Search

Although opioids are effective for neonatal postoperative pain management, cumulative opioid exposure may be detrimental. Pain management practices vary among providers, but practice guidelines may promote consistency and decrease opioid use.To develop a pain management guideline (PMG) for neonates undergoing minor surgical procedures with the overarching goal of reducing opioid use without compromising the pain experience. The specific aim was for neonatal intensive care unit providers to adhere to the PMG at least 50% of the time.An interdisciplinary pain and sedation work group in a large level IV neonatal intensive care unit developed an evidence-based PMG for minor surgical procedures. Nurses and providers were educated on the new guideline, and rapid cycle quality improvement methodology provided an opportunity to adjust interventions over 3 months.The PMG was used for 32 neonates following minor surgical procedures: 18 (56%) of the neonates received only acetaminophen and no opioids, 32% required 0.15 mg/kg dose equivalent of morphine or less, and only 9% required more than 0.15 mg/kg dose equivalent of morphine. Overall, opioid use decreased by 88% compared with rates before implementation of the PMG. Providers adhered to the PMG approximately 83.3% of time.A PMG is a systematic approach to direct nurses and providers to appropriately assess, prevent, and treat neonatal pain following minor surgery while alleviating opioid overuse.Future research should focus on determining and mitigating barriers to nurse/provider use of the PMG and developing and implementing a PMG for major surgical procedures.

Patients can experience significant pain during routine procedures in the plastic surgery clinic. Methods for clinical pain reduction are often impractical, time-consuming, or ineffective. Vibration is a safe, inexpensive, and highly applicable modality for pain reduction that can be readily utilized for a wide variety of procedures. This study evaluated the use of vibration as a viable pain-reduction strategy in the clinical plastic surgery setting. Patients requiring at least 2 consecutive procedures that are considered painful were enrolled in the study. These included injections, staple removal, and suture removal. In the same patient, one half of the procedures were performed without vibration and the other half with vibration. After completing the procedures, the patients rated their pain with vibration and without vibration. The patient and the researcher also described the experience with a short questionnaire. Twenty-eight patients were enrolled in the study. Patients reported significantly less pain on the Numeric Rating Scale pain scale when vibration was used compared with the control group (p < .001). The average pain score was 3.46 without vibration and 1.93 with vibration, and vibration with injections resulted in the greatest improvement. Eighty-six percent of the patients claimed that vibration significantly reduced their pain. Vibration is an effective method of pain reduction. It significantly reduces the pain experienced by patients during minor office procedures. Given its practicality and ease of use, it is a welcome tool in the plastic surgery clinic.

Introduction There have been substantial changes in the provision of surgical services and in surgical training over the last twenty years. Consultants now have a much greater role in delivery of care, but concerns have been raised over surgical trainees' lack of experience, particularly with trauma and emergency cases. Methods The logbooks of surgical trainees undertaking 6 month posts during 1992–3 and 2009–12 in both the United Kingdom (UK) and South Africa (RSA) were analysed. Results There was a 50% reduction in total hours worked between the UK posts in 1992–3 and 2011–12. The trainee post in RSA 2009–10 completed 15% more hours than the equivalent UK trainee post. Elective cases predominated in both UK posts (70–83%) whilst in RSA the number of trauma cases was substantial (21–26%). The UK 2011/12 trainee was rarely the primary operator (30%) compared with all other training periods (72–82%). This was due to a combination of relatively less minor and more major elective surgical cases in the recent UK post compared with the historical UK post or either RSA post. Conclusion RSA has consistently offered more exposure to emergency, and especially trauma, surgery than the UK as well as more opportunity to act as primary operator. Re-introduction of “minor operations” lists for junior surgical trainees, acceptance of the importance for trainees to act as the primary operator, maintenance of the traditional “firm” structure and support for trainees who wish to spend a period of time abroad may help to improve clinical training and experience for UK surgical trainees.

