Postoperative Analgesic Therapy Research Articles

Long-Term Outcome of Chest Wall and Diaphragm Repair with Biological Materials.

Chest wall and/or diaphragm reconstruction aims to preserve, restore, or improve respiratory function; conserve anatomical cavities; and upkeep postural and upper extremity support. This can be achieved by utilizing a wide range of different grafts made of synthetic, biological, autologous, or bioartificial materials. We aim to review our experience with decellularized bovine pericardium as graft in the past decade. We conducted a retrospective analysis of patients who underwent surgical chest wall and/or diaphragm repair with decellularized bovine pericardium between January 1, 2012 and January 13, 2022 at our institution. All records were screened for patient characteristics, intra-/postoperative complications, chest tube and analgesic therapy duration, length of hospital stay, presence or absence of redo procedures, as well as morbidity and 30-day mortality. We then looked for correlations between implanted graft size and postoperative complications and gathered further follow-up information at least 2 months after surgery. A total of 71 patients either underwent isolated chest wall (n = 51), diaphragm (n = 12), or pericardial (n = 4) resection and reconstruction or a combination thereof. No mortality was recorded within the first 30 days. Major morbidity occurred in 12 patients, comprising secondary respiratory failure requiring bronchoscopy and invasive ventilation in 8 patients and secondary infections and delayed wound healing requiring patch removal in 4 patients. There was no correlation between the extensiveness of the procedure and extubation timing (chi-squared test, p = 0.44) or onset of respiratory failure (p = 0.27). A previously demonstrated general viability of biological materials for various reconstructive procedures appears to be supported by our long-term results.

VENTRAL MEDIAN AND LATERAL FLANK APPROACH FOR OVARIOHYSTERECTOMY IN CAT

This study was conducted to compare Ventral Median Approach (OHM) and Lateral Flank Approach (OHF) for feline ovariohysterectomy (OH). Fifteen healthy local female cats (Felis catus) with body weights ranged 2-4 kg and aged 1-2 years were divided into two groups, OHM (n= 8) and OHF (n= 7). Prior to OH, the cats were anesthethized using ketamine-xylazine and the sugery was performed by the same operator. The wound scoring showed a significantly higher difference in the OHM group on day 3 and 4 post-surgery. Scores of erythematous, swelling and dehiscence showed no significant differences. The 4Avet pain scale was significantly higher in OHF at the 2, 6, and 12-hours post surgery. The pain response was evaluated using baseline tactile Semmes-Weinstein Monofilaments and was significantly higher in OHF than OHM on day 1 to day 5 post surgery. Blood hematology, blood glucose and wound healing duration did not differ significantly between groups. The OHF approach showed greater post-operative pain than the OHM approach. Wound dehiscence was observed in two cats (25%) in OHM group from day 4 post-operative. The OHM approach showed a greater risk of complications than the OHF group and therefore requires better post-operative care. The OHF group showed a smaller risk of complications but requires better post-operative analgesic therapy.

Intravenous Magnesium Sulfate for Acute Pain Management After Laparotomy Surgery: A Case Series

Introduction: Perioperative pain management is indicated to relieve patient complaints, allow early mobilization after surgery, reduce the duration of hospital stay, and provide a better level of satisfaction. This study aims to describe the use of magnesium sulfate in post-laparotomy patients.
 Case presentation: There were two cases, and the first was a 41-year-old female patient with endometrial cysts and adenomyosis who underwent laparotomy under general anesthesia. The patient was given magnesium sulfate 30 mg/kgBW 20 minutes before induction, then a continuous dose via a syringe pump 10 mg/kgBW/hour until the operation was completed. This patient showed an NRS scale 1 hour after surgery 1/10 and after 24 hours a maximum of 3/10. The second case was a 42-year-old female patient with suspected Leimiosarcoma who underwent a total hysterectomy and bilateral salpingoovorectomy under general anesthesia. Patients also received the same administration of magnesium sulfate and were assessed on the NRS scale up to 2 hours postoperatively 1/10 and after 24 hours a maximum of 2/10.
 Conclusion: Magnesium sulfate is used as an adjuvant in postoperative analgesia and analgesic therapy to treat acute or chronic pain and has antinociceptive effects due to NMDA receptor blocking, making it useful for the prevention of central sensitization.

