Search

Background: Gynaecological surgeries are performed by abdominal incision is common and post-operative pain and discomfort is always anticipated. TAP block is a regional anaesthetic technique which blocks the abdominal neural afferents by administrating local anaesthetic drugs into the neuro-fascial plane. The other method for postoperative analgesia is surgical wound infiltration with local anaesthetic drugs. The aim of this study was to evaluate the post-operative analgesic efficacy of TAP block versus wound infiltration in gynaecological surgeries.Methods: The study was a prospective randomized study conducted on patients undergoing open gynaecological surgeries, conducted at the Government medical college and ESI hospital, Coimbatore. The study was initiated after obtaining an ethical clearance from the institution. Group A: patients who underwent bilateral TAP block with 0.3 ml/kg 0.25% Bupivacaine on each side. Group B: patients who received wound infiltration of 0.25% Bupivacaine 0.6ml/kg.Results: TAP block provided superior analgesic effect than the surgical site infiltration group, without significant changes in the hemodynamic parameters. The duration of analgesia was longer and the need of Tramadol in the postoperative period was found to be lesser in the TAP block group as compared to wound infiltration group.Conclusions: The TAP block is an effective and safe technique for postoperative analgesia for gynaecological surgeries than compared to the surgical wound infiltration. The requirement of Tramadol as a postoperative analgesia was less with TAP block compared to surgical wound infiltration.

Introduction Intravenous and peri-articular magnesium has been shown to reduce perioperative analgesic consumption. With this background, subcutaneous infiltration was hypothesized to potentiate the subcutaneous infiltration of local anaesthetic agent. Aim To comparatively evaluate the efficacy of magnesium sulphate as an adjunct to ropivacaine in local infiltration for postoperative pain following lower segment cesarean section. Materials and methods Sixty parturients undergoing cesarean delivery were randomized to either group A or B in a double blinded manner. After uterine and muscle closure but before skin closure, Group A was administered local subcutaneous wound infiltration of Injection (Inj) ropivacaine 0.75% 150 milligram (mg) or 20 millilitres(ml) whereas, group B patients were given a local subcutaneous wound infiltration of Inj magnesium sulphate 750 mg (1.5 ml of Inj 50% Magnesium sulphate) added to Inj ropivacaine 0.75% (18.5 ml) making a total volume of 20 ml. In postoperative period, Heart rate (HR), Mean Arterial Pressure (MAP), Visual Analogue Score (VAS), supplemental analgesic consumption and timing of each subsequent analgesic was noted for the initial 24 hours. Results There was no difference in the timings for the requirement of first Intravenous (IV) rescue analgesic among both the groups (p=0.279). However, the need for 2(nd) and 3(rd) doses of rescue analgesics was significantly later in group B and the difference was statistically significant with p-value of 0.034 and 0.031 respectively. The number of patients who were administered 2(nd), 3(rd) and 4(th) doses of rescue analgesics was significantly greater in group A as compared to group B. None of the patients in group B needed more than 4 doses of rescue analgesia while in group A, 5 patients were administered a rescue analgesic for 5(th) time. The cumulative analgesic requirement in the initial 24 hours was also greater in group A as compared to group B and the difference was statistically significant (p =0.01). The incidence of adverse effects was similar in both the groups. Conclusion Subcutaneous infiltration of magnesium along with local anaesthetic prolongs the analgesic efficacy of local anaesthetic and is not associated with any significant adverse effects.

The aim of the study is to evaluate the efficacy of post-incisional wound infiltration with levobupivacaine in preventing the postoperative pain associated with inguinal hernia repair in children. Thirty boys, ASA I - II, aged 2 - 12 yrs., undergoing unilateral inguinal hernioplasty under general anaesthesia as day-case patients were allocated randomly to have postoperative analgesia either with post-incisional wound infiltration with levobupivacaine 1.25 mg/kg or with paracetamol 30 mg/kg administered rectally. Postoperative pain was assessed initially in the Post-Anaesthesia Care Unit and on the ward by an observer and afterwards for the next 24 h by the parents, using the Poker Chip Tool for preschoolers and the Visual Analogue Scale for older children, respectively. Postoperative pain was managed by giving paracetamol. The duration of the postoperative analgesia was estimated based on the time when rescue analgesia was first given. Assessment of the quality of postoperative analgesia was based on the children's behaviour. The wound infiltration group showed an increased duration of postoperative analgesia (p < 0.001) and early mobilisation, while the efficacy of postoperative analgesia tended to be more adequate, although no statistically significant difference was noted.

Fifty children who underwent day case herniotomy received either a caudal injection of 1 ml/kg bupivacaine 0.25% or infiltration of the wound edges at the end of surgery with 0.5 ml/kg bupivacaine 0.25%, allocated at random. Postoperative pain and demeanour were assessed initially by an observer and later by use of a parental questionnaire. Wound infiltration of local anaesthetic solution provided analgesia which was comparable to that associated with caudal block, and the incidence of side effects was similar in the two groups. Wound infiltration of local anaesthetic offers a simple, safe alternative to caudal block for provision of postoperative analgesia in this group of patients.