OBJECTIVE:: To determine the effect of surgical invasiveness on plasma levels of arginine, citrulline, ornithine, and nitric oxide (NO) in humans. BACKGROUND:: Surgical trauma may have a profound effect on the metabolism of NO. However, human studies reported both increased and decreased NO levels after hemorrhagic shock. Arginine, citrulline, and ornithine are key amino acids involved in NO metabolism, but studies evaluating these amino acids together with NO and during 2 types of surgery are lacking. This study tests the hypothesis that major surgery has a more profound effect on plasma levels of arginine, citrulline, NO, and ornithine than minor surgery. METHODS:: Fifteen patients undergoing minor surgery (vulvectomy) and 13 patients undergoing major surgery (laparotomy) were prospectively followed up for 4 days. Plasma was collected for evaluation of levels of arginine, citrulline, NO, and ornithine. RESULTS:: Throughout the experiment, arginine levels did not significantly differ between experimental groups. Perioperative plasma citrulline levels were significantly lower in the laparotomy group than in the vulvectomy group, whereas both groups showed a decrease in citrulline levels at the end of the operation and 24 hours postoperatively. Roughly the same pattern was seen for plasma NO and ornithine levels. However, ornithine levels in the laparotomy group showed a more drastic decrease at the end of the operation and 24 hours postoperatively than citrulline and NO levels. CONCLUSIONS:: The level of surgical invasiveness has the most profound effect on plasma levels of ornithine. In addition, heavier surgical trauma is paired with lower postoperative levels of citrulline and NO metabolites than lighter surgery. It is suggested that surgical trauma stimulates the laparotomy group to consume significantly more ornithine, possibly for use in wound healing.

The objective of the report was to study the efficacy and safety of ketamine and midazolam combination in the procedural sedation of incision and drainage of abscesses in the adult emergency department (ED) patients. This prospective observational study enrolled patients aged 16-60 years (American Society of Anesthesiologists class I) requiring abscess drainage in an adult ED. Patients received 2 mg/kg of ketamine infusion over 5 min and midazolam 2-5 mg titrated to deep sedation according to Ramsay sedation scale. Primary outcome was patient satisfaction using pain score after procedure. Secondary outcomes included adverse effects, hemodynamics alterations and recovery time. Descriptive statistics were calculated using SPSS software. Fifteen patients were recruited. One patient was excluded because of difficulty with pain score interpretation. Seventy-nine percent were male patients. The mean age was 29. The mean size of abscess was 3.4 cm. The mean dose of midazolam was 3.2 mg. Eighty-six percent did not experience any pain for the procedure. Only two patients (14%) reported mild pain during the procedure. There were no significant adverse events or complications. Three patients had giddiness, two had vomiting and only one reported an unpleasant dream. The median systolic blood pressure and heart rate elevation were 30+/-5.1 mmHg and 12.5+/-3.2/min, respectively. The median time for blood pressure and pulse rate to return to baseline was 20+/-2.7 min. The use of ketamine and midazolam sedation is both well tolerated and effective for adults in the ED undergoing incision and drainage of abscesses. This study is limited by the small sample size.

Background The trend toward day-case surgery, with discharge on oral medication, has highlighted the need for effective and safe analgesics that facilitate a rapid recovery and discharge time. This study evaluated the analgesic efficacy, dose dependency, duration of action, and safety of the cyclooxygenase-2 specific inhibitor, valdecoxib, administered before oral or orthopedic surgery. Methods Eligible healthy adult patients were scheduled to undergo either extraction of two impacted third molar teeth (n = 284) or bunionectomy surgery (n = 223) with local anesthesia in two randomized, double-blind, placebo-controlled studies conducted at three centers in the United States. Patients received a single, preoperatively administered oral dose of placebo or 10 (oral surgery only), 20, 40, or 80 mg valdecoxib. Analgesic efficacy was assessed postoperatively, over a 24-h treatment period, or until the patient required rescue medication. Efficacy measures included time to rescue medication, proportion of patients requiring such rescue, pain intensity, and the Patient's Global Evaluation of Study Medication. Results In both studies, all doses of valdecoxib produced analgesia with a duration (time to rescue analgesia) and magnitude (Pain Intensity, Patient's Global Evaluation) significantly greater than placebo. A dose-dependent effect was observed up to 40 mg valdecoxib, with an 80-mg dose providing no additional analgesic benefit. In both models, all doses of valdecoxib were well tolerated, with no clinically significant treatment-related gastrointestinal, renal, or platelet-derived adverse events, and no evidence of a dose-related increase in adverse events. Conclusions Preoperative orally administered valdecoxib provides well-tolerated and effective analgesia for mild to moderate postoperative pain.

