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Little is known about functional recovery following patient discharge in an established enhanced recovery programme after video-assisted thoracoscopic lobectomy. We conducted a single-centre pilot prospective observational cohort study. We hypothesised that patients achieved early functional recovery after discharge. A total of 32 patients aged ≥ 18 years were enrolled. A digital device was used for objective activity measurements, and patient-reported outcomes were collected as subjective measurements. Primary outcomes were the difference in physical activity; sleep duration; pain; fatigue; and average quality of life scores between pre-operative baseline and 7 days following discharge. The secondary outcome was the reason for reduced daily activity during the first 7 days after discharge. Median (IQR [range]) length of stay was 3 (2-5 [1-13]) days. Up to post-discharge day 7, total, lower intensity and moderate-to-vigorous activities were lower than pre-operative activity (p

Objective assessment of fluid status in critical surgical care may help optimize perioperative fluid administration and prevent postoperative fluid retention. We evaluated the feasibility of hydration status and fluid distribution assessment by Bioimpedance spectroscopy Analysis (BIA) in patients undergoing acute high-risk abdominal (AHA) surgery. This observational study included 73 patients undergoing AHA surgery. During the observational period (0-120 h), we registered BIA calculated absolute fluid overload (AFO) and relative fluid overload (RFO), defined as AFO/extracellular water ratio, as well as cumulative fluid balance and weight. Based on RFO values, hydration status was classified into three categories: dehydrated (RFO - 10%), normohydrated (- 10% ≤ RFO ≤ + 15%), overhydrated RFO 15%. We performed a total of 365 BIA measurements. Preoperative overhydration was found in 16% of patients, increasing to 66% by postoperative day five. The changes in BIA measured AFO correlated with the cumulative fluid balance (r2 = 0.44, p .001), and change in weight (r2 = 0.55, p .0001). Perioperative overhydration measured with BIA was associated with worse outcome compared to patients with normo- or dehydration. We have demonstrated the feasibility of obtaining perioperative bedside BIA measurements in patients undergoing AHA surgery. BIA measurements correlated with fluid balance, weight changes, and postoperative clinical complications. BIA-assessed fluid status might add helpful information to guide fluid management in patients undergoing AHA surgery.

International audience; The aim of this review was to update the recommendations for optimal pain management after open and laparoscopic or robotic prostatectomy. Optimal pain management is known to influence postoperative recovery, but patients undergoing open radical prostatectomy typically experience moderate dynamic pain in the immediate postoperative day. Robot-assisted and laparoscopic surgery may be associated with decreased pain levels as opposed to open surgery. We performed a systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) with PROcedure SPECific Postoperative Pain ManagemenT (PROSPECT) methodology. Randomised controlled trials (RCTs) published in the English language, from January 2015 until March 2020, assessing postoperative pain, using analgesic, anaesthetic and surgical interventions, were identified from MEDLINE, EMBASE and Cochrane Databases. Of the 1797 studies identified, 35 RCTs and 3 meta-analyses met our inclusion criteria. NSAIDs and COX-2 selective inhibitors proved to lower postoperative pain scores. Continuous intravenous lidocaine reduced postoperative pain scores during open surgery. Local wound infiltration showed positive results in open surgery. Bilateral transversus abdominis plane (TAP) block was performed at the end of surgery and lowered pain scores in robot-assisted procedures, but results were conflicting for open procedures. Basic analgesia for prostatic surgery should include paracetamol and NSAIDs or COX-2 selective inhibitors. TAP block should be recommended as the first-choice regional analgesic technique for laparoscopic/robotic radical prostatectomy. Intravenous lidocaine should be considered for open surgeries.

Background Clinical indicators are powerful tools to quantify the safety and quality of patient care. Their validity is often unclear and definitions extremely heterogeneous. As part of the International Standardised Endpoints in Perioperative Medicine (StEP) initiative, this study aimed to derive a set of standardised and valid clinical outcome indicators for use in perioperative clinical trials. Methods We identified clinical indicators via a systematic review of the anaesthesia and perioperative medicine literature (PubMed/OVID, EMBASE, and Cochrane Library). We performed a three-stage Delphi consensus-gaining process that involved 54 clinician–researchers worldwide. Indicators were first shortlisted and the most suitable definitions for evaluation of quality and safety interventions determined. Indicators were then assessed for validity, reliability, feasibility, and clarity. Results We identified 167 clinical outcome indicators. Participation in the three Delphi rounds was 100% (n=13), 68% (n=54), and 85% (n= 6), respectively. A final list of eight outcome indicators was generated: surgical site infection at 30 days, stroke within 30 days of surgery, death within 30 days of coronary artery bypass grafting, death within 30 days of surgery, admission to the intensive care unit within 14 days of surgery, readmission to hospital within 30 days of surgery, and length of hospital stay (with or without in-hospital mortality). They were rated by the majority of experts as valid, reliable, easy to use, and clearly defined. Conclusions These clinical indicators can be confidently used as endpoints in clinical trials measuring quality, safety, and improvement in perioperative care. Registration PROSPERO 2016 CRD42016042102 (http://www.crd.york.ac.uk/PROSPERO/display_record.php? ID=CRD42016042102).

