Local anesthetics (LA) are injected via catheters placed in surgical wounds for post-operative analgesia. The primary aim of this systematic review was to assess whether LA reduce pain intensity when injected via wound catheters. A literature search was performed from Medline via PubMed, EMBASE and the Cochrane database from 1966 until November 2009. The search strategy included the following key words: pain, postoperative, catheters and local anesthetics. Two co-authors independently read every article that was initially included and extracted data into a pre-defined study record form. A total of 753 studies primarily fit the search criteria and 163 were initially extracted. Of these, 32 studies were included in the meta-analysis. Wound catheters provided no significant analgesia at rest or on activity, except in patients undergoing gynecological and obstetric surgery at 48 h (P = 0.03). The overall morphine consumption was lower (approximate to 13 mg) during 0-24 h (P less than 0.001) in these patients. No significant differences in side effects were found, except for a lower risk of wound breakdown (P = 0.048) and a shorter length of hospital stay (P = 0.04) in patients receiving LA. A statistically significant heterogeneity was seen between the studies in most end-points. LA injected via wound catheters did not reduce pain intensity, except at 48 h in a subgroup of patients undergoing obstetric and gynecological surgery. Rescue analgesic consumption was also lower in this group at 0-24 h. The magnitude of these effects was small and compounded by pronounced heterogeneity.

Background Post-operative cognitive dysfunction (POCD) after non-cardiac surgery is a well known problem in some categories of patients. This study aims to evaluate the influence of auditory evoked potential (AEP)-guided anaesthesia on the requirement for anaesthetic drugs and their influence on POCD. Methods Four hundred and fifty patients aged between 18 and 92 years scheduled for ophthalmic surgery under general anaesthesia were assigned randomly to one of two groups. In group A (AEP group), the depth of anaesthesia (DoA) was aimed at an AEP index (AAI) between 15 and 25. In group C (control group), DoA was guided by clinical signs. Hypotension was treated with fluids and vasopressors using a standardised algorithm. A mini-mental test and the Cognitive Failure Questionnaire were used to evaluate cognitive function. Results Anaesthetic drug requirements were significantly lower in group A than in group C: propofol 92.5 +/- 26.5 vs. 103.8 +/- 39.5 mg (P = andlt;0.001) and desflurane end-tidal concentration 2.5 +/- 0.58 vs. 3.3 +/- 0.79% (P andlt; 0.001). In group A, 36 patients (16%) received additional fluids and vasopressors compared to 65 patients (29%) in group C (P andlt; 0.01). AAI values differed significantly between the groups: 18 (11-21) in group A vs. 12 (10-19) in group C (P andlt; 0.001). The number of patients with POCD was 16 in group C compared to two in group A (P andlt; 0.001) at day 1 post-operation. Conclusion AEP monitoring allows dose reduction of anaesthetic agents, leading to better cardiovascular stability and decreased requirements for intra-operative fluids and vasopressors. Cognitive decline seen following minor ophthalmic surgery, even when anaesthesia is assessed clinically, is short-lived with no long-term sequelae.

BACKGROUND: Local infiltration analgesia (LIA)-using a combination of local anesthetics, nonsteroidal anti-inflammatory drugs, and epinephrine, injected periarticularly during surgery-has become popular in postoperative pain management after total knee arthroplasty (TKA). We compared intrathecal morphine with LIA after TKA. less thanbrgreater than less thanbrgreater thanMETHODS: In this double-blind study, 50 patients scheduled to undergo TKA under spinal anesthesia were randomized into 2 groups: group M, 0.1 mg morphine was injected intrathecally together with the spinal anesthetic and in group L, LIA using ropivacaine, ketorolac, and epinephrine was infiltrated in the knee during the operation, and 2 bolus injections of the same mixture were given via an intraarticular catheter postoperatively. Postoperative pain, rescue analgesic requirements, mobilization, and home readiness were recorded. Patient-assessed health quality was recorded using the Oxford Knee Score and EQ-5D during 3 months follow-up. The primary endpoint was IV morphine consumption the first 48 postoperative hours. less thanbrgreater than less thanbrgreater thanRESULTS: Mean morphine consumption was significantly lower in group L than in group M during the first 48 postoperative hours: 26 +/- 15 vs 54 +/- 29 mg, i.e., a mean difference for each 24-hour period of 14.2 (95% confidence interval [CI] 7.6 to 20.9) mg. Pain scores at rest and on movement were lower during the first 48 hours in group L than in group M (P andlt; 0.001). Pain score was also lower when walking in group L than in group M at 24 hours and 48 hours postoperatively (P andlt; 0.001). In group L, more patients were able to climb stairs at 24 hours: 50% (11 of 22) versus 4% (1 of 23), i.e., a difference of 46% (95% CI 23.5 to 68.5) and at 48 hours: 70% (16 of 23) versus 22% (5 of 23), i.e., a difference of 48% (95% CI 23 to 73). Median (range) time to fulfillment of discharge criteria was shorter in group L than in group M, 51 (24-166) hours versus 72 (51-170) hours. The difference was 23 (95% CI 18 to 42) hours (P = 0.001). Length of hospital stay was also shorter in group L than in group M: median (range) 3 (2-17) versus 4 (2-14) days (P = 0.029). Patient satisfaction was greater in group L than in group M (P = 0.001), but no differences were found in knee function, side effects, or in patient-related outcomes, Oxford Knee score, or EQ-5D. less thanbrgreater than less thanbrgreater thanCONCLUSIONS: LIA technique provided better postoperative analgesia and earlier mobilization, resulting in shorter hospital stay, than did intrathecal morphine after TKA.

