Background: As day surgery includes more extensive procedures focus should be put on late outcome. The frequency of day surgery‐related return visits and the associated morbidity were examined to ...identify suitable indicators of quality.
Methods: From two centres, 16,048 patients underwent 18,736 day surgery operations including 4,829 surgical abortions. Patients were retrospectively analysed for contacts to Danish hospitals within 60 post‐operative days and the associated morbidity and mortality. Data were obtained from the Danish National Patient Registry and the National Causes of Death Registry. Patient records were studied to validate contacts as being definite, likely, possible or not related.
Results: Altogether 113 patients (not including the surgical abortions) were readmitted to hospitals with 117 complications definitely or likely related to day surgery. The most common complications were haematomas or haemorrhage (0.40%) and infections (0.29%). Morbidity after the two most common procedures, hernia repair and knee arthroscopy, was observed in 1 : 39 patients and 1 : 220 patients, respectively. More serious complications included four patients with septic arthritis of the knee and six patients with venous thromboembolism. After surgical abortion, pelvic inflammation and bleeding were observed in 3.1% and 2.2%, respectively, with centre differences. Altogether no myocardial infarctions, central nervous system deficits, pneumonias or deaths were recorded that could definitely or likely be related to day surgery.
Conclusion: Day surgery in Denmark is a safe practice. Readmission rates, haematomas and wound infections are likely future indicators of outcome quality after day surgery.
Background: Post‐tonsillectomy pain can be severe. We investigated the analgesic effect from combinations of paracetamol, pregabalin and dexamethasone in adults undergoing tonsillectomy.
Methods: In ...this randomized double‐blind study, 131 patients were assigned to either group A (paracetamol+placebo), group B (paracetamol+pregabalin+placebo) or group C (paracetamol+pregabalin+dexamethasone). Pre‐operatively, patients received either paracetamol 1000 mg, pregabalin 300 mg, dexamethasone 8 mg or placebo according to their allocation. Post‐operative pain treatment included paracetamol 1000 mg 4 × and ketobemidone 2.5 mg p.n. Ketobemidone consumption, pain scores visual analogue scale (VAS), nausea, sedation, dizziness, number of vomits and consumption of ondansetron were recorded 2, 4 and 24 h after the operation. P<0.05 was considered statistically significant.
Results: The mean 24‐h VAS‐pain score at rest was reduced in group C (P<0.003) vs. group A. The mean 24‐h VAS‐pain scores during swallowing were reduced in group B (P=0.009) and group C (P<0.003) vs. group A. Consumption of ketobemidone (1–4 h post‐operatively) was lower in group B (P=0.003) and group C (P=0.003) vs. group A. The mean 24‐h dizziness score was higher in group B (P<0.003) and C (P=0.003) vs. group A. Other parameters including re‐operation for post‐tonsillectomy bleeding were not different between groups.
Conclusion: Pregabalin and pregabalin+dexamethasone reduced post‐operative pain scores and consumption of ketobemidone following tonsillectomy. Dizziness was increased with pregabalin.
Background: The aim of the present study was to investigate whether a combination of rofecoxib and gabapentin could improve pain relief and reduce opioid requirements, compared with rofecoxib alone, ...during the first 5 days after tonsillectomy.
Methods: In a randomized, double‐blind, placebo‐controlled study, 49 patients received gabapentin 1200 mg pre‐operatively, followed by gabapentin 2 × 600 mg on the day of operation and gabapentin 3 × 600 mg for the next 5 days, or placebo. Both groups were given rofecoxib 50 mg daily. In the post‐operative care unit, intravenous morphine was administered in doses of 2.5 mg on request. From 4 h to 5 days post‐operatively, ketobemidone was offered as escape drug. Pain at rest and during swallowing, and side‐effects, were assessed using a four‐point verbal rating scale.
Results: As a result of the global withdrawal of rofecoxib, the study had to be terminated prematurely. This report comprises the results from 22 patients in the gabapentin group and 27 patients in the placebo group. Gabapentin reduced ketobemidone requirements during the first 24 h post‐operatively 4.5 mg (standard deviation, 3.0 mg) in the placebo group vs. 2.0 mg (standard deviation, 2.0 mg) in the gabapentin group; P < 0.003. Gabapentin induced more dizziness (P < 0.002), gait disturbance (P < 0.02) and vomiting (P < 0.05) during days 0–5 than placebo. No other statistically significant differences were observed.
Conclusion: Gabapentin reduced opioid requirements in the first 24 h after tonsillectomy. The benefits of the reduced opioid intake may be overshadowed by the drawbacks of side‐effects.
This article presents a case study where a modified version of strategic option development and analysis (SODA) is applied to enhance the level of citizens’ participation in a strategic forest ...management planning process managed by the Danish Forest and Nature Agency. The case is interesting because of structural differences between traditional Soft OR and public participation settings. Research shows that SODA can nevertheless improve public involvement in several ways, including stakeholders’ perception of being involved, stakeholders’ commitment, structuring of the planning context, communication of stakeholder perspectives, identification and management of conflicts, decision process transparency, and agency accountability for final planning outcomes. The primary problems encountered relate to the difficulty of reading the cognitive maps, time requirements, and selection of facilitator. The general impression is that SODA can improve the present practice, and moreover provide a feasible platform for wider integration of stakeholder groups in the tactical planning process.