BACKGROUND: The Ilioinguinal/iliohypogastric nerve block has been shown to significantly decrease opioid analgesic requirements and side effects after inguinal herniotomy. We compared the effect of pre-incisional field block with 0.25% bupivacaine and post-incisional wound infiltration with 0.25% bupivacaine for postoperative pain control after inguinal herniotomy.PATIENTS & METHODS: This was a randomized controlled double blind study in 62 ASA I and II children aged 1-7 years scheduled for inguinal herniotomy. They were assigned to receive either pre-incision field block (group I) or post-incision wound infiltration at the time of wound closure (group II). The pain score was assessed in the recovery room using mCHEOPS score and VAS or FLACC score at home by the parents for 24 hours.RESULTS: The mean pain scores during the 2 hour stay in the recovery room, at 12 and 18 hours at home were similar in both groups, p > 0.05. However, the mean pain scores were significantly lower at 6 hours at home in group I (1.22 ± 0.57) than in group II (1.58 ±0.90), p 0.05.CONCLUSION: We have demonstrated that both pre-incisional ilioinguinal/iliohypogastric field block and post incisional wound infiltration provided adequate postoperative analgesia for 24 hours after inguinal herniotomy.

Our objective was to assess clinical and financial outcomes with long-acting liposomal bupicavaine (LB) in laparoscopic colorectal surgery.Patients that received local infiltration with LB were strictly matched to a control group, and compared for postoperative pain, opioid use, length of stay (LOS), hospital costs, and complication, readmission, and reoperation rates.A total of 70 patients were evaluated in each cohort. Operative times and conversion rates were similar. LB patients had lower post-anesthesia care unit pain scores (P = .001) and used less opioids through postoperative day 3 (day 0 P.01; day 1 P = .03; day 2 P = .02; day 3 P.01). Daily pain scores were comparable. LB had shorter LOS (mean 2.96 vs 3.93 days; P = .003) and trended toward lower readmission, complication, and reoperation rates. Total costs/patient were $746 less with LB, a savings of $52,200 across the cohort.Using local wound infiltration with LB, opioid use, LOS, and costs were improved after laparoscopic colorectal surgery. The additional medication cost was overshadowed by the overall cost benefits. Incorporating LB into a multimodal pain regiment had a benefit on patient outcomes and health care utilization.

Context: With modern lifestyle, there has been a steep increase in the number of low back pain patients in clinical practice. Lumbar microdiscectomy is one of the most common surgeries performed for this problem. Postoperative pain management is extremely important aspect of such advanced surgical technique among which wound infiltration is an efficient method. Aims: The aim of the study was to compare the efficacy of dexmedetomidine added to ropivacaine verses plain ropivacaine following wound infiltration in terms of pain scores, requirement of rescue analgesia, and related adverse effects. Settings and Design: Randomized, prospective, controlled, double-blind study over a period of 1 year in a tertiary care hospital. Materials and Methods: Sixty patients scheduled for lumbar discectomy were randomly allocated into two groups. Group A received wound infiltration with 30 ml 0.2% ropivacaine before wound closure and Group B received wound infiltration with 1ug/kg dexmedetomidine added to 30 ml of 0.2% ropivacaine before wound closure. Data retrieved were demographic data, visual analog scores, postoperative pain scores, rescue analgesia by patient controlled analgesia pump, recovery profile, and adverse effects. Statistical Analysis Used: Data were analyzed using statistical software SPSS version 22. Mann–Whitney test, Kruskal–Wallis test, and Chi-square test were used as applicable. Results: Demographic data were comparable between the groups. Requirement of rescue analgesia was significantly less in Group B where combination of dexmedetomidine and ropivacaine was given. Conclusions: Dexmedetomidine provided effective postoperative analgesia and reduced fentanyl consumption when administered in wound infiltration with ropivacaine.

Introduction Intraoperative wound infiltration with local anaesthetic is commonly used. Apart from the obvious immediate action it has been supported that a possible down regulation of pain receptors may lead to longer effects. Our aim was to compare the use of local anaesthetic versus placebo in order to assess if indeed there is a late beneficial effect. Methods We conducted an RCT involving 400 consecutive general surgery patients randomized in 2 groups: Group A = placebo, Group B = wound infiltration with 15 ml of ropivacaine 10%. We recorded the preoperative and postoperative pain for the 1st week as well as the type and quantity of the analgesia used during the study period. Results No significant difference was found between the groups in all known confounding factors recorded. No significant difference was found in the intensity of postoperative pain. More people of group A required NSAIDs during the first 3 PO days while more people of Group B required stronger painkillers. For those patients who underwent a non urgent operation and especially laparoscopic surgery higher pain score was recorded in the group B from the 3 rd PO day onwards. Discussion Intraoperative local infiltration of the wound with local anaesthetic offers no further benefit for the general surgery apart from that of the immediate PO period. There is no late effect for pain control. Considering that during the immediate postoperative period stronger systematic painkillers are given the intraoperative, infiltration of the wound with the local anaesthetic under study offers no obvious benefit.