Effect of Dezocine on Hemodynamic Indexes of Postoperative Patients With Traumatic Brain Injury (TBI)---A Pilot Study.

Background: Due to pain and other stimuli, patients with traumatic brain injury (TBI) after surgery show excited Sympathetic Nervous system, increased intracranial pressure, brain tissue swelling, intracranial hemorrhage, or reduced cerebral perfusion pressure, seriously threatening the life and prognosis of patients. The effect of dezocine on postoperative analgesia after TBI remains largely undetermined. Objective: In the present study, we aimed to investigate the efficacy and safety of dezocine in postoperative sedative and analgesic therapy for a craniocerebral injury. Methods: The patients were randomly divided into two groups (n = 40) as follows: dezocine group (Group A) and control group (Group B). Electrocardiography (ECG), heart rate (HR), blood pressure, and oxygen saturation (SpO2) were routinely monitored after postoperative return to the ward. Both groups were initially injected with 5 mg·kg−1·h−1 propofol to maintain sedation, and the dose was adjusted according to the patient’s condition. Vital signs of patients were recorded at T1 (the base value when arriving at the ward), T2 (before the sedative agent was used) and T3 (use of dezocine or 0.9% saline solution for 8 h), T4 (use for 1 day), T5 (use for 3 days), T6 (termination of dezocine or 0.9% saline solution for 1 day), and T7 (termination for 3 days), and mean arterial pressure (MAP) and HR values were also recorded. The total amount of propofol, total fluid inflow, blood loss, and urine output were recorded within 24 h. The number of coughs of each patient was recorded within 1 day after entry, and the incidence of adverse events, such as insufficient oxygenation (SaO2 reduced by about 5% from the base value), hypotension, bradycardia, laryngospasm, bronchospasm, and so on, was assessed. Results: Compared with the control group (group B), the hemodynamics of the dezocine group (group A) was more stable, there were significant differences in MAP and HR (p < 0.05), and the stress response was milder. The total amount of propofol, total fluid inflow, blood loss, and urine volume of the dezocine group were significantly improved compared with the control group (p < 0.05). Moreover, the incidence of adverse events, such as cough, in the dezocine group was significantly reduced compared with the control group (p < 0.05). Conclusions: Dezocine, as a drug with a strong analgesic effect and obvious sedative effect, was suitable for craniocervical surgery, and it could significantly improve the stability of airway and hemodynamics in TBI patients during anesthesia recovery.

Quality of Life and Early Functional Evaluation in Direct-to-Implant Breast Reconstruction After Mastectomy: A Comparative Study Between Prepectoral Versus Dual-Plane Reconstruction

BackgroundIn conservative mastectomies, in which the native skin envelope is preserved, positioning an implant in the submuscular plane commonly leads to functional consequences like upper limb movement impairment and animation phenomena. In recent years, however, a new conservative prepectoral breast reconstruction technique has been proposed, with demonstrated surgical safety and aesthetic effectiveness. The aim of our study was to explore and compare the functional and aesthetic outcomes of the prepectoral/acellular dermal matrix (ADM)-wrapped implant procedure versus subpectoral/ADM-assisted reconstruction. Patients and MethodsA retrospective nonrandomized comparative study of 94 patients (121 breasts) undergoing direct-to-implant breast reconstruction after skin-/nipple-sparing and skin reduction was conducted from February 2013 to October 2017. Fifty-five patients (group A) received subpectoral ADM-assisted reconstruction with dual-plane implant positioning, and 39 patients (group B) received prepectoral partially or totally ADM-wrapped implant reconstruction. Patients were allocated to either group A or B depending on the mastectomy flap thickness and vitality, as assessed clinically during the operation. Details of rehabilitation program, postoperative pain at 72 hours, postoperative analgesic therapies, demographic data, and complications were recorded. Upper limb function was assessed before and 1 month after surgery by a physiatrist according to a precise protocol. Patients were asked to fill in the BREAST-Q reconstruction questionnaire after surgery to evaluate outcomes. ResultsDifferences in upper limb function between groups, namely flexion (P = .03), abduction (P = .003), internal rotation (P = .02), and external rotation (P = .05), were statistically significant. Although most patients required postoperative rehabilitation, the individual rehabilitation intervention frequency was greater in the subpectoral group (91% in group A vs 74% in group B). There was also a significant difference in postoperative pain (within 72 hours), with less pain perceived in the prepectoral group (P = .01). Furthermore, prepectoral patients reported slightly better postoperative quality of life than subpectoral patients, particularly in the domains of sexual well-being (P = .005) and satisfaction with breast (P = .002). ConclusionIn our case series, prepectoral implant positioning with partial or total ADM coverage led to less impairment of upper limb function in terms of flexion, abduction, and internal and external rotation, and also reduce the need for rehabilitation. Furthermore, as a result of the less invasive procedure, prepectoral patients had less immediate postoperative pain and were more satisfied with breast appearance.