We have studied the effect of continuous extradural analgesia with bupivacaine and morphine, initiated before or after colonic surgery, in a double-blind, randomized study. Thirty-two patients were ...allocated randomly to receive an identical extradural block initiated 40 min before surgical incision (n = 16) or at closure of the surgical wound (n = 16). The extradural regimen consisted of a bolus of 7 ml of plain bupivacaine 7.5 mg ml−1 plus morphine 2 mg and continuous extradural infusion of a mixture of bupivacaine 7.5mg ml−1 plus morphine 0.05 mg ml−1, 4 ml h−1 for 2 h, followed by a continuous extradural infusion of a mixture of bupivacaine 2.5mgml−1 plus morphine 0.05 mg ml−1, 4 ml−1 h−1, continued for 72 h after operation. In addition, all patients received similar general anaesthesia. There was no significant difference in request for additional morphine and no significant differences between the groups in pain scores (visual analogue scale or verbal) during rest or ambulation at any time of measurement. These results do not suggest that timing of analgesia with a conventional extradural regimen is of major clinical importance in patients undergoing colonic surgery
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.
Introduction
Intravenous (IV) fluid is a key intervention in the management of septic shock. The benefits and harms of lower versus higher fluid volumes are unknown and thus clinical equipoise ...exists. We describe the protocol and detailed statistical analysis plan for the conservative versus liberal approach to fluid therapy of septic shock in the Intensive Care (CLASSIC) trial. The aim of the CLASSIC trial is to assess benefits and harms of IV fluid restriction versus standard care in adult intensive care unit (ICU) patients with septic shock.
Methods
CLASSIC trial is an investigator‐initiated, international, randomised, stratified, and analyst‐blinded trial. We will allocate 1554 adult patients with septic shock, who are planned to be or are admitted to an ICU, to IV fluid restriction versus standard care. The primary outcome is mortality at day 90. Secondary outcomes are serious adverse events (SAEs), serious adverse reactions (SARs), days alive at day 90 without life support, days alive and out of the hospital at day 90 and mortality, health‐related quality of life (HRQoL), and cognitive function at 1 year. We will conduct the statistical analyses according to a pre‐defined statistical analysis plan, including three interim analyses. For the primary analysis, we will use logistic regression adjusted for the stratification variables comparing the two interventions in the intention‐to‐treat (ITT) population.
Discussion
The CLASSIC trial results will provide important evidence to guide clinicians’ choice regarding the IV fluid therapy in adults with septic shock.
A multiple of stakeholder goals, regarding natural resource utilisation, are integrated into an overall provincial strategic forest and fisheries utilisation decision support system providing a ...platform for defining tactical forest planning objectives within a 10-year planning horizon. The case study area is a 5362
ha mangrove forest enterprise, divided into a buffer zone and a full protection zone, which has 46 permanent staff, 575 farming households, 450 near-shore fishing families, and 200 landless families. The analyses are based on a modification of the forest management planning package PEB, which incorporates multi-objective (political, economic, and biological) linear programming using a 10-year planning horizon based on stand data. Numerous stakeholders' goals are included in the forest management plan. A revenue of US$ 2.6 million in the 10-year planning period is achieved of which 46% is generated from forestry in the full protection zone, 33% from non-farm forestry, and 21% from farm forestry in the buffer zone. The full protection zone forest has the potential to generate the highest revenue and, therefore, a discussion is made on allowing limited forestry in the zone. If the firewood value is included, the revenues would increase to US$ 3.4 million. Findings suggest that firewood collection for landless, fishermen, and farmers is sustainable and, therefore, ought to be legalized. The value of on-farm silviculture and firewood collection accounts for 10% of net revenues, which can be compared to the other income generators: tiger shrimp (8%), mud crab (6%), sluice-gate fishery (44%), animal husbandry (5%), and off-farm activities (27%). The ecological linkage between mangroves and fisheries provides a major additional gross margin of between US$ 4 and 12 million from fisheries alone. A discussion on the general applicability, strengths, and shortcomings of the system is made.
In a double-blind, randomized study, epidural infusions of low-dose morphine (0.2 mg/h) combined with low-dose bupivacaine (10 mg/h) were compared with epidural infusions of low-dose morphine (0.2 ...mg/h) alone for postoperative analgesia at rest and during mobilization and cough in 24 patients after elective major abdominal surgery. All patients in addition received systemic piroxicam (20 mg daily). No significant differences were observed between the groups at any assessment of pain at rest (P greater than 0.05), whereas pain in the morphine/bupivacaine group was significantly reduced during mobilization from the supine into the sitting position 12 and 30 h after surgical incision and during cough 8, 12, and 30 h after surgical incision (P less than 0.05). We conclude, that low-dose epidural bupivacaine potentiates postoperative low-dose epidural morphine analgesia during mobilization and cough. Evaluation of postoperative analgesic regimens should include assessment of pain during various activities as different analgesics may have differential effects on pain at rest and during mobilization.
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