Gabapentin for acute and chronic post-surgical pain

Pain after surgery remains a significant clinical problem as it impairs recovery adversely and may lead to the transition to chronic pain. Opioid medications are far from ideal agents in suppressing postoperative pain. Gabapentin -an anticonvulsant with antihyperalgesic properties- originally efficacious against neuropathic pain seems to be very promising for the management of pain after surgery as well. Gabapentin, by decreasing noxious stimulus-induced excitatory neurotransmitter release at the spinal cord, may attenuate central sensitization, and eventually decrease postoperative late pain. Furthermore, different sites of action may be pertinent to a synergistic effect with opioids. Both actions (antihyperalgesic effect and synergy with opioid analgesia) may manifest as analgesia and/or opioid-sparing effect after surgery. This has been confirmed by a variety of clinical studies, in a variety of settings. Most of these studies have shown that either single preoperative or repeated doses of gabapentin, continued for up to a few days after surgery, decrease acute postoperative pain and/or need for postoperative opioids. This has been shown for procedures such as abdominal and vaginal hysterectomy, breast surgery for cancer (mastectomy or lumpectomy), lumbar discectomy and spinal fusion, laparoscopic cholecystectomy and other, such as ENT surgery. Finally, a few studies indicate that perioperative gabapentin may as well decrease chronic pain several weeks after surgery

Use of rocuronium and sugammadex under neuromuscular transmission monitoring in a patient with multiple sclerosis

Multiple sclerosis (MS) is a potentially disabling disease characterized by demyelinating lesions in the central nervous system. One of the anesthetic challenges encountered in surgical patients with MS is the management of neuromuscular blockade (NMB) and its reversal. We report a case of a 31-year-old female patient suffering from MS, who underwent gynecological surgery under general anesthesia with sevoflurane, fentanyl, and rocuronium which was successfully reversed with sugammadex. Neuromuscular transmission (NMT) monitoring was used to guide the intraoperative doses of rocuronium and also the reversal of NMB by the use of sugammadex to ensure a safe tracheal extubation. In addition, delivered volatile was titrated according to anesthetic depth monitoring (Bispectral Index) while esophageal temperature was also monitored for the maintenance of normothermia. Postoperatively, a multimodal analgesic scheme offered a high-quality analgesia and sleep, minimization of anxiety, and increased patient satisfaction. At 1-month follow-up, the patient's course was uncomplicated without any MS exacerbation. We consider that the use of rocuronium and sugammadex under NMT monitoring may represent a useful and safe choice in patients with MS

Pretreatment with nitrous oxide enhances induction of anesthesia with sevoflurane: A randomized controlled trial

Background: Inhalation anesthesia with sevoflurane may be enhanced by several drugs or techniques. The aim of the present study was to investigate the effect of nitrous oxide (N2O) pretreatment on the speed of anesthesia induction with sevoflurane. Materials and Methods: Eighty patients scheduled for hysteroscopy under general anesthesia were randomly assigned to inhale for 10 min before induction 50% N2O in oxygen or air via a facemask. Anesthesia was induced with 7-8% sevoflurane in oxygen via a facemask. Bispectral index (BIS), end-tidal carbon dioxide (EtCO2) tidal volume, respiratory rate, oxygen saturation (SpO2), and heart rate were recorded every minute during the 10 min pretreatment periods and every 30 s during the first 300 s of induction with sevoflurane. During induction of anesthesia inspired and end-tidal sevoflurane concentrations were also recorded. Results: During the 10 min of inspired 50% N2O or air BIS, EtCO2, tidal volume, respiratory rate and heart rate values did not differ between the two groups except for the SpO2, which was higher in the N2O group (P <0.001). During induction of anesthesia the N2O group exhibited lower BIS values (P = 0.001), being significant at 60-150 s (P <0.001, P <0.001, P = 0.002, P = 0.014) as well as at 270 s (P = 0.004). EtCO2and tidal volume were consistently lower in the N2O group (P = 0.001, P = 0.041 respectively) and respiratory rate was higher (P = 0.007). Conclusion: Our results show that pretreatment of the patients with 50% N2O for 10 min enhances the speed of induction with sevoflurane as assessed by the BIS monitoring