Comparison of preemptive paracetamol, paracetamol-diclofenac & paracetamol-tramadol combination on postoperative pain after elective abdominal surgery under general anesthesia, Ethiopia: a randomized control trial study, 2018

BackgroundIn the practice of postoperative pain management, pain is still poorly managed in low resource setting where the practice of epidural and opioid free analgesia is impractical. There has been a recent trend of combining different drugs and concept of preemptive analgesia but the therapeutic superiority remains understudied for postoperative pain management. The aim of this study is to assess postoperative analgesic effect of preemptive Paracetamol, Paracetamol-diclofenac and Paracetamol-tramadol combination in patients undergoing laparotomy surgery.MethodsThree-arm, randomized control trial study conducted on 63 patients undergone laparotomy surgery; group-P (paracetamol 1 g), group-PD (1 g + diclofenac 75 mg) and group-PT (paracetamol 1 g + tramadol 100 mg). The Numerical Rating Scale (NRS) pain rating system was used for this study. The primary endpoint of the study was total amount of analgesia consumption. Post-operative analgesic therapy [intravenous tramadol, 50 mg] were provided when patients complain of pain (request medication) or a numeric rating scale ≥4 was recorded. Secondary endpoint of the study were the time of first analgesic request and the intensity of the pain during 24 h post-op follow up period. Parametric data were analyzed using (ANOVA) and nonparametric data analyzed by Kuruska-Wallis H rank test. Chi-square test used for categorical variable. Statistical significance were sated at p value < 0.05 with a power of 80%.ResultsThe mean total tramadol consumption was significant higher in paracetamol group 250 ± 79.06 mg compared to paracetamol-diclofenac (173.81 ± 87.49 mg p = 0. 008) and paracetamol-tramadol (154.76 ± 70.54 mg p = 0. 001) group. Time to first analgesic request was significantly shorter within paracetamol group (87.62 ± 20.95 min) compared to paracetamol-diclofenac (103.01 ± 23.53 min p = 0.029) and paracetamol-tramadol (144.05 ± 14.72 min p < 0.001) group. There was statistically significant difference at 4th, 6th and 8th hour showing lower median pain score in paracetamol-tramadol group compared to paracetamol group.ConclusionPreemptive combination of paracetamol-tramadol and paracetamol-diclofenac reduce total tramadol consumption and prolongs time to first analgesic request compared to paracetamol alone in patients undergoing laparotomy surgery.Trial registrationThe study was retrospectively registered on 07 July 2019 at Pan African Clinical Trial Registry with the identification number of PACTR201908890749145. It was accepted on 14 August 2019.

TREATMENT OF HOCK JOINT FRACTURES IN A DOG - CASE RAPORT

The techniques of stabilizing the fracture of the hock joint fractures in a dog are developed in order to ensure the reposition and stabilization of the limbs. In our case, after a clinical examination, RTG analysis of the broken joint and assessment of the general condition of the dog, a surgical procedure was selected. In the dissociative anesthesia, with minimal tissue damage, the reposition of dislocated joint surfaces was made. The traumatized joint was reponated and fixed with cortical screws interconnected by cerclage wire. Screws provide the required stability of the talotibial joint surfaces. In the postoperative period, analgesic and antibiotic therapy was used, and fixation of the treated fracture of the hock joint was done. Also, recommendations and advice for postoperative treatment of a dog in home conditions were given to the owner. After forty days a surgery was performed in order to extract the cortical screws and cerclage wires, according to the standard procedure. In our case, after a complete and successful repair of the fracture, the dog recovered after two months and did not have symptoms of lameness. The results of successful surgical treatment were the reason to show this case as study report, in order to provide an alternative solution or advice to colleagues who could encounter similar fracture in small animal practice.