Effective peri-operative pain management is a prerequisite for optimal recovery after surgery. Despite published evidence-based guidelines from several professional groups, postoperative pain management remains inadequate. The procedure-specific pain management (PROSPECT) collaboration consists of anaesthetists and surgeons with broad international representation that provide healthcare professionals with practical and evidence-based recommendations formulated in a way that facilitates clinical decision-making across all stages of the peri-operative period on a procedure-specific basis. The aim of this manuscript is to provide a detailed description of the current PROSPECT methodology with the intention of providing the rigour and transparency in which procedure-specific pain management recommendations are developed. The high methodological standards of the recommendations should improve the quality of clinical practice. ispartof: ANAESTHESIA vol:74 issue:10 pages:1298-1304 ispartof: location:England status: published

Background Preoperative single high-dose glucocorticoid may have early outcome benefits in total hip arthroplasty (THA) and knee arthroplasty (TKA), but long-term safety aspects have not been evaluated. Methods From October 2013, the departments reporting to the prospective Lundbeck Foundation Database for Fast-track Hip and Knee Replacement introduced preoperative methylprednisolone (MP) 125 mg as part of a multimodal analgesic protocol in TKA. We analysed the risk of length of hospital stay (LOS) >4 days, 30 and 90 day readmissions in patients with MP vs patients having TKA before the use of MP and adjusted for comorbidity and place of surgery. An unadjusted comparison was specifically done to evaluate deep prosthetic infections. Results Of a total of 3927 TKA procedures, 1442 received MP. Median LOS was 2 days in both groups, but the fraction with LOS >4 days was 6.0% vs 11.5% (P 4 days in adjusted analysis [odds ratio (OR) 0.51; confidence interval (CI) 0.39–0.68; P Adjusted analysis did not identify MP to be associated with 30 day (OR 1.18; CI 0.89–1.56; P=0.25) or 90 day (OR 1.12; CI 0.86–1.46; P=0.39) readmissions. The incidence of deep infections requiring surgical intervention was 0.8% vs 0.7% with MP vs without, respectively (P=0.78). Conclusions In this detailed prospective cohort study, preoperative high-dose glucocorticoid administration was not associated with LOS >4 days, readmissions or infectious complications in TKA patients without contraindications. Clinical trial registration NCT01515670.

The purpose of this study was to assess early physical function after total hip or knee arthroplasty (THA/TKA), and the correlation between patient-reported outcome measures, physical performance and actual physical activity (measured by actigraphy).A total of 80 patients aged 55 to 80 years undergoing THA or TKA for osteoarthritis were included in this prospective cohort study. The main outcome measure was change in patient reported hip or knee injury and osteoarthritis outcome score (HOOS/KOOS) from pre-operatively until post-operative day 13 (THA) or 20 (TKA). Secondary measures were correlations to objectively assessed change in physical performance (paced-walk, chair-stand, stair-climb tests) at day 14 (THA) or 21 (TKA) and actual physical activity (actigraphy) measured at day 12 and 13 (THA) or 19 and 20 (TKA).Patients reported improved physical function (HOOS or KOOS) pre-operatively until day 13 (THA) or 20 (TKA) with a mean difference of 7 (95% confidence interval (CI) 1 to 13, p = 0.033) and 6 (95% CI 1 to 12, p = 0.033) percentage points, respectively. By contrast, objectively assessed physical function and activity declined, with no correlations between subjective and objective assessments for either THA or TKA patients (rEarly improvement in patient-reported physical function after THA/TKA does not correlate with objectively assessed function, and patient reported outcomes should not be used as the only measure of recovery. Cite this article

Background Maximising patient comfort during and after surgery is a primary concern of anaesthetists and other perioperative clinicians, but objective measures of what constitutes patient comfort in the perioperative period remain poorly defined. The Standardised Endpoints in Perioperative Medicine initiative was established to derive a set of standardised endpoints for use in perioperative clinical trials. Methods We undertook a systematic review to identify measures of patient comfort used in the anaesthetic, surgical, and other perioperative literature. A multi-round Delphi consensus process that included up to 89 clinician researchers was then used to refine a recommended list of outcome measures. Results We identified 122 studies in a literature search, which were the basis for a preliminary list of 24 outcome measures and their definitions. The response rates for Delphi Rounds 1, 2, and 3 were 100% (n=22), 90% (n=79), and 100% (n=13), respectively. A final list of six defined endpoints was identified: pain intensity (at rest and during movement) at 24 h postoperatively, nausea and vomiting (0–6 h, 6–24 h, and overall), one of two quality-of-recovery (QoR) scales (QoR score or QoR-15), time to gastrointestinal recovery, time to mobilisation, and sleep quality. Conclusions As standardised outcomes will support benchmarking and pooling (meta-analysis) of trials, one or more of these recommended endpoints should be considered for inclusion in clinical trials assessing patient comfort and pain after surgery.

Laparoscopic colonic resection may facilitate early postoperative recovery due to reduced surgical stress, pain and ileus. However, large randomised studies have only shown marginal improvements in outcome compared with open surgery, reporting a median hospital stay of about 5-7 days. Concomitant with these developments multimodal rehabilitation, which involves a revision of general postoperative care principles, improved pain relief with epidural analgesia and early oral nutrition and mobilization, has demonstrated greater improvements in recovery after open surgery, resulting in a median hospital stay of about 2-4 days. Recent single centre, randomised studies where laparoscopic and open colonic resection are combined with multimodal rehabilitation have not resolved the debate regarding which is the optimal operative technique. Therefore, new strategies are required to integrate laparoscopy with multimodal rehabilitation in order to establish its advantages, cost effectiveness and indications in specific groups of patients or colorectal procedures, thus justifying widespread application of the laparoscopic technique.