Local anesthetic infiltration prior to surgical incision closure is a frequently used technique in the operating room. Debate continues, with clinicians, as to the effectiveness of this technique in pain reduction. A literature review using PubMed with the criteria of "local anesthetic infiltration and pain reduction" was conducted for the use of local anesthetic infiltration prior to surgical closure. The search provided 137 results that were then categorized and reviewed, the studies that reviewed the effectiveness (pain reduction) of single dose infiltration of local anesthetics into the surgical wound was small, only numbering 23 studies. The use of local anesthetics before surgical incision or a continuous infusion of the local anesthetics into the surgical wound in the immediate post-operative period is more widely studied, but the effectiveness of this practice varies greatly between studies. The efficacy of using a single pre-closure local anesthetic infiltration ranged from producing a modest reduction in post-surgical pain to no change in post-surgical pain. This systematic review revealed that few studies have examined the effectiveness of local anesthetic infiltration into surgical incisions on post-operative pain outcomes and these results vary greatly as to the effectiveness of this surgical practice.

Background: Adequate analgesia is important after surgery and in particular after ambulatory surgery. Preemptive administration of analgesics, ie, prior to commencing surgery, has many theoretical advantages. Methods: In this prospective randomized study, the use of preincisional bupivacaine was compared with a postincision dose for the relief of postoperative pain, in 74 patients undergoing day-case breast biopsy. Results: Demographic criteria were similar in both groups. There were no differences in pain scores postoperatively on the visual analog scale (VAS): VAS at 30 minutes 4.5 ([SD] 2.4) versus 4.7 (1.9); P = not significant (NS); VAS at 60 minutes 3.3 (2.3) versus 3.6 (2.2); P = NS; VAS at 120 minutes 1.9 (1.7) versus 2.5 (2.0); P = NS; VAS at 240 minutes 0.9 (1.0) versus 1.3 (1.4); P = NS. There was no difference in the number of patients requiring additional analgesia: 13 (36%) versus 18 (47%); P = NS. Nor was there a difference in the time to additional analgesia: 55.0 (37.8) versus 55.3 (39.2) minutes; P = NS. Conclusions: The administration of local anaesthesia prior to starting surgery does not appear to have any advantage over its postoperative administration in patients undergoing ambulatory breast biopsy.

The purpose of this study was to assess the analgesic effects of wound infiltration with 300 mg ropivacaine. A total of 77 inpatients scheduled for inguinal hernia repair were randomized, to receive postoperative local infiltration with 40 ml ropivacaine 7.5 mg/ml or placebo. Wound pain, consumption of analgesics and time when patients were fit for discharge were assessed. Pain scores upon mobilization and coughing were significantly lower in the ropivacaine group over 0–24 h. At rest, this difference was noted until 12 h. The mean time to the first request for analgesics was significantly longer in the ropivacaine group. The consumption of analgesics was comparable. The median time when patients were fit for discharge occurred significantly earlier in the ropivacaine group. Wound infiltration with ropivacaine after inguinal hernia repair results in lower postoperative pain scores, delays the requirement for additional analgesics, and allows earlier patient discharge.

Novel local anesthetic blocks have become increasingly popular in the multimodal pain management following abdominal surgery, but have not been evaluated in a procedure-specific manner in colorectal surgery.This study aims to evaluate the efficacy of novel local anesthetic techniques in colorectal surgery.Electronic literature search of PubMed, EMBASE, and Cochrane databases (date range, January 1990 to February 2013) STUDY SELECTION: Randomized controlled trials comparing a novel local anesthetic technique with placebo/routine analgesia in adults undergoing open or laparoscopic colonic or rectal resection were selected.This is a meta-analysis of randomized controlled trials evaluating novel local anesthetic wound infiltration techniques such as wound catheter, transversus abdominis plane block, and intraperitoneal instillation in colorectal surgical procedures. The comparator group was defined as placebo/routine analgesia.The primary outcome was opiate requirement at 24 hours. Secondary outcomes included opiate requirements at 48 hours, pain numerical rating score at 24 and 48 hours at rest and on movement, recovery (length of stay, nausea and vomiting, time until bowel movement and diet resumption), and complications. Subgroup analysis was performed to evaluate specific local anesthetic techniques and open and laparoscopic surgery.Twelve randomized controlled trials compared local anesthetic techniques with placebo/routine analgesia. Local anesthetic techniques demonstrated a significant reduction in opiate requirement at 48 hours. Local anesthetic techniques were also associated with lower pain scores on movement at 24 and 48 hours, shorter length of stay, and earlier resumption of diet.The diverse study design led to statistical heterogeneity in several analyses.Novel local anesthetic wound infiltration techniques in colorectal surgery appear to reduce opiate requirements, to reduce pain scores, and to improve recovery in comparison with placebo/routine analgesia.

We hypothesized that improved acute postoperative pain relief will be achieved using general anaesthesia (GA) either in combination with continuous thoracic paravertebral block (GA-cPVB) or single shot (GA-sPVB) as compared to GA supplemented by local wound infiltration (GA-LWI) after unilateral major breast cancer surgery. A randomised controlled trial was conducted in 46 adult women in a day-care or short-stay hospital setting after major breast cancer surgery. Pain-intensity was measured using an 11-point visual analogue scale (VAS) until postoperative day 2. GA-sPVB was stopped due to slow inclusion. No significant difference in VAS score was noted between GA-LWI (VAS median 0.5 (interquartile range 0.18-2.00)) and GA-cPVB, (VAS 0.3 (0.00-1.55, p = 0.195)) 24 hours after surgery or at any point postoperatively until postoperative day 2. We conclude that both GA-LWI and GA-cPVB anaesthetic techniques are equally effective in treatment of acute postoperative pain after major oncological breast surgery. As GA-LWI is easily to perform with fewer complications and it is more cost-effective it should be preferred over GA-cPVB.