The SiLaC procedure for pilonidal sinus disease: long-term outcomes of a single institution prospective study.

In 2014, we started to treat pilonidal sinus disease in our institution with sinus laser-assisted closure (SiLaC) procedure. The aim of the present study was to evaluate the safety and efficacy of the SiLaC procedure in a single institution prospective study on a large cohort of patients and with a long follow-up period, and try to determine what factors that could influence healing and recurrence. A prospective study was conducted on consecutive patients with primary pilonidal sinus disease operated on with the SiLaC procedure at our institution from March 2015 to August 2017. Demographic and surgical data, outcomes, and complications were prospectively recorded and compared between the healed and not healed/recurrence groups to find factors influencing healing. Postoperative follow-up was performed in the outpatient clinic every 2weeks for 2months. In March 2018, patients were questioned by mail or phone to assess long-term recurrences. There were 200 patients. The healing rate was high (94%) with a mean healing time of 19.5 ± 14.4days. Mean operative time (9.4 ± 2.6min) and mean duration of postoperative analgesic therapy (4.72 ± 5.64days) were short. Postoperative complications (15%) were mainly infection (9.5%). There was a response rate of 77.5% to mail/phone questionnaires about recurrence. The recurrence rate was 14.9%. Mean time until recurrence was 193.5 ± 87.19days. The incidence of secondary openings, complications, and infection in the healing vs not healed or recurrence groups, was 24.8% vs 56.6%, 19.2% vs 40%, and 8.8% vs 30%, respectively. SiLaC is an effective, easy to perform, reproducible, and almost painless procedure. Factors influencing healing seem to be the presence of secondary openings, postoperative complications, and, especially, infection. The SiLaC procedure could become one of the treatments of choice for pilonidal sinus disease.

Use of preperitoneal wound catheter for continuous local anaesthesia after laparoscopic colorectal surgery.

The main cause of postoperative pain after abdominal surgery is the wound where laparotomy is made. Recently, laparoscopic procedures have become common in colorectal surgery. Although improving the tolerance of the surgery, postoperative pain management still remains adiscussed problem. The use of an epidural catheter used to be generally recommended in the open surgery era; however, an ideal strategy for postoperative analgesic therapy after laparoscopy remains unclear. Reduced administration of opioid analgesic drugs after colorectal resection is agenerally accepted goal. Preperitoneal catheter insertion for continuous local anaesthetic (LA) infusion in the wound after surgery is asimple alternative to other pain management methods. Retrospective analysis of analgotherapy outcomes in patients undergoing laparoscopic colorectal resection procedures, divided in three patient groups according to the type of analgesia: Group 1: use of acatheter for local wound infusion (KAT) n=73; group 2: epidural analgesia (EPI) n=23; and control group 3 with combined parenteral and subcutaneous analgesia (CON) n=66. The main objective of this study was to analyse postoperative pain and the consumption of opioid analgesics in the first three days from the surgery and the incidence of any complications related to the analgesic therapy. Opioid consumption in KAT and EPI groups was significantly lower compared to CON in the first 72 hours from the surgery. The lowest postoperative pain was measured in the EPI group. Subjective perception of pain, measured using VAS, was not significantly different between the KAT and CON groups. In KAT patients, vomiting was statistically less frequent than in CON patients. There was no significantly different incidence of paralytic ileus in the KAT and CON groups and no paralytic ileus was observed in the EPI group. There was no increased incidence of SSI (surgical site infections) in the KAT group compared to the other groups. The use of the catheter was assessed as safe. Insertion and management of the catheter is unsophisticated, and we did not observe any complications in terms of application of the catheter or toxic side effects of the LA. The use of the catheter clearly reduced opioid administration in the postoperative period compared to the control group (CON) with combined parenteral and subcutaneous analgesics. The best pain control measured using the visual analog scale (VAS) was observed in the EPI group.