Objective Introduction of multimodal rehabilitation programmes after open colonic surgery for noninflammatory bowel disease has reduced hospital stay to about 2–3 days, but no data are available from open ileo-colic surgery for Crohn's disease with multimodal rehabilitation regimens. Therefore, the aim of study was to assess outcome after ileo-colic resections for Crohn's disease with multimodal rehabilitation. Materials and methods Thirty-two consecutive ileo-colic resections for Crohn's disease in 29 patients received epidural analgesia and enforced postoperative oral nutrition and mobilization with a scheduled stay of 2 days. Results Median time to defaecation was 2.5 days and postoperative hospital stay was 3 days. During a 30-day postoperative follow-up there was two re-admissions, one for mechanical bowel obstruction (9 days) and one because of fever and vomiting (6 days). Except for one wound abscess, one cystitis and one pneumonia, no other complications occurred. Conclusion Fast-track multimodal rehabilitation in open ileo-colic resections for Crohn's disease reduces hospital stay and with low morbidity and readmission rate.

Pain after Caesarean section is often treated with opioids with a risk of side effects. Wound infiltration with local anaesthetics is effective and has few side effects, but volume vs. dose concentration has not been examined.Ninety patients scheduled for elective Caesarean section included in a randomised, double-blinded, placebo-controlled trial receiving infiltration with 50 ml ropivacaine 0.5% or 125 ml ropivacaine 0.2% or 50 ml 0.9% saline (placebo) during surgery. Surgery was performed under lumbar spinal anaesthesia. Primary endpoint was post-operative pain. Secondary endpoints were rescue analgesic, post-operative nausea and vomiting, time spent in the postanesthesia care unit (PACU) and time to first mobilisation.No difference in pain response between groups, but time until maximum pain score was prolonged in the ropivacaine 0.5% group compared with the placebo group (P = 0.0493). The administration of ketobemidone at 24 h post-operatively in the ropivacaine 0.5% group was reduced compared with the placebo group (P = 0.020), and between the ropivacaine 0.2% group and the ropivacaine 0.5% group (P = 0.044). No significant differences between groups were found concerning time spent in the PACU, to first mobilisation or in number of women with nausea/vomiting (P ≥ 0.05). No complications related to ropivacaine were observed.Systematic infiltration with a high concentration, low volume compared with low concentration, high volume showed no significant effect on post-operative pain intensity. However, a statistically significant, but clinically limited opioid sparing effect was demonstrated compared with placebo in the high concentration, low volume group.

Background: Preoperative fasting may lead to a fluid deficit of about 1 litre, which may contribute to perioperative discomfort and morbidity. We therefore examined the association between perioperatively administered fluids aiming to correct dehydration and clinical outcome. Methods: Review of randomized, controlled, clinical trials evaluating clinical outcome, in which fluid versus no fluid was administered pre- or intraoperatively, attempting to correct preoperative fluid deficits. Data were obtained from a Medline search (1966–2001), and references cited in original papers. Seventeen trials met the inclusion criteria. Results: Based on the amount of fluid administered, we divided the studies into two groups. In nine studies, fluid administration was

Background Quantitative reviews of postoperative pain management have demonstrated that the number of patients needed to treat for one patient to achieve at least 50% pain relief (NNT) is 2.7 for ibuprofen (400 mg) and 4.6 for paracetamol (1000 mg), both compared with placebo. However, direct comparisons between paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) have not been extensively reviewed. The aims of this review are (i) to compare the analgesic and adverse effects of paracetamol with those of other NSAIDs in postoperative pain, (ii) to compare the effects of combined paracetamol and NSAID with those of either drug alone, and (iii) to discuss whether the adverse effects of NSAIDs in short-term use are justified by their analgesic effects, compared with paracetamol. Methods Medline (1966 to January 2001) and the Cochrane Library (January 2001) were used to perform a systematic, qualitative review of postoperative pain studies comparing paracetamol (minimum 1000 mg) with NSAID in a double-blind, randomized manner. A quantitative review was not performed as too many studies of high scientific standard (27 out of 41 valid studies, including all major surgery studies) would have been excluded. Results NSAIDs were clearly more effective in dental surgery, whereas the efficacy of NSAIDs and paracetamol seemed without substantial differences in major and orthopaedic surgery, although firm conclusions could not be made because the number of studies was limited. The addition of an NSAID to paracetamol may confer additional analgesic efficacy compared with paracetamol alone, and the limited data available also suggest that paracetamol may enhance analgesia when added to an NSAID, compared with NSAIDs alone. Conclusions Paracetamol is a viable alternative to the NSAIDs, especially because of the low incidence of adverse effects, and should be the preferred choice in high-risk patients. It may be appropriate to combine paracetamol with NSAIDs, but future studies are required, especially after major surgery, with specific focus on a potential increase in side-effects from their combined use.

Moderate to severe pain in the first week after axillary lymph node dissection (ALND) for breast cancer is experienced by approximately 50% of the patients. Damage to the intercostobrachial nerve (ICBN) has been proposed as a risk factor for the development of persistent pain following breast cancer surgery but with limited information on acute post-operative pain. The aim of the present study was to examine the influence of ICBN handling on pain during the first week after ALND.The study was part of a larger prospective cohort study on persistent pain after breast cancer treatment. Pain and sensory disturbances were assessed pre-operatively, within the first 72 h post-operatively and a week after surgery. Intraoperative handling of the nerve was recorded by the surgeon as preserved, partially preserved or sectioned.One hundred forty-one patients were treated with ALND level I + II, and the ICBN could be identified in 125 (89%) patients. Of the 17 not identified, eight were stated as without any sign of the nerve and were included in analysis as sectioned. Thus, the analysis included 133 patients in which 45 (34%) of these the ICBN was preserved, 39 (29%) partially preserved and 49 (37%) sectioned. At 1 week after surgery, 104 patients (78%) reported pain, whereas 35 (26%) reported moderate to severe pain. There was no difference between the ICBN groups in pain scores or sensory disturbances measured pre-operatively compared to 1 week post-operatively.The type of ICBN handling during ALND may not influence acute post-operative pain in the first week after surgery.