Background: Caesarean section is one of the most frequently performed surgeries in obstetrics. Optimal pain relief of the mother is possible with multimodal methods. Wound infiltration is one of the simplest and safe methods. The aim of the study was to compare the analgesic efficacy of wound infiltration of bupivacaine, with tramadol and bupivacaine mixture for postoperative pain. Materials and Methods: After obtaining Institutional Ethical Committee approval, 60 pregnant women of age group 18–35 years, undergoing elective caesarean section under spinal anaesthesia were included in the study. The patients were randomized into two groups of 30 each. Patients belonging to group B received bupivacaine 0.25% 0.7 mg/kg (diluted to 20 mL with normal saline), while those belonging to group T received tramadol 2 mg/kg mixed in bupivacaine 0.25% 0.7 mg/kg (diluted to 20 mL with normal saline). The time for first request of analgesia, numerical rating scale score, and cumulative consumption of diclofenac and tramadol in 24 h were compared. Results: The time for first request of analgesia in group T was 386.17 ± 233.84 min compared to group B which was 192.50 ± 134.77 (P < 0.0002). The total diclofenac consumption in the first 24 h was significantly reduced in group T when compared to group B (P < 0.0068). Conclusions: Subcutaneous wound infiltration with tramadol and bupivacaine prolongs the pain-free period and analgesic consumption after caesarean section, while it also enhances the patient satisfaction.

Local anesthetics may be delivered directly into the the surgical wound are may useful for postoperative pain relief in the surgical patients. A lecture discusses advantages and drawbacks of postoperative wound infiltration analgesia.

Since hip resurfacing arthroplasty is usually performed on younger and more active patients, the anaesthetic methods can be adjusted accordingly, to permit a lower level of hypotension during the operation in order to minimize blood loss even with simultaneous bilateral hip resurfacing. Since we started using a stringent anaesthesia protocol, we have lowered our transfusion rates to almost zero. We try to reduce the blood loss by the use of controlled hypotension and by the use of tranexamic acid, and if there is a risk for blood loss we use cell saving techniques. Specific anaesthetic measures for unilateral and bilateral hip resurfacing and for revision of hip resurfacing are described in this chapter. Analgesic measures, including patient controlled intravenous analgesia and epidural anaesthesia, regional analgesia and local wound infiltration are also discussed.

Tramadol is a potent analgesic. However, the analgesia efficacy of tramadol, particularly its minimum effective dose (MED), is not clear. The aim of this study is to find MED of tramadol for postoperative analgesia in infants. The continual reassessment method (CRM) was performed to find MED. Infants undergoing surgeries were included in the 3 phases of this series. In each phase, 24 participants were allocated a different tramadol dose. Pain intensity was measured by face, legs, activity, cry, consolability (FLACC) measurement at 3-hour intervals. Tramadol was considered ineffective if the FLACC score was higher than 4 in 10 at anytime. In phase 1, seven dose levels were used within the range 0.1-0.4 mg·kg(-1)·h(-1). Phase 1 was insufficient to identify the MED, and we increased the dose to 0.4-0.8 mg·kg(-1)·h(-1) in phase 2. Phase 2 was insufficient to identify the MED. In phase 3, local anesthetic wound infiltration was introduced, and the tramadol dose levels tested were the same as in phase 1. The successful analgesia probability of tramadol 0.4 mg·kg(-1)·h(-1) was 82.1% (95% CI, 0.742-0.925) in phase 1. In phase 2, it was 84.7% (95% CI, 0.789-0.991) with the dose 0.8 mg·kg(-1)·h(-1). Phase 1 and phase 2 were insufficient to identify the MED. In phase 3, the successful analgesia probability for dose 0.35 mg·kg(-1)·h(-1) was 96.7% (95% CI, 0.853-0.997).We have demonstrated that tramadol provides insufficient analgesia for surgeries considered to cause moderate-to-severe postoperative pain in infants if used as the sole analgesic, and that local anesthetic wound infiltration enhances the efficacy of tramadol.

Although many smaller studies have addressed anaesthetic care for bariatric surgical patients, comprehensive systematic literature reviews have yet to be compiled, and much evidence includes expert panel opinion. This review summarises study results in bariatric surgical patients regarding pre-anaesthesia evaluation, the perioperative impact of sleep-disordered breathing, airway management at anaesthetic induction and emergence, maintenance of anaesthesia, postoperative pain management, utility of clinical-care pathways and feasibility of outpatient bariatric surgery. The 'ramped' upper-body, reversed Trendelenburg position at anaesthetic induction and manual application of positive end-expiratory pressure (PEEP) is recommended. Intra-operative hypoxaemia can be treated with the combination of PEEP and recruitment manoeuvres, and attention to airway management at emergence is critical. Local anaesthetic wound infiltration and non-steroidal anti-inflammatory drugs should be part of multimodal opioid-sparing postoperative analgesia. Implementation of bariatric clinical-care pathways seems beneficial. Considering the prevalence of sleep apnoea in these patients, outpatient bariatric surgery remains controversial, but is probably safe for certain procedures, provided there is strict adherence to preoperative eligibility and home-care protocols.

