Transversus abdominis plane (TAP) block is an alternative to spinal morphine for analgesia after Caesarean section but there are few data on its comparative efficacy. We compared the analgesic ...efficacy of the TAP block with and without spinal morphine after Caesarean section in a prospective, randomized, double-blinded placebo-controlled trial.
Eighty patients were randomized to one of four groups to receive (in addition to spinal anaesthesia) either spinal morphine 100 µg (SM) or saline (SS) and a postoperative bilateral TAP block with either bupivacaine (TLA) 2 mg kg−1 or saline (TS).
Pain on movement and early morphine consumption were lowest in groups receiving spinal morphine and was not improved by TAP block. The rank order of median pain scores on movement at 6 h was: SMTLA (20 mm)<SMTS (27.5 mm)<SSTS (51.5 mm)<SSTLA (52.0 mm) (P<0.05, highest vs lowest). The rank order of median morphine consumption at 6 h was: SMTS (4.0 mg)<SMTLA (5.0 mg)<SSTLA (8.0 mg)<SSTS (12.0 mg) and at 24 h was: SMTLA (5.0 mg)<SMTS (6.0 mg)<SSTS (9.5 mg)<SSTLA (15.0 mg) (P<0.05, highest vs lowest). Sedation scores and patient satisfaction did not differ between groups. Anti-emetic use and pruritus were highest in the SMTLA group.
Spinal morphine—but not TAP block—improved analgesia after Caesarean section. The addition of TAP block with bupivacaine 2 mg kg−1 to spinal morphine did not further improve analgesia.
Individual patient information from clinical trials is infrequently available, but can provide insights for clinical trials and practice.
We analysed individual patient information from five ...randomized trials (913 patients) of i.v. patient-controlled analgesia (IVPCA) plus epidural placebo, morphine sulphate (MS) 5 mg, or extended-release epidural morphine (EREM; DepoDur™) at doses of 5–30 mg, to explore effects of a range of epidural morphine doses. Pain and opioid requirement on first and second postoperative days, dose–response, clinically relevant comparisons of IVPCA without epidural morphine, 5 mg MS, and 10 mg EREM, and relationship between patient rating and other measures were described.
There were three strong findings. Epidural morphine resulted in greater patient satisfaction, despite higher rates of adverse events. Those describing their analgesic medication as ‘very good’ or ‘excellent’ used IVPCA opioid less and had pain scores significantly below the global mean, whereas those describing their medication as ‘poor’ or ‘fair’ had pain scores significantly above the mean. Epidural morphine meant less need for postoperative IVPCA opioid than epidural placebo. The therapeutic gain with EREM was lower pain scores with less IVPCA opioid. Moderate or severe pruritus was more common with IVPCA plus epidural morphine, whatever the formulation, compared with IVPCA plus placebo.
Analysis of individual patient data from high-quality clinical trials provides important insights into characteristics of new agents not immediately apparent from original trials, and also informing clinical practice. Prophylactic epidural morphine provides a better patient experience than IVPCA alone.
Multi-disciplinary collaborative care for pregnant women with complex and emergent conditions is essential. Logistical planning, clear communication and human factor awareness are all non-clinical ...skills which need to be utilised in order to maximise outcomes. We describe the case of a proximal aortic dissection in the late third trimester of pregnancy diagnosed in a peripheral hospital that was transferred to a cardiothoracic centre for successful operative management 160 km away. This required the time-sensitive mobilisation and liaison of a receiving cardiothoracic, anaesthesiology and perfusionist team in conjunction with obstetric and midwifery support from an affiliated maternity hospital, as well as the national neonatal transport team. We emphasise the importance of multidisciplinary team management in complex cases and how imperative good inter-disciplinary communication is to ensure safe inter-hospital transfer.
Ketamine is a N-methyl-D-aspartic acid (NMDA) antagonist that has been associated with temporary clinical improvement in patients with depression. Studies using magnetic resonance spectroscopy (MRS) ...have shown that major depression is associated with decreased levels of glutamate and glutamine (Glx) in the anterior cingulate cortex, which normalize with clinical recovery. The present study aimed to test whether a ketamine infusion would increase cortical Glx levels in healthy volunteers. Healthy volunteers received an intravenous infusion of ketamine (0.5 mg kg−1, n = 8) or saline (n = 9) over 40 minutes. MRS measurements were obtained at baseline, during, and at the end of the infusion. The infusion of ketamine had significant effects on mental state but there was no effect of ketamine on the levels of Glx (F
3,39 = 1.70, p = 0.18) or glutamate (F
3,39 = 48, p = 0.70). This study suggests that the gradual infusion of low-dose ketamine in antidepressant doses not cause changes in cortical glutamate or glutamine in healthy volunteers that are visible by proton MRS.
Background
There is contradictory evidence regarding the merits of restricted versus liberal perioperative intravenous (IV) fluid administration in bowel surgery. This study sought to audit ...perioperative fluid management in elective colectomy in Ireland and to analyse the impact of such on operative outcomes.
Methods
A national surgical trainee collaborative audit of perioperative fluid management was performed. Data from each site was collected prospectively over a selected 3-week period within a pre-defined 2-month block. Collected variables included demographics, type of operation/anaesthethic, volume/type of fluid administration pre-, intra- and post-operatively, 30-day morbidity and mortality. Primary outcome was fluid balance 24-h post-operatively with further analysis to identify the impact of this on 30-day morbidity. ROC curves were generated to identify the critical volume at which fluid balance was associated with 30-day morbidity.
Results
Ninety-four patients were enrolled from 17 hospitals. Mean age was 64 years. A total of 48.9% (
N
= 46) were managed by ERAS and 51.1% (
N
= 48) received bowel preparation. Almost 70% of cases (
N
= 63) were completed by minimally invasive techniques. Significant 30-day morbidity requiring hospital readmission was low 6.4% (
n
= 6). Median fluid balance at 24 h was + 715 ml (IQR 165–1486 ml). On multivariate analysis, high BMI (
p
= 0.02), indication for surgery (
p
= 0.02) and critical care admission (
p
= 0.008) were significantly predictive of 30-day morbidity. Twenty-four hour fluid balance >+ 665 ml was associated with increased risk of 30-day morbidity on univariate but not multivariate analysis, implying association but not causation.
Conclusion
Overall, perioperative fluid management was within an acceptable range with minimal impact on 30-day morbidity following elective colorectal surgery.
PDF