Urinary trypsin inhibitor (UTI) is a physiological protease inhibitor produced in the liver and excreted into urine. Urinary trypsin inhibitor-like antigen has been demonstrated on glial cells in the brain. This study measured cerebrospinal UTI levels in various conditions. Seven subjects in each of the following groups were studied: patients undergoing spinal anesthesia for minor surgery, spinal anesthesia for cesarean section, removal of meningioma, or at postoperative day 3 after ruptured intracranial aneurysm clipping. Cerebrospinal fluid was collected from a spinal needle, a needle puncturing the sylvian fissure, or a drainage tube from the optical carotid cistern. Urine was collected from a urinary catheter. Cerebrospinal and urinary UTI concentrations were measured by radioimmunoassay, and the urinary UTI concentration was divided by urinary creatinine concentration to give the systemic UTI concentration. The cerebrospinal UTI concentration in the brain tumor and postoperative state groups was significantly higher than in the spinal anesthesia and cesarean section groups. The systemic UTI concentration in the cesarean section and postoperative state groups was significantly higher than in the spinal anesthesia and brain tumor groups. The present results demonstrate that UTI can be detected in the cerebrospinal fluid, and suggest that cerebrospinal UTI increases in patients with a brain tumor or inflammation and is not affected by systemic UTI.

None of the natural and synthetic colloids currently available is free from the risk of side effects.This study was performed to contribute to the epidemiology of adverse reactions of the widely used 200/0.5 hydroxyethyl starch 6% solution (HES). Study end points were anaphylactoid reactions during preanesthesia infusion and perioperative course, and pruritus 5 days postoperatively (clinical examination and inquiry) and 8 wk after application (mailed patient questionnaire). We consecutively randomized 750 patients undergoing minor elective surgery into two parallel groups treated with HES (from two different manufacturers) and one control group treated with lactated Ringer's solution. The study population was well matched among the groups and consisted of patients of both sexes, aged 18-95 yr, ASA physical status I-III. No drug-related anaphylactoid reactions were detected during either of the observation intervals. There was no episode of pruritus after the fifth postoperative day. Incidence of pruritus after 8 wk was quite frequent but not significantly different (chi squared test, P = 0.77): 9.1% and 12.0% in the two HES groups and 11.5% in the lactated Ringer's solution control group. Except for pruritis, we conclude that HES was associated with no more complications than lactated Ringer's solution. Implications: Anaphylactoid reactions and pruritus (itching) after the administration of a 6% hydroxyethyl starch (200/0.5) versus lactated Ringer's solution were assessed in a prospective, randomized, controlled study. There were no differences, although there was a more than 10% incidence of pruritus in both groups. (Anesth Analg 1998;86:850-5)

Midazolam has GABAergic effects in children that may modify propofol-induced involuntary movements, yet delay recovery. In a double-blind, randomized study, 24 children (2-7 yr of age, ASA physical status I or II) undergoing short surgical procedures received midazolam 0.5 mg/kg (Group M) or placebo (Group P) per os 20-30 min before propofol anesthesia (5 mg/kg intravenously followed by an infusion). Blind observers scored sedation and anxiety levels (scale 1-4) before premedication, at separation from parents, and at induction of anesthesia. Induction and emergence were videotaped, and body movements were recorded. During recovery, times to eye opening and maximum Steward (SS = 6) and Vancouver Sedative Recovery (VSRS = 22) scores were noted. Parents were questioned about side effects that may have occurred during the following week. Both groups were similar in age, sex, weight, timing of premedication, propofol dose, and duration of surgery. The incidence of involuntary movements did not differ between groups but was higher at induction (79%) than on emergence (25%) (P < 0.05). Anxiety and sedation scores were similar in Group P and Group M, but recovery took longer after midazolam, with eye opening (mean +/- SD) 24 +/- 7 vs 43 +/- 18 min, maximum SS (median and range) 27 (13-37) vs 55 (24-138) min, and maximum VSRS 51 (30-100) vs 80 (50-130) min. Children returned to normal activity in 1 (0-5) day, and none exhibited neurological complications. We conclude that an oral premedicant dose of midazolam prolongs recovery from anesthesia in children without affecting dystonic movements after propofol.