Assessment and pathophysiology of pain in cardiac surgery.

Analysis of the problem of surgical pain is important in view of the fact that the success of surgical treatment depends largely on proper pain management during the first few days after a cardiosurgical procedure. Postoperative pain is due to intraoperative damage to tissue. It is acute pain of high intensity proportional to the type of procedure. The pain is most intense during the first 24 hours following the surgery and decreases on subsequent days. Its intensity is higher in younger subjects than elderly and obese patients, and preoperative anxiety is also a factor that increases postoperative pain. Ineffective postoperative analgesic therapy may cause several complications that are dangerous to a patient. Inappropriate postoperative pain management may result in chronic pain, immunosuppression, infections, and less effective wound healing. Understanding and better knowledge of physiological disorders and adverse effects resulting from surgical trauma, anesthesia, and extracorporeal circulation, as well as the development of standards for intensive postoperative care units are critical to the improvement of early treatment outcomes and patient comfort.

Association Between Acute Pain and Hemodynamic Parameters in a Postoperative Surgical Intensive Care Unit

I conducted a prospective repeated-measure study in the general surgery intensive care unit to investigate the associations among acute postoperative pain, analgesic therapy, and hemodynamic parameters. I selected 33 patients and recorded 84 episodes of pain. I measured intensity of pain and hemodynamic parameters after patients were transferred from the postanesthesia care unit to the general surgery intensive care unit, immediately before analgesic therapy and at 15, 30, and 45 minutes after analgesic therapy. Acute pain increased systolic (SBP), diastolic (DBP), and mean arterial blood pressure (MAP); pulse rate (PR); and arterial oxygen saturation. Fifteen minutes after analgesic therapy, SBP and PR decreased, and DBP, MAP, and oxygen saturation increased. Thirty minutes after therapy, SBP, MAP, and PR decreased, and DBP and oxygen saturation increased. Forty-five minutes after therapy, SBP, MAP, and PR decreased, and DBP and oxygen saturation increased. I saw no significant hemodynamic parameter changes during postoperative episodes of pain.

Oral oxycodone for pain after caesarean section: A randomized comparison with nurse-administered IV morphine in a pragmatic study

Background and aimsThe present randomized open label parallel group study was conducted to evaluate if an oral oxycodone (OXY) regimen can be at least equally effective and as safe for postoperative analgesia after caesarean section (CS) as a standard of care program using nurse-administered intravenous morphine (IVM), followed by oral codeine. MethodsEighty women (40+40) were scheduled for elective CS under spinal anaesthesia. All patients received postoperative multimodal analgesic therapy, including ibuprofen and paracetamol. The OXY group got standardized extended release and short acting oral treatment (and in a few cases intravenous OXY) as needed and the other group received current standard of care, IVM as needed for 24h, followed by codeine. Opioid treatment lasted maximum five days. Outcome measures were pain intensity (numerical rating scale, NRS), opioid requirements, duration of administering opioids and safety for mother and newborn. All opioids in the study were expressed in OXY equivalents, using a conversion table. As the bioavailability of each opioid has a certain extent of interindividual bioavailability this conversion represents an approximation. The possible influence of opioids on the newborns was evaluated by the Neurological Adaptive Capacity Score at birth and at 24 and 48h. ResultsDuring the first 24h, there were no differences between treatments in opioid requirements or mean pain intensity at rest but pain intensity when asking for rescue medication was lower in the OXY than in the IVM group (mean±SD; 5.41±6.42 vs. 6.42±1.61; p=0.027). Provoked pain (uterus palpation) during the first 6h was also less in the OXY group (3.26±2.13 vs. 4.60±2.10; p=0.007). During the 25–48h period postoperatively, patients on OXY reported significantly lower pain intensity at rest (2.9±1.9 vs. 3.8±1.8; p=0.039) and consumed less opioids (OXY equivalents; mg) (31.5±9.6 vs. 38.2±38.2; p=0.001) than those on IVM/codeine. The total amount of opioids 0–5 days postoperatively was significantly lower in the OXY than in the IVM/codeine group (108.7±37.6 vs. 138.2±45.1; p=0.002). Duration of administering opioids was significantly shorter in the OXY group. Time to first spontaneous bowel movement was shorter in the OXY group compared with the IVM/codeine group. No serious adverse events were recorded in the mothers but the total number of common opioid adverse effects was higher among women on IVM/codeine than among those receiving OXY (15 vs. 3; p=0.007). No adverse outcomes in the newborns related to treatment were observed in either group. ConclusionsIn a multimodal protocol for postoperative analgesia after CS better pain control and lower opioid intake was observed in patients receiving oral OXY as compared to those on IVM/codeine. No safety risks for mother and child were identified with either protocol. ImplicationsOur findings support the view that use of oral OXY is a simple, effective and time saving treatment for postoperative pain after CS.

