane in combination with intravenous remifentanil on time for discharge from the postanaesthesia care unit and need for postanaesthesia care unit management after elective laparoscopic cholecystectomy. Methods: 231 ASA Grade I–II patients, undergoing elective laparoscopic cholecystectomy in seven University teaching hospital, were randomly allocated to receive a desflurane–remifentanil (n = 105) or sevoflurane–remifentanil (n = 126) anaesthetic. A blinded observer recorded times for emergence and postanaesthesia care unit discharge (achievement of an Aldrete score ≥9), number of patients eligible for postanaesthesia care unit discharge when exiting the operating room and occurrence of adverse events. Results: Intraoperative cardiovascular stability was similar in the two groups. Emergence, response and extubation occurred earlier after desflurane (5.4 ± 3 min, 5.5 ± 3 min and 7.5 ± 4 min) than sevoflurane (6.6 ± 3.5 min, 7.2 ± 4 min and 9.1 ± 4.2 min) (P = 0.0005, 0.05 and 0.003, respectively). Postanaesthesia care unit bypass was possible in 44 desflurane–remifentanil patients (41%) and 55 sevoflurane– remifenatnil patients (43%) (P = 0.69), while postanaesthesia care unit discharge occurred after 46 min (25th–75th percentiles: 18–40 min) with desflurane and 64 min (25th–75th percentiles: 20–50 min) with sevoflurane (P = 0.04). Postoperative nausea and vomiting was observed in 40 desflurane–remifentanil patients (36%) and 53 sevoflurane–remifentanil patients (42%) (P = 0.42). Conclusions: Both the desflurane–remifentanil and sevoflurane–remifentanil combinations provide a similarly adequate intraoperative cardiovascular stability. Emergence and postanaesthesia care unit discharge were faster with desflurane–remifentanil than sevoflurane–remifentanil, but this was not associated with a larger proportion of postanaesthesia care unit bypass, confirming that no clinically relevant differences are present between the two agents.

Summary

Background and objective: We have evaluated the effects of propofol and its relationship with K+ channels on human isolated umbilical vessels. Methods: Umbilical vessel rings were suspended in isolated organ baths containing Krebs–Ringer solution. In the first series of experiments the effect of propofol (10−9–10−4M) was examined in a concentration-dependent manner on umbilical vessels precontracted with KCl (60 mmol). In the second series, these effects were studied in the presence of tetraethylammonium. Results: A mild contraction was produced by low dose propofol in both precontracted umbilical artery and umbilical vein segments. 10−4M propofol caused significant relaxation in both umbilical artery and umbilical vein. The relaxation response was significantly reduced by the addition of 10−1 M tetraethylammonium. Conclusion: These results suggested that the responses of propofol on KCl-induced contractions of both umbilical artery and vein were dose dependent, and this effect involved Ca2+ activated K+ channels.

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Background and objective: Data on the effectiveness of cyclooxygenase 2 inhibitors in postoperative pain therapy vary widely. We tested in a prospective, placebo-controlled, randomized, double-blind trial the hypotheses that perioperative (i.e. preoperative and postoperative) administration of the cyclooxygenase 2 inhibitor rofecoxib decreases pain scores and morphine consumption after spine, breast and orthopaedic surgery. Methods: Five hundred and forty patients scheduled for spine, breast or orthopaedic surgery were randomly assigned to receive in combination with postoperative morphine via patient controlled analgesia pump for 4 days either rofecoxib 50 mg administered perioperatively, rofecoxib 50 mg administered only postoperatively, or placebo. Primary outcome criteria were pain score at rest (numeric rating scale 0–4) and morphine consumption. Results: Perioperative rofecoxib significantly decreased pain score 0 (0–1) vs. 1 (0–2) (median (interquartile range)), and morphine consumption 18 (6–33) vs. 22.5 (12–38) compared with placebo. In contrast, rofecoxib when administered only postoperatively did not significantly improve analgesic effects or side-effects at time of assessment of the main criteria (24 h after skin closure), but during the follow-up period at 48 h and 72 h after skin closure pain scores and morphine consumption were improved compared to placebo. The analgesic effects of rofecoxib were independent from the type of surgery. Conclusions: Perioperative administration of the cyclooxygenase 2 inhibitor rofecoxib decreases pain scores and morphine consumption after orthopaedic, breast and spine surgery. However, the benefit of preoperative administration of the cyclooxygenase 2 inhibitor seems to be only moderate, suggesting that early postoperative administration may be a useful alternative approach. There is no evidence that the type of surgery influences analgesic effects of cyclooxygenase 2 inhibitors.

Summary

Background and objective: To compare the anaesthetic characteristics in terms of onset and offset times of the sensory and motor blocks of prilocaine 1% and ropivacaine 0.75% alone and in different combinations when used for brachial plexus anaesthesia in axillary perivascular blocks. Methods: After informed consent 96 ASA I–III patients undergoing forearm or hand surgery participated in this prospective, randomized, double-blind study. Patients received either prilocaine 1% 40 mL (G1), prilocaine 1% 30 mL and ropivacaine 0.75% 10 mL (G2), prilocaine 1% 20 mL and ropivacaine 0.75% 20 mL (G3) or ropivacaine 0.75% 40 mL (G4) for axillary perivascular brachial plexus anaesthesia. Onset and duration of sensory and motor blocks in the distribution of the musculocutaneous, radial, median and ulnar nerves were assessed. Results: The onset time of the sensory and motor blocks of the whole brachial plexus differed only between patients in G4 with ropivacaine 0.75% 40 mL demonstrating a later motor onset in comparison to all other groups and a later sensory onset in comparison to G1 and G2 (P < 0.01). The addition of ropivacaine resulted in longer offset times of the sensory and motor blocks. The median offset time of the motor block was 179.5 min in G1, 262 min in G2, 389.5 min in G3 and 745 min in G4 (P < 0.01). The median offset time of the sensory block was 163.5 min in G1, 277 min in G2, 383.5 min in G3 and 784 min in G4 (P < 0.01). There was no difference in onset and offset times between sensory and motor blocks within the groups. Conclusions: For axillary perivascular brachial plexus block prilocaine 1% alone and in combination with ropivacaine 0.75% was similar in terms of onset of sensory and motor blocks but different in duration of sensory and motor blocks without a differential sensory and motor offset.

Summary

Background and objective: This placebo-controlled study was performed to evaluate the efficacy of dexmedetomidine compared with meperidine and placebo in preventing postanaesthetic shivering. Methods: We studied 120 patients (ASA I–II) scheduled for elective abdominal or orthopaedic surgery of about 1–3 h duration. Forty patients in each group randomly received 1 μg kg−1 of dexmedetomidine, 0.5 mg kg−1 of meperidine or saline 0.9% as placebo, intravenously (i.v.). Mean arterial pressure, heart rate, oxygen saturation and central body temperature were measured. Extubation, awakening and orientation times, shivering, pain, recovery and sedation scores were recorded. Results: Postanaesthetic shivering was seen in 22 patients in the placebo group, four patients in the meperidine group and six patients in the dexmedetomidine group. Sedation scores were significantly higher in the dexmedetomidine group compared with meperidine and placebo groups. Both dexmedetomidine and meperidine caused a significantly prolonged extubation and awakening time compared with placebo. Also, dexmedetomidine caused a significantly prolonged orientation time compared with other two groups. Conclusion: Intraoperative intravenously administration of dexmedetomidine 1 μg kg−1 reduces postanaesthetic shivering as does meperidine 0.5 mg kg−1 in patients after major surgery.