The pharmacokinetics of oxycodone have been determined after single-dose administration by the intravenous (4.6-7.3 mg), oral (tablets, 9.1 mg and syrup, 9.1 mg), and rectal (30 mg) routes, in 48 patients undergoing minor surgery. There were no significant differences in the mean elimination half-lives between the intravenous (5.45 +/- 1.43 h), oral tablets (5.65 +/- 1.13 h), oral syrup (4.80 +/- 1.13 h), and rectal suppository (5.40 +/- 1.19 h) formulations of oxycodone. After intravenous administration, the mean plasma clearance of oxycodone was 25.5 +/- 10.1 L/h and the mean volume of distribution at steady state was 2.5 +/- 0.8 L/kg. The mean normalized area under the curve (AUC/D) obtained after intravenous dosing (48.2 +/- 30.2 micrograms.h/L/mg) was more than twice the AUC/D values obtained after the administration of oxycodone tablets (19.8 +/- 3.5 micrograms.h/L/mg), oxycodone syrup (17.5 +/- 5.3 micrograms.h/L/mg), and rectal suppository (20.3 +/- 5.1 micrograms.h/L/mg), indicating that the amount of oxycodone reaching the systemic circulation after the extravascular routes of administration was < 50% of that obtained after intravenous dosing. The mean absorption lag times after oxycodone tablets (0.52 +/- 0.33 h), oxycodone syrup (0.48 +/- 0.40 h), and rectal suppository (0.76 +/- 0.47 h) were consistent with the onset of pharmacological effects reported by the patients.

A new minimally invasive technique has recently been described which enables gastric emptying to be assessed on repeated occasions without the need for animal sacrifice. This technique has been applied to study the effect of a laparotomy or gastrotomy on gastric emptying in the rat. Groups of 10 animals underwent either a laparotomy or a gastrotomy, or were unoperated controls. Solid and liquid gastric emptying studies were performed preoperatively, and for two postoperative months. Emptying was unchanged in unoperated controls. Laparotomy animals showed delayed emptying of both solids and liquids, returning to normal by two months. Gastrotomy animals showed a similar delay in solid emptying, but liquid emptying was within the normal range postoperatively. It is concluded that minor abdominal surgery causes marked alteration in gastric emptying. The comparable emptying delay for patients is unknown, but this should be considered when patients are recovering from operation, and when interpreting postoperative gastric emptying studies.

We have studied prospectively 600 patients who had spinal anaesthesia for minor surgery, to evaluate the incidence of transient radicular irritation after the block. The anaesthetic agent (hyperbaric 5% lignocaine, hyperbaric 0.5% bupivacaine or plain 0.5% bupivacaine) was chosen according to the anticipated duration of surgery. We obtained information after operation from 537 patients (282 by telephone, 255 by letter). Ten percent of patients anaesthetized with hyperbaric 5% lignocaine (27 patients) had transient bilateral radiating pain in the lower extremities, buttocks, or both. Typically the pain started within 24 h after spinal anaesthesia, lasted less than 2 days and was described as mild. Lignocaine was the only variable that correlated with this pain. Two patients complained of symptoms after hyperbaric 0.5% bupivacaine but these were atypical compared with pain after lignocaine. None of the patients anaesthetized with plain bupivacaine had similar complaints. We conclude that the use of 5% hyperbaric lignocaine for spinal anaesthesia should be reconsidered. (Br. J. Anaesth. 1995; 74: 328–329)

This study was set up to evaluate the effects of propofol infusion anaesthesia on immunological function in minor surgery. Twenty-seven patients (median age 51 years, ASA 1-2) scheduled for minor breast surgery were randomly assigned to two groups. Anaesthesia was induced in group 1 with propofol 2.5 mg.kg-1 and maintained with propofol 12 mg.kg-1 x h-1 and 30% O2 in air, whereas in group 2 anaesthesia was induced with thiopentone 4 mg.kg-1 and maintained with 70% N2O in O2. Fentanyl and vecuronium were used in both groups. The percentages of T cells (p < 0.001), B cells (p < 0.01) and memory T cells increased (p < 0.01) in both groups. T helper cell percentages increased in the propofol but not in the thiopentone group (p < 0.05). The percentages of natural killer cells decreased from pre-induction values in both groups (p < 0.001). No changes were seen in lymphocyte proliferative responses. Minor breast surgery under propofol or conventional combined anaesthesia had only minor effects on the immune response. The higher percentage of T helper cells after propofol anaesthesia compared to conventional combined anaesthesia is beneficial, but its clinical importance remains to be determined.