Physiological and operative severity score for the enumeration of mortality and morbidity scoring systems for assessment of patient outcome and impact of surgeons' and anesthesiologists' performance in hepatopancreaticobiliary surgery

Context: The physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) is a scoring system used to predict morbidity and mortality. Aims: We compared the physiological and operative risk, the expected morbidity and mortality, and the observed postoperative mortality among patients operated by different surgeons and anesthetized by different anesthesiologists. Settings and Design: This was a retrospective, single center study. Subjects and Methods: The anesthetic records of 159 patients who underwent hepatopancreaticobiliary surgery were analyzed for the physiological and operative severity, POSSUM morbidity, POSSUM and Portsmouth POSSUM (P-POSSUM) mortality scoring systems, observed mortality in 30-days, 3, 6, and 12 months postoperatively, duration of surgery, and units of packed red blood cells (PRBC) transfused. These variables were compared among patients operated by five different surgeons and anesthetized by seven different anesthesiologists. Statistical Analysis: One-way analysis of variance was used for normally and Kruskal–Wallis test for nonnormally distributed responses. Differences in percentages of postoperative mortality were assessed by Chi-squared test. Results: The physiological severity, POSSUM morbidity, POSSUM and P-POSSUM mortality scores, and observed mortality at 1, 3, 6, and 12 months postoperatively did not differ among patients operated by different surgeons and anesthetized by different anesthesiologists. Duration of surgery (P < 0.001), PRBC units transfused (P = 0.002), and operative severity (P = 0.001) differed significantly among patients operated by different surgeons. Conclusions: The physiological severity score, POSSUM and P-POSSUM scores did not differ among patients operated by different surgeons and anesthetized by different anesthesiologists. The different operative severity scores did not influence the observed mortality in the postoperative period

Perioperative Dexmedetomidine or Lidocaine Infusion for the Prevention of Chronic Postoperative and Neuropathic Pain After Gynecological Surgery: A Randomized, Placebo-Controlled, Double-Blind Study

Introduction The transition of acute to chronic postoperative pain (CPP) remains a significant burden to the rehabilitation of patients. The research for adjuvants to prevent CPP continues; among others, dexmedetomidine and lidocaine seem promising agents. Methods This is a long-term follow-up of a randomized, placebo-controlled, double-blind study on women who underwent open abdominal gynecological surgery and received dexmedetomidine or lidocaine or placebo infusion perioperatively (n = 81). The effect of these adjuvants on the development of CPP and neuropathic pain was assessed during a 12-month follow-up. Eighty-one (81) women ASA I-II, aged between 30 and 70 years, were randomly assigned to receive either dexmedetomidine (DEX group) or lidocaine (LIDO group) or placebo (CONTROL group) perioperatively. Before anesthesia induction, all patients received a loading intravenous dose of either 0.6 mu g/kg dexmedetomidine or 1.5 mg/kg lidocaine or placebo, followed by 0.6 mu g/kg/h dexmedetomidine or 1.5 mg/kg/h lidocaine or placebo until last suture. Patients were followed up to obtain the long-term outcomes at 3, 6, and 12 months. At these time-points, pain intensity was assessed with the Numerical Rating Scale, (NRS: 0-10) and the development of neuropathic elements with the Douleur Neuropathique 4 (DN4) score. Prognostic parameters that could affect chronic pain and its components were also identified. Results Data from 74 women were analyzed. Dexmedetomidine significantly reduced NRS scores comparing to placebo at 3 months (p = 0.018), while at 6 months, lidocaine was found superior to placebo (p = 0.02), but not to dexmedetomidine, in preventing neuropathic pain (DN4 &lt; 4). Regarding secondary endpoints, higher NRS cough scores at 48 h were associated with statistically significant NRS and DN4 scores at 3, 6, and 12 months (p &lt; 0.02). At 6 months, a statistically significant correlation was also found between higher NRS values and older age (p = 0.020). Conclusions Dexmedetomidine was superior to placebo regarding the duration and severity of CPP, while lidocaine exhibited a protective effect against neuropathic elements of CPP

