Study shows patients require less painkilling medication after breast-cancer surgery if they have opiate-free anesthesia

ScienceDaily. Published online: 30 May 2016.

Image shows Remifentanil’s 3D molecular structure

In this study, painkiller requirements were examined after patients received opiate anaesthesia and non-opiate anaesthesia. A randomised controlled trial was conducted, containing two groups each containing 33 breast cancer patients undergoing a mastectomy or lumpectomy. The study took place between September 2014 and July 2015 at the Jules Bordet Institute, Brussels.

Perioperative non-opiate analgesia was obtained by combining clonidine (0.2 mcg/kg), ketamine (0.3 mg/kg) and lidocaine (1.5 mg/kg). An extra bolus of ketamine (0.2mg/kg) was given if necessary. Opiate analgesia was obtained via a combination of remifentanil infusion, ketamine (0.3 mg/kg) and lidocaine (1.5 mg/kg). Both groups received intravenous paracetamol (1000mg/6h) and intravenous diclofenac (75 mg/12h). Patients received a PCA (patient-controlled analgesia) pump for breakthrough pain during the first 24 hours post-operatively.

Clinical characteristics and post-operative piritramide painkiller consumption (through the patient controlled pump) were assessed during the first 24 hours post-operatively. Data were not complete for two patients in the non-opiate group, and thus a total of 64 patients were included in the study. The total mean piritramide usage 24 hours post-operatively was 8.1 mg (range 2.0-14.5) in the non-opiate group and 13.1 mg (range 6.0-16.0) in the opioid group. The difference observed was statistically significant.

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Blood Pressure Monitoring for the Anesthesiologist: A Practical Review

Bartels, K. et. al. Blood Pressure Monitoring for the Anesthesiologist: A Practical Review.

 Anesthesia & Analgesia: June 2016 – Volume 122 – Issue 6 – p 1866–1879

Periodic, quantitative measurement of blood pressure (BP) in humans, predating the era of evidence-based medicine by over a century, is a component of the American Society of Anesthesiologists standards for basic anesthetic monitoring and is a staple of anesthetic management worldwide.
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image source: Jason Saul – Flickr // CC BY-ND 2.0

This narrative review article discusses the details of BP measurement and the advantages and disadvantages of both noninvasive and invasive monitoring, as well as the principles and algorithms associated with each technique.

Current Concepts In the Management of The Difficult Airway

Hagberg, C.A. Anesthesiology News. Volume 13, Number 1. Published online 17 May 2016

Management of the difficult airway remains one of the most relevant and challenging tasks for anesthesia care providers. This review focuses on several of the alternative airway management devices/techniques and their clinical applications, with particular emphasis on the difficult or failed airway. It includes descriptions of many new airway devices, several of which have been included in the ASA Difficult Airway Algorithm.

Guides include:

  • Endotracheal Tube Guides
  • Lighted Stylets
  • Video Laryngoscopes
  • Indirect Rigid Fiber-Optic Laryngoscopes
  • Supraglottic Ventilatory Devices
  • Devices for Special Airway Techniques
  • Positioning Devices
  • Cricothyrotomy Devices
  • Tracheostomy Devices

Read the full review here

Efficacy and safety of intravenous lidocaine for postoperative analgesia and recovery after surgery: a systematic review with trial sequential analysis

Weibel, S. et al . British Journal of Anesthesia. (2016) 116 (6): 770-783.

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Image source: JL Johnson // CC BY-SA 2.0

Background: Improvement of postoperative pain and other perioperative outcomes remain a significant challenge and a matter of debate among perioperative clinicians. This systematic review aims to evaluate the effects of perioperative i.v. lidocaine infusion on postoperative pain and recovery in patients undergoing various surgical procedures.

Methods: CENTRAL, MEDLINE, EMBASE, and CINAHL databases and ClinicalTrials.gov, and congress proceedings were searched for randomized controlled trials until May 2014, that compared patients who did or did not receive continuous perioperative i.v. lidocaine infusion.

Results: Forty-five trials (2802 participants) were included. Meta-analysis suggested that lidocaine reduced postoperative pain (visual analogue scale, 0 to 10 cm) at 1–4 h (MD −0.84, 95% CI −1.10 to −0.59) and at 24 h (MD −0.34, 95% CI −0.57 to −0.11) after surgery, but not at 48 h (MD −0.22, 95% CI −0.47 to 0.03). Subgroup analysis and trial sequential analysis suggested pain reduction for patients undergoing laparoscopic abdominal surgery or open abdominal surgery, but not for patients undergoing other surgeries. There was limited evidence of positive effects of lidocaine on postoperative gastrointestinal recovery, opioid requirements, postoperative nausea and vomiting, and length of hospital stay. There were limited data available on the effect of systemic lidocaine on adverse effects or surgical complications. Quality of evidence was limited as a result of inconsistency (heterogeneity) and indirectness (small studies).

Conclusions: There is limited evidence suggesting that i.v. lidocaine may be a useful adjuvant during general anaesthesia because of its beneficial impact on several outcomes after surgery.

Read the abstract here

Read the full review on Cochrane here

Black or white coffee before anaesthesia?: A randomised crossover trial

Larsen, B. et al. European Journal of Anaesthesiology. June 2016. 33 (6). pp. 457–462

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Image source: kate mccarthy // CC BY-ND 2.0

Background: In current preoperative fasting guidelines, coffee with milk is still regarded by many as solid food. Evidence on the consequences for gastric volume of adding milk to coffee 2 h before anaesthesia is still weak.

Objectives: The aim of this study was to compare the gastric volume by MRI in healthy volunteers after drinking coffee with and without added milk.

Design: A randomised crossover trial where all participants were exposed to three coffee and milk mixtures performed as a noninferiority study with a predefined noninferiority limit of 12 ml.

Setting: Department of Day Surgery and Department of Radiology, Aarhus University Hospital, Aarhus, Denmark. The study was conducted between August 2013 and February 2014.

Participants: Total 32 healthy volunteers, aged 18 to 71 years.

Interventions: The participants fasted for 6 h for solid food, and 2 h before the MRI examination of gastric volume, each participant ingested one of three coffee mixtures: 175 ml coffee, including either 0 or 20 or 50% full fat milk. Each participant was studied by MRI three times separated by a minimum time interval of 2 days. The order of coffee mixture ingested was determined by random allocation.

Main Outcome Measure: Gastric volume as measured by MRI.

Results: The mean gastric volume for black coffee was 27.8 ml, for coffee with 20% milk 17.9 ml and for coffee with 50% milk 20.6 ml. Compared to black coffee, the gastric volume for 20% milk was significantly decreased with a difference of −10.0 ml (95% confidence interval, −18.2, −1.8), and for 50% milk it was insignificantly decreased, −7.2 ml (95% confidence interval, −17.4, +2.9). The upper confidence interval for the difference in gastric volume between the ‘no milk added’ group and each ‘milk added’ group did not reach the noninferiority limit of 12 ml.

Conclusion: The study provides evidence that adding up to 50% full fat milk to coffee leads to no or only a minimal increase of the gastric volume 2 h later. The results support a liberalisation of policy on the addition of milk to hot drinks before planned anaesthesia.

Read the abstract here