Deep pain complaints are more frequent than cutaneous in post-surgical patients, and a prevalent finding in quantitative sensory testing studies. However, the preferred assessment method - pressure algometry - is indirect and tissue unspecific, hindering advances in treatment and preventive strategies. Thus, there is a need for development of methods with direct stimulation of suspected hyperalgesic tissues to identify the peripheral origin of nociceptive input.We compared the reliability of an ultrasound-guided needle stimulation protocol of electrical detection and pain thresholds to pressure algometry, by performing identical test-retest sequences 10 days apart, in deep tissues in the groin region. Electrical stimulation was performed by five up-and-down staircase series of single impulses of 0.04 ms duration, starting from 0 mA in increments of 0.2 mA until a threshold was reached and descending until sensation was lost. Method reliability was assessed by Bland-Altman plots, descriptive statistics, coefficients of variance and intraclass correlation coefficients.The electrical stimulation method was comparable to pressure algometry regarding 10 days test-retest repeatability, but with superior same-day reliability for electrical stimulation (P 0.05). Between-subject variance rather than within-subject variance was the main source for test variation. There were no systematic differences in electrical thresholds across tissues and locations (P 0.05).The presented tissue-specific direct deep tissue electrical stimulation technique has equal or superior reliability compared with the indirect tissue-unspecific stimulation by pressure algometry. This method may facilitate advances in mechanism based preventive and treatment strategies in acute and chronic post-surgical pain states.

Glucocorticoids are frequently used to prevent post-operative nausea and vomiting (PONV), and may be part of multimodal analgesic regimes. The objective of this review was to evaluate the overall benefit vs. harm of perioperative glucocorticoids in patients undergoing hip or knee surgery. A wide search was performed in PubMed, Embase, and Cochrane Central to identify relevant randomized clinical trials. A systematic approach was used, starting from the PRISMA recommendations. The Cochrane Collaboration's tool was used for risk of bias assessment. Studies were divided into three groups: systemic glucocorticoid administration analogous to 10 mg or ≤ 10 mg dexamethasone, and local glucocorticoid administration. Seventeen studies with data from 1081 patients were included in the final qualitative synthesis. Benefit (of any kind) with glucocorticoid vs. placebo was reported in 15 studies. PONV was reduced with systemic glucocorticoid. Pain was reduced with high-dose systemic and local glucocorticoid, but not with low-dose systemic glucocorticoid. Systemic inflammatory markers were reduced with low-dose and high-dose systemic glucocorticoid, and with local glucocorticoid. Functional recovery was improved with local glucocorticoid. All studies were small-sized and none sufficiently powered to meaningfully evaluate uncommon adverse events. Most of the local administration studies had poor scientific quality (high risk of bias). Due to clinical heterogeneity and poor scientific quality, no meta-analysis was performed. In conclusion, in addition to PONV reduction with low-dose systemic glucocorticoid, this review supports high-dose systemic glucocorticoid to ameliorate post-operative pain after hip and knee surgery. However, large-scale safety and dose-finding studies are warranted before final recommendations.

The aim of this systematic review was to evaluate the available literature on the management of pain after laparoscopic colorectal surgery.Randomized studies, published in English between January 1995 and July 2011, assessing analgesic and anaesthetic interventions in adults undergoing laparoscopic colorectal surgery, and reporting pain scores, were retrieved from the Embase and MEDLINE databases. The efficacy and adverse effects of the analgesic techniques was assessed. The recommendations were based on procedure-specific evidence from a systematic review and supplementary transferable evidence from other relevant procedures.Of the 170 randomized studies identified, 12 studies were included. Overall, all approaches including ketorolac, methylprednisolone, intraperitoneal instillation of ropivacaine, intravenous lidocaine infusion, intrathecal morphine and epidural analgesia improved pain relief, reduced opioid requirements and improved bowel function. However, there were significant differences in the study designs and the variables evaluated, precluding quantitative analysis. The L'Abbé plots of the data from the epidural analgesia studies included in this review indicate that the pain scores in the nonepidural groups, although higher than those in the epidural groups, were within an acceptable level (i.e. 4/10).Infiltration of surgical incisions with local anaesthetic at the end of surgery, systemic steroids, conventional nonsteroidal anti-inflammatory drugs or cyclooxygenase-2-selective inhibitors in combination with paracetamol with opioid used as rescue are recommended. Intravenous lidocaine infusion is recommended, but not as the first line of therapy. However, neuraxial blocks (i.e. epidural analgesia and spinal morphine) are not necessary based on high risk:benefit ratio.

Smoking and alcohol use impair post-operative outcomes. However, no studies include fast-track surgery, which is a multimodal-enhanced recovery programme demonstrated to improve outcome. We hypothesised that outcome is similar in smokers and alcohol users as in non-users after fast-track hip and knee arthroplasty.Prospective questionnaires on co-morbidity and smoking/alcohol use were cross-referenced with the Danish National Health Registry to investigate relationship between smoking/alcohol use and length of stay of4 days and readmissions ≤ 90 days after fast-track hip and knee arthroplasty.In 3041 consecutive patients, 458 reported smoking and 216 drinking2 drinks a day, of which 66 did both. Smokers/alcohol users were younger than non-users (mean age: 64.3 vs. 68.0 years, P0.001). Multiple regression analysis showed no relation between length of stay of4 days and smoking (odds ratio [95% confidence interval], P) (1.34 [0.92-1.95], 0.127) or alcohol use (0.59 [0.30-1.16], 0.127). Thirty- and ninety-day readmission rate was 6.6% (n = 201) and 9.4% (n = 285). Multiple logistic regression analysis showed an increased risk of readmissions in smokers at 30 (1.60 [1.05-2.44], 0.028) but not 90-day follow-up (1.17 [0.80-1.73], 0.419). No increased risk of readmissions was found in alcohol users at 30 (0.94 [0.50-1.76], 0.838) or 90-day follow-up (0.83 [0.47-1.49], 0.532). No increased risk of specific readmissions (i.e. wound infections or pneumonia) typically related to smoking/alcohol use was found in smokers (1.56 [0.93-2.62], 0.091) or alcohol users (1.00 [0.47-2.15], 0.999) at 90-day follow-up.Influence of smoking or alcohol use may be less pronounced in fast-track hip and knee arthroplasty compared with data with conventional care programmes.