Application of mesh plug tension-free repair of inguinal hernia in grass-roots hospital

Objective To evaluate the clinical value of application of mesh plug tension-free repair of ingui-nal hernia in grass-roots hospital .Methods A total of 32 patients with inguinal hernia treated by benison-free ingui-nal herniorrhaphy with mesh plug and 28 patients treated with the traditional herniorrhaphy were retrospectively ana-lysed.Results The mean operation time and the postoperative hospital stay of group A were 56.94min and 5.25d, and those of group B were 69.61min and 5.96d,the mean operation time and the postoperative hospital stay of group A were significantly shorter than those of group B （t=-2.891、-3.284,all P〈0.05）.Patients needed postoperative analgesic therapy （10 cases） and patients suffered from urine retation （ 2 cases ） of group A were less than group B（χ2 =8.014,5.357,all P〈0.05）.There were 3 cases with postoperative scrotum hematoma in each group and they had no statistical difference for that（P〉0.05）.All cases received follow-up for 20-40 months,there were no recur-rence in group A during the follow-up period,but 2 cases recurrence in group B .Conclusion Mesh plug tension-free repair of inguinal hernia has the advantages of shorter operation time ,more rapid recovery ,less complications and low-er recurrence rate ,so it is suitable for popularization and application in grass-roots hospital . Key words: Hernia,inguinal; Herniorrhaphy,tension-free

Combination of pre-emptive port-site and intraoperative intraperitoneal ropivacaine for reduction of postoperative pain: a prospective cohort study

ObjectiveTo evaluate the effectiveness of intraoperatively applied local ropivacaine added to standard analgesic therapy in reducing postoperative pain intensity and opioid requirement under routine hospital conditions. Study designIn this prospective controlled cohort study, 303 consecutive patients receiving a gynaecological laparoscopic intervention at the Jena University Hospital were included. The study cohort (n=168) received, in addition to standard pain management, a port-site (PS) infiltration with ropivacaine prior to incision and intraperitoneal (IP) instillation at the end of surgery. On the first postoperative day patients answered a validated questionnaire, and requirement of rescue analgesics was assessed. ResultsPain intensity was assessed on an 11-point numeric rating scale (NRS) from 0=no pain to 10=most severe pain. Reported pain intensity for movement-related pain was significantly lower (p=.001) in the study group compared with the control group (4.4 (SD 2.4) vs. 5.3 (SD 2.2) respectively). Minimal pain intensity after operation was also significantly lower in the study cohort (2.6 (SD 1.7) vs. 2.1 (SD 1.8), (p=.007)). Significantly fewer patients required rescue opioids for analgesia in the ropivacaine cohort (p=.001). The requested dose of rescue opioid (piritramide) in this cohort was also lower (p=.035) with 6.5mg (SD 4.9) vs. 8.7mg (SD 6.6), and demanded later (p=.001) with 4.3h after surgery vs. 3.1h. Patients in the study cohort experienced less nausea (p=.046). Higher satisfaction scores with pain management were reported in the ropivacaine group 12.7 (SD 2.5) vs. 11.6 (SD 2.8) (p<.001) (16-point NRS with 0=not at all, 15=completely satisfied). ConclusionAddition of pre-emptive port-site plus intraperitoneal ropivacaine to standard postoperative analgesic therapy reduced postoperative pain intensity and opioid consumption in gynaecological laparoscopy.