Postoperative pain management is essential in the perioperative care of neonates and infants but it requires a high level of care. Wound infiltration with bupivacaine, a long-acting local anesthetic, is a simple method with minimal complications. However, studies on the effectiveness of wound infiltration in neonates and infants are lacking. The purpose of this study was to investigate the effectiveness of wound infiltration with bupivacaine for postoperative analgesia in neonates and infants undergoing abdominal surgery.A prospective, randomized controlled trial was conducted in 34 neonates and infants. The patients were randomized into two groups: the bupivacaine (B) group and the control (C) group. A standardized anesthetic protocol was used for each patient. Before wound closure, the surgical site of each patient in the B group was infiltrated with 2 mg/kg of bupivacaine, whereas no surgical site anesthetic infiltration was used in the C group. The neonatal infant pain scale (NIPS) score was used to evaluate postoperative pain, and fentanyl 0.5-1.5 μg/kg was administered when the NIPS score was ≥4. In regard to the fentanyl requirement, the NIPS score and the numbers of patients whose NIPS score was ≥4 were compared between the two groups.The median fentanyl dose requirements in the B group and C group were 1 and 0.5 μg/kg, respectively; and the difference was not statistically significant (p = 0.255). The postoperative NIPS scores in the two groups were not significantly different. In addition, there were no significant differences in the numbers of patients whose NIPS score was ≥4 at 6, 12, 18, and 24 h postoperatively.In neonates and infants, wound infiltration with bupivacaine had no significant effect on pain relief or fentanyl requirement during the first 24 h after major abdominal surgery.

Objectives This randomized double-blind study was designed to compare the postoperative analgesic effect of clonidine administered intravenously or in wound infiltration with bupivacaine. Methods Sixty adults of ASA grade I–II undergoing open cholecystectomy were randomly allocated into three groups. Group 1 (control group) patients received wound infiltration with 30 ml of 0.25% bupivacaine at the end of surgery. Group 2 patients received 3 μg kg−1 clonidine intravenously after resection of gall bladder plus wound infiltration with 30 ml of 0.25% bupivacaine. Group 3 patients received wound infiltration with 3 μg kg−1 clonidine with 30 ml of 0.25% bupivacaine. A standard general anaesthesia technique was used. Postoperative analgesia was provided with i.v. diclofenac and morphine on demand. Postoperative pain, number of patients requiring rescue analgesia and total morphine consumption during 24 h after operation was recorded. Results Postoperative morphine consumption was significantly less in patients receiving clonidine by either route when compared with the control group (P Conclusions Clonidine 3 μg kg−1 provided effective postoperative analgesia and reduced morphine requirement when administered intravenously or in wound infiltration with bupivacaine. However, the incidence of complications was less with wound infiltration. Clinical trial registry of India (www.ctri.nic.in/), registration number CTRI/2012/12/003258.

Background There have been few studies describing wound infiltration with additional intraarticular administration of multimodal analgesia for total knee arthroplasty (TKA). In this study, we assessed the efficacy of wound infiltration combined with intraarticular regional analgesia with epidural infusion on analgesic requirements and postoperative pain after TKA. Methods 40 consecutive patients undergoing elective, primary TKA were randomized into 2 groups to receive either (1) intraoperative wound infiltration with 150 mL ropivacaine (2 mg/mL), 1 mL ketorolac (30 mg/mL), and 0.5 mL epinephrine (1 mg/mL) (total volume 152 mL) combined with intraarticular infusion (4 mL/h) of 190 mL ropivacaine (2 mg/mL) plus 2 mL ketorolac (30 mg/mL) (group A), or (2) epidural infusion (4 mL/h) of 192 mL ropivacaine (2 mg/mL) combined with 6 intravenous administrations of 0.5 mL ketorolac (30 mg/mL) for 48 h postoperatively (group E). For rescue analgesia, intravenous patient-controlled-analgesia (PCA) morphine was used. Morphine consumption, intensity of knee pain (0–100 mm visual analog scale), and side effects were recorded. Length of stay and corrected length of stay were also recorded (the day-patients fulfilled discharge criteria). Results The median cumulated morphine consumption, pain scores at rest, and pain scores during mobilization were reduced in group A compared to group E. Corrected length of stay was reduced by 25% in group A compared to group E. Interpretation Peri- and intraarticular analgesia with multimodal drugs provided superior pain relief and reduced morphine consumption compared with continuous epidural infusion with ropivacaine combined with intravenous ketorolac after TKA.

The purpose of this study was to compare the pain of infiltration between unbuffered lidocaine and buffered lidocaine in a traumatic laceration. Solutions of unbuffered 1% lidocaine and buffered 1% lidocaine were randomly assigned to Site I or Site II of a single laceration for each subject, with the patient serving as self-control. Pain scores were recorded for each site, and an anesthetic preference was determined for each patient. It was found that buffered lidocaine had a preference ratio of 3.0 over unbuffered lidocaine (95% confidence interval, 1.86 to 4.84; P less than 0.0001). It was also found that Site I was preferred more often than Site II regardless of which medication was used. The conclusion is that buffered lidocaine is preferred over unbuffered lidocaine and that the order of injection is an important factor in trials that involve multiple sequential injections in the same patient.