It is well known that chest drains are associated with severe movement-related acute pain. These noxious stimuli could play a significant role in development and maintenance of persistent post-operative pain. Therefore we studied chest drain sites in post-thoracotomy pain syndrome (PTPS) patients, in regard to pain and sensory dysfunction.We quantified thermal and pressure thresholds on both the chest drain side and the contralateral side in 11 PTPS patients and 10 pain-free post-thoracotomy patients 33 months after the thoracotomy. On average, each patient had two chest drains inserted during surgery.At follow up, two patients experienced pain at the chest drain sites, but had maximal pain near or at the thoracotomy scar. Comparison between chest drain side and control side for all 21 patients demonstrated significantly elevated thresholds for warmth detection and heat pain on the chest drain side (P0.01), but not for cool detection or pressure. No significant differences between chest drain side and control side were observed within PTPS or pain-free patients. Comparing PTPS and pain-free patients (chest drain-to-control side), no significant differences in thresholds were found. Although all 11 PTPS patients suffered from incisional pain, only two patients had pain from chest drains.Increased thresholds for thermal detection suggest that chest drain insertion is associated with late nerve injury. Because no significant differences in sensory thresholds between PTPS and pain-free patients were found, the pathophysiological role of small fibre nerve injury from chest drains in relation to PTPS remains unclear.

Experimental studies in animals, healthy volunteers, and patients with chronic pain suggest exercise to provide analgesia in several types of pain conditions and after various nociceptive stimuli. To our knowledge, there is no data on the effects of exercise on pain and nociceptive function in surgical patients despite early mobilisation being an important factor to enhance recovery. We therefore investigated possible effects of mobilisation on post-operative pain and nociceptive function after total knee arthroplasty (TKA).Thirty patients undergoing TKA under standardised anaesthesia and analgesia underwent an exercise (mobilisation) strategy on the first post-operative morning consisting of 25-m walking twice, with a 20-min interval. Pain was assessed at rest and during passive hip and knee flexion before, and 5 and 20 min after walk, as well as during walk. Nociceptive function (pain threshold and tolerance) was assessed with pressure algometry and an electrical stimulus.Pain at rest (supine) and during hip and knee flexion was significantly reduced 5 min (P0.03) and 20 min (P0.003) after walk compared with before walk, and pain was reduced during the second walk compared with the first walk (P0.034). Knee pain pressure threshold (P = 0.002) but not tolerance (P = 0.27) was increased following walk compared with before walk.This first exploratory hypothesis-generating pilot study suggests mobilisation to promote analgesic effects after TKA calling for future studies with a randomised, controlled design on exercise dose-response effects in post-surgical patients.

Bleeding and postoperative anaemia after total hip arthroplasty (THA) may trigger transfusion of red blood cells (RBC). However, large observational studies have reported associations between RBC transfusion and increased postoperative morbidity and mortality. As major bleeding or severe postoperative anaemia is intrinsically linked with RBC transfusion, direct causality between transfusion and adverse outcomes remains unclear. This study aimed to identify possible relations between RBC transfusion, severe bleeding or anaemia and mortality in all patients who died90 days after THA in Denmark in 2008.Nationwide review of patient records. Cases of adverse transfusion events, infections following transfusion, severe perioperative bleeding or anaemia and possible causal relations to mortality were identified by two independent reviewers.Of 6932 THA patients, 45 (0·6%) were transfused within 30 days and died90 days from surgery. Three patients (7%) died from causes possibly related to either severe anaemia, major bleeding alone or major bleeding with transfusion-related acute lung injury, while five (11%) died from infections occurring after RBC transfusion. Mortality in the remaining 37 patients (82%) was of unknown cause (nine patients) or related to patient or surgical factors (28 patients).Transfusion-related mortality after THA included cases of major perioperative bleeding or severe postoperative anaemia with delayed RBC transfusion in addition to possible complications to RBC transfusion per se. Future studies should account for pretransfusion haemoglobin and perioperative blood loss when evaluating RBC transfusion-associated outcomes after surgery.

Post-anaesthesia care unit (PACU) admission must be well founded and the stay as short as possible without compromising patient safety. However, within the concept of fast-track surgery, studies are limited in addressing the question: why are patients staying in the PACU?All patients operated with primary unilateral total hip or knee arthroplasty (THA or TKA) under spinal anaesthesia were included in this hypothesis-generating, prospective, observational cohort study during a 4-month period. Surgical technique, analgesia, and perioperative care were standardized. Well-defined PACU discharge criteria that had to be met on two successive assessments were evaluated every 15 min until discharge. The primary outcome was time to meet PACU discharge criteria. Secondary outcomes were actual discharge time from the PACU, specific factors detaining patients in the PACU, and potential complications at the surgical ward at follow-up 24 h post-operatively.One hundred sixty-three patients were included in the final analysis (69 THA and 94 TKA). Time to meet PACU discharge criteria was [median (interquartile range)(95% confidence interval)]: 15 min (15-15)(15-116) for THA and 15 min (15-15)(15-75) for TKA. Actual discharge time from PACU was: 25 min (20-35)(16-198) for THA and 25 min (20-31)(15-107) for TKA. Reasons for not meeting PACU discharge criteria in 15 min were mainly low oxygen saturation and pain. The short stay in the PACU did not impose complications at the surgical ward.The vast majority of patients (85%) operated with THA and TKA under low-dose spinal anaesthesia may achieve pre-defined PACU discharge criteria in 15 min. Large-scale studies should be performed to evaluate safety aspects after short PACU stay.