Preventive analgesia for postoperative pain control: a broader concept.

Pain from surgical procedures occurs as a consequence of tissue trauma and may result in physical, cognitive, and emotional discomfort. Almost a century ago, researchers first described a possible relationship between intraoperative tissue damage and an intensification of acute pain and long-term postoperative pain, now referred to as central sensitization. Nociceptor activation is mediated by chemicals that are released in response to cellular or tissue damage. Pre-emptive analgesia is an important concept in understanding treatment strategies for postoperative analgesia. Pre-emptive analgesia focuses on postoperative pain control and the prevention of central sensitization and chronic neuropathic pain by providing analgesia administered preoperatively but not after surgical incision. Additional research in pre-emptive analgesia is warranted to better determine good outcome measurements and a better appreciation with regard to treatment optimization. Preventive analgesia reduces postoperative pain and consumption of analgesics, and this appears to be the most effective means of decreasing postoperative pain. Preventive analgesia, which includes multimodal preoperative and postoperative analgesic therapies, results in decreased postoperative pain and less postoperative consumption of analgesics.

Laparoscopic Versus Open Reversal of a Hartmann Procedure: A Single‐Center Study

Re-anastomosis after a Hartmann procedure is associated with a higher morbidity and mortality than other elective colorectal operations. The goal of this comparative study was to evaluate whether laparoscopic reversal is a justified operative approach, although the initial operation is most often an emergency laparotomy. A retrospective analysis was conducted on data collected on all 70 patients who underwent laparoscopic and open reversal of a Hartmann procedure at the Department of Surgery, University of Schleswig-Holstein, Campus Lübeck, between January 1999 and December 2011. Together with general demographic data, the analysis included the indication for the initial Hartmann procedure, time to reversal, intraoperative findings, the choice of operative method, operating time, postoperative pain control, return of normal bowel function, length of hospital stay, and peri- and postoperative morbidity and mortality. In most patients, the Hartmann procedure was performed after a perforated sigmoid diverticulitis. We were not able to find any statistically significant differences with respect to gender, body mass index (BMI) and American Society of Anesthesiologists classification between the laparoscopic group (LG) (N = 24 patients) and the open group (OG) (N = 46). In the LG, patients were significantly younger (p = 0.019). The median operating time was 210 min (75-245) in the LG, which was significantly longer than in the OG (166 min; 66-230). The statistical analysis of the duration of postoperative analgesic therapy (LG 7 days; OG 12 days), return to normal diet (LG 3 days; OG 4 days), return of normal bowel function (LG 3 days; OG 4 days) and length of hospital stay (LOS) (LG 10 days; OG 15 days) detected significant differences in advantage for the LG. Unplanned return to theatre during index admission was only necessary in the OG (N = 7, 15.2 %). With a median follow-up of 8 months (range 1-20), we observed a comparable number of minor complications in both groups but a significantly higher number of major complications in the OG (N = 27, 58.7%) (p = 0.001). Conversion occurred in three cases (12.5%). There was no mortality in either of the two groups. This study was able to demonstrate the feasibility of the laparoscopic approach. In terms of postoperative results it should be seen as equivalent to the open procedure. However, the laparoscopic approach requires profound surgical expertise. The indication should be made after a careful risk/benefit analysis for each individual patient.

Obstructive Sleep Apnea, Pain, and Opioid Analgesia in the Postoperative Patient

Obstructive sleep apnea (OSA) is a common health problem among surgical patients. Human evidence supports that important components of OSA like sleep fragmentation and intermittent hypoxia may enhance pain behavior and also increase sensitivity to opioid analgesia. To the extent that these effects might affect postoperative opioid pharmacology, OSA may impact the risk for opioid-induced ventilatory impairment (OIVI), a potentially serious complication in the postoperative patient. On the other hand, certain pathophysiological features of OSA might promote the development of OIVI due to enhancing respiratory compromise and/or through suppressing arousal from sleep in response to an airway obstruction event. Nonetheless, possible determinants of OIVI are not limited to factors associated with sleep-disordered breathing and current evidence does not support a direct relationship between an isolated preoperative diagnosis of OSA and increased risk for OIVI during postoperative analgesic therapy. Older age, comorbidity burden, and increased postoperative sedation, seem to be important promoters of potentially severe OIVI in the postoperative patient. Accepted strategies to prevent OIVI without interfering with postoperative analgesia include adopting opioid-sparing analgesic techniques, as well as establishing intense patient monitoring with emphasis on the respiratory and mental capacities.