Background A major risk with epidural analgesia is accidental dural puncture (ADP), which may result in post-dural puncture headache (PDPH). This survey was conducted to explore the incidence of ADP, the policy for management of PDPH and the educational practices in epidural analgesia during labour in the Nordic countries. Methods A postal questionnaire was sent to the anaesthesiologist responsible for Obstetric anaesthesia service in all maternity units (n=153) with questions relating to the year 2008. Results The overall response rate was 93%. About 32% (22-47%) of parturients received epidural analgesia for labour. There were databases for registering obstetric epidural complications in 13% of Danish, 24% of Norwegian and Swedish, 43% of Finnish and 100% of hospitals in Iceland. The estimated incidence of ADP was 1% (n approximate to 900). Epidural blood patch (EBP) was performed in 86% (n approximate to 780) of the parturients. The most common time interval from diagnosis to performing EBP was 24-48 h. The success rate for EBP was greater than 75% in 67% (62-79%) of hospitals. The use of diagnostic CT/MRI before the first or the second EBP was exceptional. No major complication was reported. Teaching of epidurals was commonest (86%) in the non-obstetric population and 53% hospitals desired a formal training programme in obstetric analgesia. Conclusion We found the incidence of ADP to be approximately 1%. EBP was the commonest method used for its management, and the success rate was high in most hospitals. Formal training in epidural analgesia was absent in most countries and trainees first performed it in the non-obstetric population.

This study was done to assess the efficacy of a perineural catheter for pain relief following carpal tunnel release (CTR). Sixty-six patients undergoing open CTR under local anaesthesia (LA) were randomly divided into three groups: Groups A and B had a perineural catheter and Group C served as non-blinded control group. Postoperative pain relief was by self-administration of either ropivacaine (Group A) or saline (Group B) via an elastometric pump and by oral paracetamol in Group C. Patients in Group A had a significantly greater difference in summed pain intensity than Group B. Fewer patients in Group A requested supplementary analgesics than in Group C. Patient satisfaction was higher in Group A than in Group B on day 1. However better analgesia was not associated with better functional recovery.

Background. There is some evidence that epidural analgesia (EDA) reduces tumour recurrence after breast and prostatic cancer surgery. We assessed whether EDA reduces long-term mortality after colorectal cancer surgery. Methods. All patients having colorectal cancer surgery between January 2004 and January 2008 at Linkoping and Orebro were included. Exclusion criteria were: emergency operations, laparoscopic-assisted colorectal resection, and stage 4 cancer. Statistical information was obtained from the Swedish National Register for Deaths. Patients were analysed in two groups: EDA group or patient-controlled analgesia (PCA group) as the primary method of analgesia. Results. A total of 655 patients could be included. All-cause mortality for colorectal cancer (stages 1-3) was 22.7% (colon: 20%, rectal: 26%) after 1-5 yr of surgery. Multivariate regression analysis identified the following statistically significant factors for death after colon cancer (Pless than0.05): age (greater than72 yr) and cancer stage 3 (compared with stage 1). A similar model for rectal cancer found that age (greater than72 yr) and the use of PCA rather than EDA and cancer stages 2 and 3 (compared with stage 1) were associated with a higher risk for death. No significant risk of death was found for colon cancer when comparing EDA with PCA (P=0.23), but a significantly increased risk of death was seen after rectal cancer when PCA was used compared with EDA (P=0.049) [hazards ratio: 0.52 (0.27-1.00)]. Conclusions. We found a reduction in all-cause mortality after rectal but not colon cancer in patients having EDA compared with PCA technique.

Background. Postoperative pain after radical retropubic prostatectomy is moderate to severe. The primary aim of this study was to assess whether intra-abdominal local anaesthetics provide similar analgesia compared with thoracic epidural analgesia (TEA). less thanbrgreater than less thanbrgreater thanMethods. Fifty patients, ASA I-II, participated in this prospective, double-blinded study. All patients had TEA. After operation, they were randomized into two groups of 25 patients: Group PCLA (patient-controlled local analgesia): self-administration of 10 ml of ropivacaine 2 mg ml(-1) via the intra-abdominal catheter for 48 h. Group TEA: infusion of 10 ml h(-1) of ropivacaine 1 mg ml(-1), fentanyl 2 mg ml(-1), and epinephrine 2 mg ml 21 epidurally for 48 h. The primary endpoint was pain on coughing at 4 h after operation. Rescue medication was morphine i.v. as required. less thanbrgreater than less thanbrgreater thanResults. Pain on coughing at 4, 24, and 48 h was significantly lower in Group TEA [0 (0-10)] compared with Group PCLA [4 (0-10)] (Pandlt;0.05). Significantly lower pain intensity was also found in Group TEA compared with Group PCLA at the incision site, deep pain, and pain on coughing at 4 and 24 h (Pandlt;0.05). Morphine consumption was significantly greater in Group PCLA [12 (0-46)] compared with Group TEA [0 (0-20)] at 0-48 h after operation [median (range)] (P=0.015). Maximum expiratory pressure was higher in Group TEA compared with Group PCLA at 24 h (Pandlt;0.01). less thanbrgreater than less thanbrgreater thanConclusions. TEA provides superior postoperative pain relief with better preservation of expiratory muscle strength compared with PCLA.