This study investigated the antinociceptive and anti-inflammatory effect of a topical non-steroidal anti-inflammatory drug in human thermal injury. Twelve healthy unmedicated volunteers had identical burn injuries produced on the medial side of both calves with a 49 degrees C 15 x 25 mm thermode. Ketorolac gel or placebo were randomly applied on the right or left calf 1.5 h before burn injury, immediately after burn injury and 6 and 12 h later in a double-blind trial where every subject served as his own control. Heat pain detection thresholds (HPDT), head pain tolerance (HPT), mechanical pain detection thresholds (MPDT) and the intensity of burn-induced erythema (erythema index, EI) were assessed in the area of the thermal injury, and areas of hyperalgesia to pin prick were determined outside the injury before and 3, 6 and 24 h after the burn injury. Burn injury led to a decrease in HPDT, HPT and MPDT, an increase in EI and development of mechanical hyperalgesia (P0.05). Ketorolac gel had no effect on any of the nociceptive or inflammatory variables studies (P0.2).

Thirty-two patients scheduled for total knee arthroplasty were randomized to receive an identical epidural blockade initiated 30 min before surgical incision (N = 16), or at closure of the surgical wound (N = 16). Before induction of general anaesthesia the epidural catheter was tested with bupivacaine 7.5 mg.ml-1, 2 ml. General anaesthesia was induced with thiopentone, pancuronium or atracurium, and fentanyl 0.1-0.3 mg, and maintained with N2O/O2 and enflurane. The epidural regimen consisted of a bolus of 16 ml of bupivacaine 7.5 mg.ml-1 plus morphine 2 mg, and continuous infusion of bupivacaine 1.25 mg.ml-1 plus morphine 0.05 mg.ml-1, 4 ml.h-1 for the first 24 h, and bupivacaine 0.625 mg.ml-1 plus morphine 0.05 mg.ml-1, 4 ml.h-1, for the next 24 h after operation. Additional morphine 2.5-5 mg was administered i.v. or i.m. for the first 24 h postoperatively, and ketobemidone or morphine 5-10 mg orally or rectally from 24 h to 7 d postoperatively, on request. Paracetamol 1000 mg every 8 h was administered from 48 h to 7 days postoperatively. No significant differences were observed in request for additional opioids, or in pain scores at rest or during mobilisation of the operated limb, during or after cessation of the epidural regimen. These results do not suggest timing of analgesia with a conventional, continuous epidural regimen to be of major clinical importance in patients undergoing total knee arthroplasty.

Forty-two patients scheduled for total knee arthroplasty (n = 20) or hip arthroplasty (n = 22) were randomly allocated to receive either continuous epidural bupivacaine/morphine for 48 h postoperatively plus oral piroxicam, or general anaesthesia followed by a conventional intramuscular opioid and acetaminophen regimen. Patients undergoing knee- or hip arthroplasty treated with epidural analgesia had significantly lower pain scores during mobilization under the 48 h epidural infusion compared with patients receiving conventional treatment, while no important differences were observed after cessation of the epidural regimen. However, the achieved pain relief had no impact on postoperative convalescence parameters, such as ambulation, patient activity including need for nursing care, fatigue or hospital stay. Late postoperative pain, fatigue and conservative attitudes and routines in the postoperative care, were the most important reasons limiting mobilization and activity. We conclude that effective early (48 h) postoperative pain relief with balanced analgesia does not per se lead to important improvements in convalescence and hospital stay.

The use of laparoscopic colonic surgery in Denmark was analysed with particular reference to the length of stay.Data were obtained from the Danish National Patient Registry to assess duration of hospital stay after laparoscopic colonic surgery in Denmark within the 11-year period from 2000 to 2010.There were 4582 laparoscopic colonic resections performed, reaching about 1000 operations/year in the last 2 years (2009-2010). Length of stay decreased from a median of 7 to 4 days, while mean length of stay only decreased from 9 to 7 days.The use of laparoscopic colonic resection has increased in Denmark over the last 11 years and with a concomitant decrease in postoperative length of stay. However, there is a need for further improvement by combining the laparoscopic technique with fast-track recovery.

A double-blind randomized controlled study was conducted to compare the effect of magnesium oxide (1 g 12-h) with placebo given within an evidence-based multimodal rehabilitation programme on gastrointestinal recovery, pain, mobilization and hospital stay after open colonic resection.Of 62 potentially eligible patients, 13 were excluded, leaving 22 in the magnesium oxide group and 27 in the placebo group. The main outcome measure was time to normalization of bowel function. Secondary outcome measures included postoperative nausea, vomiting, pain, fatigue, mobilization and length of postoperative hospital stay.The median times to first flatus and defaecation in the laxative and placebo groups were 18.0 vs 14.0 h and 42 vs 50 h (P0.15). Early intake of liquids, protein drinks and solid food, nausea and vomiting, pain, fatigue and mobilization were similar in the groups (P0.3). The median postoperative hospital stay was 3 days in both groups (P0.65).Magnesium oxide does not enhance the recovery of gastrointestinal function within the context of an evidence-based multimodal rehabilitation programme after open colonic surgery.