Anatomic features of the neck as predictive markers of difficult direct laryngoscopy in men and women: A prospective study

Background and Aims: Difficult airway assessment is based on various anatomic parameters of upper airway, much of it being concentrated on oral cavity and the pharyngeal structures. The diagnostic value of tests based on neck anatomy in predicting difficult laryngoscopy was assessed in this prospective, open cohort study. Methods: We studied 341 adult patients scheduled to receive general anaesthesia. Thyromental distance (TMD), sternomental distance (STMD), ratio of height to thyromental distance (RHTMD) and neck circumference (NC) were measured pre-operatively. The laryngoscopic view was classified according to the Cormack-Lehane Grade (1-4). Difficult laryngoscopy was defined as Cormack-Lehane Grade 3 or 4. The optimal cut-off points for each variable were identified by using receiver operating characteristic analysis. Sensitivity, specificity and positive predictive value and negative predictive value (NPV) were calculated for each test. Multivariate analysis with logistic regression, including all variables, was used to create a predictive model. Comparisons between genders were also performed. Results: Laryngoscopy was difficult in 12.6% of the patients. The cut-off values were: TMD ≤7 cm, STMD ≤15 cm, RHTMD >18.4 and NC >37.5 cm. The RHTMD had the highest sensitivity (88.4%) and NPV (95.2%), while TMD had the highest specificity (83.9%). The area under curve (AUC) for the TMD, STMD, RHTMD and NC was 0.63, 0.64, 0.62 and 0.54, respectively. The predictive model exhibited a higher and statistically significant diagnostic accuracy (AUC: 0.68, P < 0.001). Gender-specific cut-off points improved the predictive accuracy of NC in women (AUC: 0.65). Conclusions: The TMD, STMD, RHTMD and NC were found to be poor single predictors of difficult laryngoscopy, while a model including all four variables had a significant predictive accuracy. Among the studied tests, gender-specific cut-off points should be used for NC

Effects of Intravenous Versus Epidural Lidocaine Infusion on Pain Intensity and Bowel Function After Major Large Bowel Surgery: a Double-Blind Randomized Controlled Trial

We compared the effects of intravenous lidocaine (IVL) with lumbar epidural lidocaine analgesia (LEA) on pain and ileus after open colonic surgery. Between December 2011 and February 2013, 60 patients were randomly allocated to IVL, LEA, or control group. The IVL group received intraoperatively lidocaine 2 % intravenously (1.5 mg/kg bolus, 2 mg/kg/h infusion) and normal saline (NS) epidurally. The LEA group received lidocaine epidurally (1.5 mg/kg bolus, 2 mg/kg/h infusion) and NS intravenously. The control group received NS both intravenously and epidurally, as bolus and infusion. All NS volumes were calculated as if containing lidocaine 2 % at the aforementioned doses. We assessed pain intensity at rest/cough at 1, 2, 4, 12, 24, and 48 h postoperatively (numerical rating scale 0-10), 48-h analgesic consumption, and time to first flatus passage. Data from 60 patients (20 per group) were analyzed. The IVL group had significantly lower pain scores at rest and cough compared to LEA or control group only at 1, 2, and 4 h postoperatively (P &lt; 0.005 for all comparisons). The 48-h analgesic requirements and time to first flatus passage did not differ significantly between IVL group and LEA or control group (P &gt; 0.05). Compared with LEA-lidocaine or placebo, intravenous lidocaine offered no clinically significant benefit in terms of analgesia and bowel function