Effect of Intravenous Paracetamol on Postoperative Morphine Requirements in Neonates and Infants Undergoing Major Noncardiac Surgery

Ceelie, Ilse*; De Wildt, Saskia N.*; Van Dijk, Monique*; Van Den Berg, Margreet H. M. J.*; Van Den Bosch, Gerbrich E.*; Duivenvoorden, Hugo J.†; De Leeuw, Tom G.‡; Mathot, Ron§; Knibbe, Catherijne A. J.*∥¶; Tibboel, Dick*Author Information

Effect of Intravenous Paracetamol on Postoperative Morphine Requirements in Neonates and Infants Undergoing Major Noncardiac Surgery

Continuous morphine infusion as standard postoperative analgesic therapy in young infants is associated with unwanted adverse effects such as respiratory depression. To determine whether intravenous paracetamol (acetaminophen) would significantly (>30%) reduce morphine requirements in neonates and infants after major surgery. Single-center, randomized, double-blind study conducted in a level 3 pediatric intensive care unit in Rotterdam, The Netherlands. Patients were 71 neonates or infants younger than 1 year undergoing major thoracic (noncardiac) or abdominal surgery between March 2008 and July 2010, with follow-up of 48 hours. All patients received a loading dose of morphine 30 minutes before the end of surgery, followed by continuous morphine or intermittent intravenous paracetamol up to 48 hours postsurgery. Infants in both study groups received morphine (boluses and/or continuous infusion) as rescue medication on the guidance of the validated pain assessment instruments. Primary outcome was cumulative morphine dose (study and rescue dose). Secondary outcomes were pain scores and morphine-related adverse effects. The cumulative median morphine dose in the first 48 hours postoperatively was 121 (interquartile range, 99-264) μg/kg in the paracetamol group (n = 33) and 357 (interquartile range, 220-605) μg/kg in the morphine group (n = 38), P < .001, with a between-group difference that was 66% (95% CI, 34%-109%) lower in the paracetamol group. Pain scores and adverse effects were not significantly different between groups. Among infants undergoing major surgery, postoperative use of intermittent intravenous paracetamol compared with continuous morphine resulted in a lower cumulative morphine dose over 48 hours. trialregister.nl Identifier: NTR1438.

Risk Factors for Chronic Pain Syndrome after Gynecological Surgery

Objective: to define risk factors for chronic postoperative pain syndrome (CPPS) in gynecological patients. Subjects and methods. The pre- and intraoperative examination data of 339 gynecological patients who had been operated on via only laparotomic approach and received postoperative traditional therapy (without adaptogens and antioxidants) were used to study the risk factors of CPPS. Postoperatively, subjective self-assessment tests were carried out using the visual analogue scale (VAS) and 4-point pain rating scale to measure pain intensity. Results. The material of 339 patients who had undergone gynecological surgery was used to investigate the importance of CPPS risk factors associated with their preoperative features and with the indicators characterizing the performed intervention. The reasons that were of statistically confirmed significance to the risk of CPPS were identified. The findings may be used to individualize a postoperative analgesic therapy regimen and they determine priority measures to prevent CPPS. Conclusion. The reasons associated with a significant increase in the relative risk of CPPS (RR, 1.3 to 2.6; p 0.05; 95% CI for RR and OR) are anemia with a preoperative hemoglobin concentration of 100 to 120 g/l, first-to-second-degree obesity, a less than 2-hour operation, an intraoperative blood loss of less than 500 ml, and preoperative parasympatotonia. Key words: gynecological surgery, chronic postoperative pain syndrome, risk factors.