Analysis was carried out of the nature and chronological order of early complications after fast-track laparoscopic rectal surgery with a view to optimizing the short-time outcome of rectal cancer surgery.A total of 102 consecutive patients who underwent elective fast-track laparoscopic rectal cancer surgery were analysed prospectively from the Danish Colorectal Cancer Database supplemented by data from the medical records. We studied in detail the nature and chronological order of postoperative morbidity and reason for prolonged stay (5 days).Twenty-five patients (25%) had one or more complications. Surgical complications occurred in 19 patients, while six patients had medical complications as the primary event. Fifteen patients underwent reoperation, three died, and eight were readmitted within 30 days. The median length of stay was 5 days (range 2-42).Postoperative morbidity remains a significant problem in the fast-track era, even in experienced surgical hands. Our results suggest that besides improvement of surgical technique further improvement of outcome lies in early recognition and proper treatment of complications and the perioperative optimization of organ function.

BackgroundOpen inguinal hernia repair is associated with moderate postoperative pain, but optimal analgesia remains controversial. The aim of this systematic review was to evaluate the available literature on the management of pain after open hernia surgery.MethodsRandomized studies, in English, published between January 1966 and March 2009, assessing analgesic and anaesthetic interventions in adult open hernia surgery, and reporting pain scores, were retrieved from the Embase and MEDLINE databases. In addition to published evidence, clinical practice was taken into account to ensure that the recommendations had clinical validity.ResultsOf the 334 randomized studies identified, 79 were included. Quantitative analysis suggested that regional anaesthesia was superior to general anaesthesia for reducing postoperative pain. Spinal anaesthesia was associated with a higher incidence of urinary retention and increased time to home-readiness compared with regional anaesthesia.ConclusionField block with, or without wound infiltration, either as a sole anaesthetic/analgesic technique or as an adjunct to general anaesthesia, is recommended to reduce postoperative pain. Continuous local anaesthetic infusion of a surgical wound provides a longer duration of analgesia. Conventional non-steroidal anti-inflammatory drugs or cyclo-oxygenase 2-selective inhibitors in combination with paracetamol, administered in time to provide sufficient analgesia in the early recovery phase, are optimal. In addition, weak opioids are recommended for moderate pain, and strong opioids for severe pain, on request.

The aim of this study was to estimate the incidence of the post-implantation syndrome/systemic inflammatory response syndrome (SIRS) after endovascular aortic repair.All patients, undergoing elective primary endovascular repair of an asymptomatic infrarenal abdominal aortic aneurysm during 2007, were retrospectively evaluated for SIRS within the first 5 postoperative days. The only exclusion-criteria were missing data. SIRS was assessed using the criteria defined by the American College of Chest Physicians and Society of Critical Care Medicine Consensus Conference Committee.Sixty-six patients were included, 40 (60%) met the SIRS criteria within the first 5 postoperative days (95% of the 40 patients met the criteria within 3 days). We found no significant differences between the SIRS and the non-SIRS group in baseline characteristics or other data including volume of the contrast media used, type of groin access, adjunctive procedures and duration of surgery. In total, 11 (28%) patients in the SIRS group and 4 (15%) patients in the non-SIRS group underwent re-interventions. Median follow-up period was 26 (range 20-32) months. Thirty-day mortality did not differ in the groups (3% in the SIRS group vs. none in the non-SIRS group).The high incidence of SIRS after EVAR is unexpected considering the minimally invasive procedure. Further studies on the cause of this response and measures to attenuate the response seem appropriate.

Identical burn injuries were induced on both calves with a 49 °C 15 × 25 mm thermode in 12 normal volunteers. Piroxicam gel 0.5% or placebo (1 gm) was applied in a double-blind and randomized manner on each leg 90 minutes before and immediately after the burn injury. The results showed that piroxicam 0.5% gel had no effect on initial 6-hour postburn changes in heat pain detection thresholds, heat pain tolerance, mechanical (Von Frey hair) pain thresholds, area of secondary hyperalgesia, or degree of inflammation assessed by a skin reflectance spectrometer.

Uncomplicated major surgery is followed by a pronounced increased feeling of fatigue extending throughout the first month in about one-third of patients. Postoperative fatigue correlates with the degree of surgical trauma but is not related to duration of general anesthesia and surgery or to preoperative nutritional status, age, or sex. Fatigue also correlates with postoperative deterioration in nutritional parameters and impaired adaptability of heart rate during exercise. Furthermore, a postoperative decrease in muscle force and endurance is related to postoperative fatigue, whereas psychological factors are of minor importance. These findings suggest postoperative fatigue to be mediated by the endocrine-metabolic response to surgery, impaired nutritional intake, or immobilization, but the relative role of these factors remains to be established. Until then, therapeutic measures against the development of postoperative fatigue should aim at reducing the surgical stress response, effective treatment of pain to facilitate mobilization, and exercise to increase postoperative nutritional intake.