The present study compared the postoperative analgesic effects of preincisional and postincisional wound infiltration with levobupivacaine and postoperative cortisol and prolactin levels in children following inguinal hernia repair.Ninety-six children aged 2-10 years who were undergoing elective inguinal hernia repair were randomly enrolled in this study. In group A (n = 32), 0.25 ml kg levobupivacaine (5 mg ml) was infiltrated after induction of general anaesthesia. In group B (n = 32), 0.25 ml kg levobupivacaine (5 mg ml) was infiltrated before the end of the surgery. Group C (n = 32) did not receive levobupivacaine infiltration at any time. Mean arterial pressure, heart rate, objective pain score, adverse effects and the number of rescue analgesics were recorded for 24 h. Blood samples were withdrawn following induction of anaesthesia and at 40 min after the end of surgery for measurement of blood cortisol and prolactin levels.The rescue analgesic administration, objective pain scores, heart rate, postoperative plasma cortisol and prolactin levels were higher in group C than in either group A or group B (P0.05). There were no differences in these parameters between the two treatment groups (P0.05). Postoperative plasma cortisol and prolactin levels were significantly higher in all three groups than preoperative plasma cortisol and prolactin levels (P0.001).Wound infiltration with levobupivacaine after induction of general anaesthesia and before the end of the surgery both provide postoperative pain relief following hernia repair, and decrease the stress response to postoperative pain.

Blockade of nociceptive afferents by the use of continuous wound infusion with local anesthetics may be beneficial in a postoperative pain management after colorectal surgery. The role of continuous wound infusion of levobupivacaine for pain relief and postoperative recovery was evaluated in a randomized, double-blinded, placebo-controlled trial. Fifty patients were included in the randomized, double-blinded, placebo-controlled trial. Elective abdominal colorectal surgery was performed through midline laparotomy. At the end of surgery two multiorifice 20-gauge epidural catheters were placed suprafascial. Patients were divided in two equal groups. Group L received through the each catheter 0.25% levobupivacaine with 4 ml bolus followed by an infusion of 4 ml/h during 48 h and Group S received 0.9% NaCl at the same protocol. Simultaneously, all patients received intravenous diclofenac 75 mg every 12 h for 48 h and patient-controlled analgesia with intravenous morphine. The safety and efficacy of the technique were investigated, postoperative visual analogue pain scores and morphine requirements at 6, 12, 24 and 48 h postoperatively. Satisfactory analgesia was achieved in both groups. Levobupivacaine infusion significantly reduced morphine consumption during the first 48 h in Group L (11.160 mg +/- 5.031) in comparison to Group S (58.280 mg +/-4.364) (P < 0.001). Nausea and vomiting were less present in Group L. No side effects were observed. Postoperative pain control with continuous suprafascial wound infusion of 0.25% levobupivacaine and intravenous diclofenac after elective colorectal surgery provides effective analgesia, decreases opioid requirements and reduces postoperative nausea and vomiting.

Background and aims: Blockade of nociceptive afferents by the use of continuous wound infusion with local anesthetics may be beneficial in a postoperative pain management after liver resection surgery. The role of continuous wound infusion of levobupivacaine for pain relief and postoperative recovery was evaluated in a randomized, double-blinded, placebo-controlled trial. Methods: Fifty patients with liver tumor were evaluated in each group. All liver resections were performed through subcostal incision with upper midline extension. At the end of surgery two multiholed wound catheters were placed suprafascial. Patients were thereafter randomly assigned to receive through the catheters 0.25% levobupivacaine (group L) or the same protocol with 0.9% NaCl (group S). In addition, all patients received patient controlled intravenous morphine analgesia and intravenous diclofenac 75 mg every 12 h for 48 h. Results: Satisfactory analgesia was achieved in both groups. Levobupivacaine infusion significantly reduced morphine consumption during the first 48 h in Group L (5.91 mg +/- 3.17) in comparison to Group S (46.61 mg +/-10.28) (P < 0.001) and improved pain relief at rest during 12 h and while coughing during 48 h. Nausea and vomiting were less present in Group L. No side effects were observed. Conclusions: Continuous suprafascial administration of 0.25% levobupivacaine at 4 ml/h through two catheters during 48 h after liver resection reduced morphine consumption, improved pain relief, and accelerated postoperative recovery.

The instillation of local anaesthetic agents into surgical wounds has been reported to be an effective method of reducing pain and narcotic requirements, using both local injection1,2 and topical application3 techniques. We performed a double-blind trial to test the value of the long-acting local anaesthetic, bupivacaine, in this role. Eighty patients undergoing elective cholecystectomy were entered into the study. They were divided into 2 groups of 40 patients to compare a local injection technique with a topical application technique. For each route of application. 20 patients received a test solution containing 0.25% plain bupivacaine, and 20 received 0.9% NaCl as a control. Postoperative analgesia in the form of intramuscular pethidine (1–1.5mg/kg) was made available to all patients on request. The degree of postoperative pain was assessed using three criteria: the time from operation to the first request for analgesia, the total dose of postoperative pethidine required during the first 3 postoperative days and the patient's rating of pain on a 10cm linear analogue scale at 24h and 72 h. There was no statistically significant difference between the degree of postoperative pain experienced by patients receiving bupivacaine and those receiving NaCl, when assessed by any criterion. There was also no significant difference found between patients receiving bupivacaine by local infiltration and those receiving the drug topically. It is concluded that the local application of bupivacaine to the wound is not an effective analgesic technique following laparotomy for cholecystectomy.