The effect of applying nitroglycerin or placebo ointment to the back of the hand before venipuncture and injection of propofol was investigated in 60 ASA physical status I unpremedicated women. Eighteen patients (67%) pretreated with nitroglycerin experienced no pain compared with 10 (33%) in the placebo group. Eleven in the placebo group experienced moderate or severe pain during injection compared with only one in the active group. The time of onset of pain in more than half the subjects occurred 10 s or longer after commencement of injection, and, in more than half the patients, the site at which pain was felt was above the injection site (with three subjects experiencing it in the shoulder). No patient had a headache or experienced postural hypotension. We conclude that nitroglycerin ointment applied to the back of the hand before injection reduces the incidence of painful injection with propofol.

446 enfants de 1 mois a 6 ans subissent des interventions mineures avec perte sanguine minime. L'administration de solutions contenant du glucose a 5% resulte en hyperglycemie

Prior research on the treatment of phobias and the psychological preparation of children for operations suggested that the stressfulness of anesthesia induction might be ameliorated by a short motion picture showing children behaving calmly during induction. This was tested in a controlled experiment with 38 children undergoing minor elective operations. The anesthetics employed were standard combinations of halothane, nitrous oxide, cyclopropane and oxygen. Children who saw the film shortly before leaving for the operating room were judged to be significantly less upset than the controls while waiting to enter the operating room and while being readied for induction. The differences between the two groups during the induction itself were negligible.

Internal hemorrhoidectomy by elastic ligation is employed at Cleveland Clinic Foundation for the symptoms of annoying prolapse and/or painless anal bleeding in patients who have normal bowel function or who have irritable bowel under optimal management instruction. Results of this treatment in 286 patients selected at random are reported. The procedure was well accepted by more than 75 per cent of the patients, and two thirds of them reported little or no discomfort. Time lost from work was a small fraction of that which would have resulted had conventional excisional treatment been employed instead.

Apneic oxygenation was studied in 13 patients undergoing Jako-Laryngoscopy with a pharyngeal catheter fur oxygen administration and 18 patients having minor surgical procedures with a cuffed endotracheal lube in place for oxygen administration. Arterial Poz,Pcoz, and pH, functional residual capacity

Short stay surgery represents an innovation in the delivery and cost of medical care. The short stay surgical unit at the Children’s Hospital of Michigan has provided urologic care for 311 children during the most recent 12 months of its operation. Eighteen patients (5.7 per cent) required postoperative hospitalization. No children have required rehospitalization after discharge from the short stay unit. Short stay surgery in pediatricurology has resulted in more economic and efficient use of hospital facilities and has decreased cost per procedure. Morbidity has not increased. Short stay surgery is well accepted by the child, parent and referring physician, and has notposed problems for the operating surgeons. Short stay urologic surgery is safe and applicable to many diagnostic and therapeutic urologie surgical procedures.

The influence of six intravenous induction agents (thiopentone, methohexitone, propanidid, Althesin, diazepam and ketamine) on plasma potassium, sodium and chloride concentrations was studied in 160 healthy female patients undergoing minor gynaecological operations. This investigation was limited to the first 10 minutes after induction. A significant decrease of plasma potassium concentration (0.24–0.29 m.equiv/1.) was observed with thiopentone, methohexitone and diazepam. Propanidid and Althesin were investigated at two dose levels. Propanidid 10 mg/kg showed a small but significant mean peak rise of 0.06 m.equiv/1. of plasma potassium. The induction agents investigated did not have a significant effect on the plasma sodium and chloride concentrations.

The antiemetic effects of droperidol, diphenidol, and placebo were compared in 210 patients subjected to minor gynecologic or urologic procedures. Atropine (0.6 mg), meperidine (1 mg/kg) body mass, and either droperidol (5 mg), diphenidol (40 mg), or 2 ml of 0.9% saline were administered IM, 1 hour before general anesthesia. Trial drugs were presented in coded ampules so that the study was conducted double-blind. Droperidol appeared superior to both diphenidol (p less than 0.01) and placebo (p less than 0.001) in the prevention of vomiting, and reduced the incidence of nausea when compared to saline (p less than 0.05). Forty-four patients experienced side effects, which occurred with similar frequency in the 3 groups studied.