BACKGROUND: The operating room is a complex work environment with a high potential for adverse events. Protocols for perioperative verification processes have increasingly been recommended by professional organizations during the last few years. We assessed personnel attitudes to a pre-operative checklist ('time out') immediately before start of the operative procedure. METHODS: 'Time out' was implemented in December 2007 as an additional safety barrier in two Swedish hospitals. One year later, in order to assess how the checklist was perceived, a questionnaire was sent by e-mail to 704 persons in the operating departments, including surgeons, anesthesiologists, operation and anesthetic nurses and nurse assistants. In order to identify differences in response between professions, each alternative in the questionnaire was assigned a numerical value. RESULTS: The questionnaire was answered by 331 (47%) persons and 93% responded that 'time out' contributes to increased patient safety. Eighty-six percent thought that 'time out' gave an opportunity to identify and solve problems. Confirmation of patient identity, correct procedure, correct side and checking of allergies or contagious diseases were considered 'very important' by 78-84% of the responders. Attitudes to checking of patient positioning, allergies and review of potential critical moments were positive but differed significantly between the professions. Attitudes to a similar checklist at the end of surgery were positive and 72-99% agreed to the different elements. CONCLUSION: Staff attitudes toward a surgical checklist were mostly positive 1 year after their introduction in two large hospitals in central Sweden.

Background and purpose Postoperative pain is often severe after total knee arthroplasty (TKA). We investigated the efficacy of the local infiltration analgesia (LIA) technique, both intraoperatively and postoperatively. Methods 48 patients undergoing TKA were randomized into 2 groups in a double-blind study. In group A, 400 mg ropivacaine, 30 mg ketorolac, and 0.5 mg epinephrine were infiltrated periarticularly during operation. In group P, no injections were given. 21 h postoperatively, 200 mg ropivacaine, 30 mg ketorolac, and 0.1 mg epinephrine were injected intraarticularly in group A, and the same volume of saline was injected in group P. All patients were followed up for 3 months. Results Median morphine consumption was lower in group A during the first 48 h: 18 (1-74) mg vs. 87 (36-160) mg in group P. Postoperative pain was lower at rest in group A during the first 27 h, and on movement during the first 48 h, except at 21 h. Time to fulfillment of discharge criteria was shorter in group A than in group P: 3 (1-7) vs. 5 (2-8) days. Patient satisfaction was higher in group A than in group P on days 1 and 7. The unbound venous blood concentration of ropivacaine was below systemic toxic blood concentrations. Interpretation The local infiltration analgesia (LIA) technique provides excellent pain relief and lower morphine consumption following TKA, resulting in shorter time to home readiness and higher patient satisfaction. There were few side effects and systemic LA concentrations were low.

Background: Major adverse cardiac events (MACEs) are a common cause of deathafter non-cardiac surgery. Despite evidence for the benefitof aspirin for secondary prevention, it is often discontinuedin the perioperative period due to the risk of bleeding.

Methods: We conducted a randomized, double-blind, placebo-controlledtrial in order to compare the effect of low-dose aspirin withthat of placebo on myocardial damage, cardiovascular, and bleedingcomplications in high-risk patients undergoing non-cardiac surgery.Aspirin (75 mg) or placebo was given 7 days before surgery andcontinued until the third postoperative day. Patients were followedup for 30 days after surgery.

Results: A total of 220 patients were enrolled, 109 patients receivedaspirin and 111 received placebo. Four patients (3.7%) in theaspirin group and 10 patients (9.0%) in the placebo group hadelevated troponin T levels in the postoperative period (P=0.10).Twelve patients (5.4%) had an MACE during the first 30 postoperativedays. Two of these patients (1.8%) were in the aspirin groupand 10 patients (9.0%) were in the placebo group (P=0.02). Treatmentwith aspirin resulted in a 7.2% absolute risk reduction [95%confidence interval (CI), 1.3–13%] for postoperative MACE.The relative risk reduction was 80% (95% CI, 9.2–95%).Numbers needed to treat were 14 (95% CI, 7.6–78). No significantdifferences in bleeding complications were seen between thetwo groups.

Conclusions: In high-risk patients undergoing non-cardiac surgery, perioperativeaspirin reduced the risk of MACE without increasing bleedingcomplications. However, the study was not powered to evaluatebleeding complications.