This is a prospective, randomized, controlled trial that compared the efficacy of different protocols of local tissue infiltration with levobupivacaine or levobupivacaine-methylprednisolone at the surgical site for pain relief after lumbar discectomy. The objective of the study was to determine the efficacy of preemptive wound infiltration with levobupivacaine and levobupivacaine-methylprednisolone at the surgical site for pain relief. Patients usually suffer significant pain after lumbar discectomy. Wound infiltration with local anesthetics with or without corticosteroids is one method to address this. A total of 100 patients were randomly allocated to five equal groups as follows: Group I had the musculus multifidi near the operated level infiltrated with 30 mL 0.25% levobupivacaine and 40 mg methylprednisolone just before wound closure; Group II had the same region infiltrated with 30 mL 0.25% levobupivacaine alone before closure; Group III had this region infiltrated with 30 mL 0.25% levobupivacaine and 40 mg methylprednisolone before the incision was made; in Group IV this region was infiltrated with 30 mL 0.25% levobupivacaine alone before incision; and in Group C (controls) this region was infiltrated with 30 mL 0.9% NaCl just before wound closure. Demographics, vital signs, postoperative pain scores and morphine usage were recorded. All four treatment groups showed significantly better results than the control group for most parameters. The treated groups had lower parenteral opioid requirements after surgery, lower incidences of nausea and shorter hospital stays. Further, the data indicate that, compared with infiltration of these drugs at wound closure, preemptive injection of levobupivacaine or levobupivacaine-methylprednisolone into the muscle near the operative site provides more effective analgesia after lumbar discectomy. Our data suggest that preemptive infiltration of the wound site with levobupivacaine alone or combined with methylprednisolone provides effective pain control with reduced opiate dose after unilateral lumbar discectomy.

Objectives This study aimed to compare the analgesic effect of ultrasound-guided transversus abdominis plane (TAP) block versus wound infiltration in patients undergoing open inguinal hernia repair. Patients and methods A total of 60 male patients scheduled for open unilateral inguinal hernia repair under general anesthesia were randomly allocated into two equal groups: group W received wound infiltration with 0.2 ml/kg of 0.25% levobupivacaine at the site of incision, and group T received ultrasound-guided TAP block with 0.5 ml/kg of 0.25% levobupivacaine. Time to first analgesic request, total morphine requirement over 24 h, and visual analogue pain score at rest and during cough were assessed over the course of 24 h. Results Total morphine requirement during the first 24 h was significantly less in group T. A total of 21 patients in group W required supplemental morphine compared with 13 patients in group T. Time to first analgesic request was significantly longer in group T. Patients receiving TAP block had significantly lower pain scores at rest for 12 h and on cough for 6 h after operation when compared with patients who received wound infiltration. Conclusion TAP block provided more reliable and effective analgesia and less total 24-h postoperative morphine consumption compared with wound infiltration with the local anesthetic.

Background and aim This study was designed to compare the postoperative analgesic effect of dexmedetomidine administered intravenously or in wound infiltration with bupivacaine in patients undergoing cesarean section. Patients and methods Ninety female patients scheduled for cesarean section were randomly allocated into three equal groups: group I received 100 ml normal saline infusion over 10 min before closure plus wound infiltration with 25 ml of 0.25% bupivacaine at the end of surgery; group II received 1 mg/kg of dexmedetomidine in 100 ml normal saline infusion over 10 min before closure plus wound infiltration with 25 ml of 0.25% bupivacaine at the end of surgery; and group III received 100 ml normal saline infusion over 10 min before closure plus wound infiltration with 1 mg/kg of dexmedetomidine added to 25 ml of 0.25% bupivacaine at the end of surgery. The number of patients requiring rescue analgesia, total morphine consumption during the first 24 h after the operation, and the level of sedation were recorded. Results Morphine consumption was significantly less in patients receiving dexmedetomidine by either route. All patients in group I required supplemental morphine, whereas 14 patients in group II and 16 patients in the wound infiltration group required supplemental morphine. Patients in group II had more hypotension and sedation compared with other groups. Conclusion Dexmedetomidine provided effective postoperative analgesia and reduced morphine consumption when administered intravenously or in wound infiltration with bupivacaine. The incidence of complications was less with wound infiltration.

This study was prompted by a complaint from a patient citing he had suffered postoperative pain and scrotal bruising. We audit postoperative pain following inguinal herniorrhaphy and patient understanding of postoperative complications. A telephone survey was carried out to assess patient experience of day-case inguinal herniorrhaphy (DIH). Having identified that there was some dissatisfaction with the outcome of DIH, a prospective audit was carried out to assess causative factors. Changes in practice were made; chiefly, the provision of patient-information leaflets and the standardisation of intraoperative and postoperative analgesia. Repeat audit then assessed the effects of these changes. Ten percent of patients had a poor understanding of postoperative complications following inguinal herniorrhaphy. Thirty-eight percent had early postoperative pain; wound infiltration of local anaesthetic at the end of inguinal herniorrhaphy reduced the incidence of early postoperative pain to 23%. Audit is an important tool in surgical quality assurance for DIH. Small changes in practice with adherence to good protocols can have a marked effect on patients’ experience.