post-thoracotomy pain syndrome (PTPS) and its social consequences have been inconsistently investigated as most studies were either small sized, focused on a limited number of risk factors or included heterogeneous surgical procedures. The current objectives were to obtain detailed information on the consequences of PTPS after thoracotomy and video-assisted thoracic surgery (VATS) from homogenous unselected nationwide data, and to suggest mechanisms for the development of PTPS.data from 1327 patients were collected using a prospective national database and combined with a detailed questionnaire.the response rate was 81.5%, resulting in 546 patients without prior thoracic surgery for the final analysis. Follow-up was 22 months (range 12-36). PTPS occurred in 33% thoracotomy patients and 25% VATS patients. Clinically relevant pain was present in 11-18% of the patients and severe pain in 4-12% depending on the level of physical activity. In PTPS patients, 64% also had pain from other locations on the body. Perceived sensory changes in the thoracic area were present in 63% of PTPS patients vs. 25% in pain-free patients (P0.001). When comparing VATS with thoracotomy, no consistent differences in the prevalence, distribution of pain, sensory changes or effect of pain on daily activities were observed although clinically relevant and severe pain was reduced after VATS.this nationwide study corroborates that PTPS is a clinically relevant problem influencing daily activities a long time after thoracotomy and VATS. Nerve injury and increased pain responsiveness may explain the majority of symptoms, the prevalence and distribution of pain including perceived sensory sensations.

The optimal transfusion strategy in hip arthroplasty remains controversial despite existing guidelines. The aim of this study was to evaluate the transfusion practice in patients undergoing primary total hip arthroplasty (THA) or revision total hip arthroplasty (RTHA) in Denmark.We performed a retrospective cohort study of all patients undergoing THA or RTHA in Denmark in 2008. Primary outcomes were intercentre variation in red blood cell (RBC) transfusion rates and the timing of transfusion related to surgery.Six thousand nine hundred thirty-two THA patients and 1132 RTHA patients were included for analysis of which 1674 (24%) THA and 689 (61%) RTHA patients received RBC transfusion. Of these, 47% of THA and 73% of RTHA patients received transfusion on the day of surgery. Transfusion rates between centres varied from 7 to 71% and between 26 and 85% in THA and RTHA patients, respectively. Patients receiving RBC transfusion had longer length of stay and for THA patients an increased odds-ratio (5·5) of death within 90 days.Despite established guidelines, RBC transfusion practice in hip arthroplasty remains highly variable between Danish hospitals. The effect of RBC transfusion on outcome after hip arthroplasty should be established in prospective randomized controlled trials.

Wound administration of local anaesthetic may be effective for postoperative pain management in knee arthroplasty, but the analgesic efficacy of local anaesthetic in relation to volume vs concentration has not been determined. In a double-blinded trial, 48 patients scheduled for total knee arthroplasty were randomly assigned to receive either a high volume/low concentration solution of ropivacaine (20 ml, 0.5%) or a low volume/high concentration solution of ropivacaine (10 ml, 1%), 6 and 24 h postoperatively through an intracapsular catheter. Pain was assessed for 2 h after administration. Pain was reduced in both groups with ropivacaine administration 24 h postoperatively (p0.02), but with no difference in analgesia between groups at all time intervals. No reduction in pain scores was observed with ropivacaine injection 6 h postoperatively. The median (IQR [range]) dose of oxycodone administered was 12.5 (10-19 [0-35]) mg in the high volume/low concentration group, and 20 mg (16-40 [0-65]) mg in the low volume/high concentration group (p = 0.005). In conclusion, intracapsular administration of local anaesthetic may have limited analgesic efficacy with no volume vs concentration relationship after total knee arthroplasty.

There is evidence that postoperative cognitive dysfunction (POCD) is a significant problem after major surgery, but the pathophysiology has not been fully elucidated. The interpretation of available studies is difficult due to differences in neuropsychological test batteries as well as the lack of appropriate controls. Furthermore, there are no internationally accepted criteria for defining POCD. This article aims to provide an update of current knowledge of the pathogenesis of POCD with a focus on perioperative pathophysiology and possible benefits achieved from an enhanced postoperative recovery using a fast-track methodology. It is concluded that the pathogenesis of POCD is multifactorial and future studies should focus on evaluating the role of postoperative sleep disturbances, inflammatory stress responses, pain and environmental factors. Potential prophylactic intervention may include minimal invasive surgery, multi-modal non-opioid pain management and pharmacological manipulation of the inflammatory response and sleep architecture.

The optimal site for wound delivery of local anaesthetic after total knee arthroplasty is undetermined. Sixty patients having total knee arthroplasty received intra-operative infiltration analgesia with ropivacaine 0.2% and were then were randomly assigned to receive either intracapsular or intra-articular catheters with 20 ml ropivacaine 0.5% given at 6 h and again at 24 h, postoperatively. Analgesic efficacy was assessed for 3 h after each injection, using a visual analogue score, where 0 = no pain and 100 = worst pain. There was no statistically significant difference between groups. Maximum pain relief (median (IQR [range])) at rest observed in the 3 h after the 6 and 24 h postoperative injections was 17 (7-31 [0-80]) and 10 (4-27 [0-50]) p = 0.27 for 6-9 h; and 17 (7-33 [0-100]) and 13 (3-25 [0-72]) p = 0.28 for 24-27 h, for intracapsular and intra-articular, respectively. Intracapsular local anaesthetic has similar analgesic efficacy to intra-articular after total knee arthroplasty.

Analysis of the nature and time course of early complications after laparoscopic colonic surgery is required to allow rational strategies for their prevention and management.One hundred and four consecutive patients who underwent elective fast-track laparoscopic colonic cancer surgery were analysed prospectively from the Danish Colorectal Cancer Database, supplemented by data from the medical records. We studied in detail the time course of morbidity and reasons for prolonged stay (3 days).Seventeen (16.3%) patients had one or more complications. Surgical complications occurred in 14 patients, of which four were preceded by medical complications. Three patients had only medical complications. Median length of stay was 3 days (range 1-44).Further improvement of outcomes after fast-track laparoscopic colonic surgery might be obtained by improved surgical performance.