Introduction Epidurals are commonly used for colorectal and general surgical patients to provide postoperative analgesia. However, they may be associated with hypotension which is often unresponsive to intravenous fluids. This audit was designed to assess the post-operative management of patients with epidurals. The standards were that epidural mediated hypotension should be recognised and managed appropriately i.e. with vasoconstrictors if required. Association of Anaesthetists of Great Britain and Ireland guidance also recommends patients with epidurals have 24 h access to clinicians experienced in epidural management. Method A retrospective audit of consecutive patients leaving recovery with thoracic epidurals in a district general hospital. Data was collected on operation, ward, hypotension, intravenous fluids, vasopressors, anaesthetic involvement, duration of epidural anaesthesia and complications. A re-audit was conducted in 2014 after introduction of a surgical High Observations Bay (HOB). Results Findings of the initial audit were that epidural mediated hypotension was common and was associated with repeated fluid challenges associated with significant morbidity. As a result formal teaching for surgical juniors about epidurals and hypotension was conducted, advising them to seek help and recommendations to minimise the use of epidurals and introduce a surgical high observation bay were made. The audit was then repeated. The rate of use of epidurals fell by 80% between the two audit cycles, from 24 patients in a 1 month period in June 2012 to 10 patients over a 2 month period in June 2014. There was a notable fall in their use in for elective colorectal surgical patients from 10 patients to 2 due to the adoption of alternate technique such as spinal anaesthesia or local anaesthetic wound infiltration. In the initial audit 63% of patients were managed on the ward and 37% were managed on High Dependency Unit (HDU), in the re-audit 0% of patients were managed on the ward, 55% on the surgical HOB and 44% on HDU with access to vasopressor if. Rates of hypotension fell from 63% to 30%. Excessive intravenous fluid challenges were noted in the initial audit but not the re-audit. Conclusion This audit led to a change in practice in our institution. There has been a significant decrease in the use of epidurals, which are now reserved for high risk patients and managed on HDU or a surgical HOB with vasopressors available if necessary. The prompt involvement of senior surgical and anaesthetic staff in the care of these patients avoids excessive ineffective fluid challenges if vasopressors are required to correct the hypotension. This avoids fluid overload whilst correcting the hypotension thereby addressing concerns about anastomotic perfusion. Disclosure of interest None Declared.

Study Design. A prospective, randomized, controlled trial that compared the efficacy of different protocols of local tissue infiltration with bupivacaine or bupivacaine-methylprednisolone at the surgical site for pain relief after lumbar discectomy. Objective. To determine the efficacy of preemptive wound infiltration with bupivacaine and bupivacaine-methylprednisolone after lumbar discectomy. Summary of Background Data. Patients usually have significant pain after lumbar discectomy. Wound infiltration with bupivacaine or bupivacaine-methylprednisolone is one method to address this. Methods. Seventy-five patients were randomly allocated to 5 equal groups as follows: Group I (n = 15) had the musculus multifidi near the operated level infiltrated with 30 mL 0.25% bupivacaine and 40 mg methylprednisolone just before wound closure; Group II (n = 15) had the same region infiltrated with 30 mL 0.25% bupivacaine alone before closure; Group III (n = 15) had this region infiltrated with 30 mL 0.25% bupivacaine and 40 mg methylprednisolone before the incision was made; in Group IV (n = 15), this region infiltrated with 30 mL 0.25% bupivacaine alone before incision; and Group C (controls, n = 15) had this region infiltrated with 30 mL 0.9% NaCl just before wound closure. Demographics, vital signs, postoperative pain scores, and morphine usage were recorded. Results. All 4 groups treated with bupivacaine or bupivacaine-methylprednisolone ( by preemptive or preclosure wound infiltration) showed significantly better results than the control group for most parameters. The treated groups had lower parenteral opioid requirements after surgery, lower incidences of nausea, and shorter hospital stays. Further, the data indicate that, compared with infiltration of these drugs at wound closure, preemptive injection of bupivacaine or bupivacaine-methylprednisolone into muscle near the operative site provides more effective analgesia after lumbar discectomy. Conclusion. In addition, our data suggest that preemptive infiltration of the wound site with bupivacaine alone provides similar pain control to preemptive infiltration of the wound site with bupivacaine and methylprednisolone combined.

Ropivacaine blood and drain levels were measured in 20 hip and 15 total knee arthroplasties after intraoperative wound infiltration with 150 to 200 mL (360-400 mg) of ropivacaine, followed by a 48-hour intra-articular pain pump infusion of 1000 mg (knees) and 300 mg (hips) commencing 12 hours postoperatively. Concentrations were below 2 microg/mL over the first 12 hours before the pain pump increased levels. Peak total ropivacaine concentration ranged from 0.65 to 4.36 microg/mL with the pain pump. The high infiltration doses produced levels below or within the safe threshold of 1 to 3 microg/mL. Pain pump infusion produced some C(max) levels above 3.0 microg/mL, but there was no clinical evidence of toxicity. Wound drain amounts (0.53-26.69 mg) indicate reinfusion should be safe, although further study is needed to confirm this.