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A new technique for postoperative pain management with local anesthetic after abdominal hysterectomy
Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

An abdominal hysterectomy (AH) is associated with moderate to severe postoperative pain. In this thesis, a new technique for postoperative pain managment has been studied in 200 patients: local anesthetic (LA) was administered intraperitoneally (IP) after elective AH.

In study I, the efficacy of an IP continuous infusion of LA given postoperatively via a catheter was compared with a placebo. The conclusion was that the postoperative pain relief was significantly improved when LA was used. The plasma concentration of LA was far below toxic concentrations.

In study II, when three different doses of LA were given at a constant infusion rate, the conclusion was that satisfactory analgesia could be achieved with low doses of LA and that no advantages were seen when higher doses of LA were administered. The highest dose of infused LA did not result in toxic plasma concentration.

Study III compared a continuous IP infusion and a patient-controlled bo-lus IP injection of LA. A significant opioid-sparing effect combined with lower required amount of LA was found when the patient-controlled LA was administered compared to the continuous infusion. This was associated with a faster return of gastrointestinal function and home readiness.

Study IV tested the hypothesis that the analgesic effect of LA given intermittently IP was superior compared to the same dose administered continuously by intravenous (IV) infusion. A significant opioid-sparing effect was found when an intermittent IP injection of lidocaine was administered. The venous blood concentration of LA was significantly lower in the IP intermittent group versus the IV group. The lower supplemental morphine consumption, coupled with the lower plasma lidocaine concentration, may confirm a local peripheral rather than a systemic effect of LA administered IP.

In conclusion, when the LA was injected continuously IP, a significant opioid- sparing effect was found, which did not increase by increasing the LA dose. The opioid-sparing effect was greater when the intermittent IP injection of LA was compared to a continuous infusion. When LA was administered IP, the mechanism of pain relief seemed to be a local rather than a central effect.

Place, publisher, year, edition, pages
Örebro: Örebro universitet , 2013. , p. 65
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 94
Keywords [en]
local anesthetics, postoperative pain, abdominal hysterectomy, intra-peritoneal, catheter, Lidocaine, Levobupivacaine
National Category
Anesthesiology and Intensive Care Surgery
Research subject
Medicine
Identifiers
URN: urn:nbn:se:oru:diva-30851ISBN: 978-91-7668-967-7 (print)OAI: oai:DiVA.org:oru-30851DiVA, id: diva2:649300
Public defence
2013-11-08, Wilandersalen, Universitetssjukhuset Örebro, S. Grev Rosengatan, 703 62 Örebro, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2013-09-18 Created: 2013-09-18 Last updated: 2017-10-18Bibliographically approved
List of papers
1. Postoperative pain after abdominal hysterectomy: A double-blind comparison between placebo and local anesthetic infused intraperitoneally
Open this publication in new window or tab >>Postoperative pain after abdominal hysterectomy: A double-blind comparison between placebo and local anesthetic infused intraperitoneally
Show others...
2004 (English)In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 99, no 4, p. 1173-1179Article in journal (Refereed) Published
Abstract [en]

Abdominal hysterectomy is associated with moderate to severe postoperative pain. We randomly divided 40 patients (ASA status I-II) undergoing elective abdominal hysterectomy into 2 groups: group P received an infusion of normal saline 5 mL/h via a catheter placed intraperitoneally at the end of surgery, and group L received 0.25% levobupivacaine 12.5 mg/h (5 mL/h). Ketobemidone was administered IV via a patient-controlled analgesia pump as a rescue analgesic in all patients. The catheter was removed after 24 h. Incisional pain, deep pain, and pain on coughing were assessed 1, 2, 3, 4, 8, 16, and 24 h after surgery by using a visual analog scale. Ketobemidone consumption during 0-72 h was recorded. Time to sit, walk, eat, and drink; home discharge; and plasma concentrations of levobupivacaine were also determined. Pain at the incision site, deep pain, and pain on coughing were all significantly less in group L compared with group P at 1-2 h after surgery. After 4 h, the mean visual analog scale pain scores at rest and during coughing remained <3 cm during most time periods. Total ketobemidone consumption during 4-24 h was significantly less in group L compared with group P (mean, 19 versus 31 mg, respectively). A less frequent incidence of postoperative nausea, but not vomiting, was also found during 4-24 h in group L compared with group P (P < 0.025). Total and free plasma concentrations of levobupivacaine were small. We conclude that levobupivacaine used as an infusion intraperitoneally after elective abdominal hysterectomy has significant opioid-sparing effects.

National Category
Anesthesiology and Intensive Care
Research subject
Anaesthesiology
Identifiers
urn:nbn:se:oru:diva-32067 (URN)10.1213/01.ANE.0000130260.24433.A2 (DOI)000224039900040 ()
Available from: 2013-10-18 Created: 2013-10-18 Last updated: 2017-12-06Bibliographically approved
2. Intraabdominal local anaesthetics for postoperative pain relief following abdominal hysterectomy: a randomized, double-blind, dose-finding study
Open this publication in new window or tab >>Intraabdominal local anaesthetics for postoperative pain relief following abdominal hysterectomy: a randomized, double-blind, dose-finding study
Show others...
2009 (English)In: European Journal of Anaesthesiology, ISSN 0265-0215, E-ISSN 1365-2346, Vol. 26, no 5, p. 421-429Article in journal (Refereed) Published
Abstract [en]

BACKGROUND AND OBJECTIVE: Local anaesthetics administered intraabdominally have been found to reduce analgesic requirements postoperatively after hysterectomy. This study was designed to assess the optimal dose of local anaesthetics for best pain relief.

METHODS: Sixty patients undergoing abdominal hysterectomy were randomly divided into three groups to receive 10 ml h infusion of levobupivacaine intraabdominally postoperatively for 48 h in a double-blind manner: group L, 7.5 mg h; group M, 12.5 mg h and group H, 17.5 mg h. Pain intensity was measured using the numeric rating scale, ketobemidone consumption over 48 h was measured with a patient-controlled analgesia pump, recovery parameters, expiratory muscle strength, time to home readiness, plasma concentration of levobupivacaine and health-related quality of life were all measured at defined time points postoperatively.

RESULTS: No differences were found between the active groups in pain intensity, recovery parameters or health-related quality of life. Pain intensity was maximal during 0-4 h and during coughing. Expiratory muscle strength decreased significantly during 0-4 h in all active groups, with no differences between the groups. Plasma concentration of levobupivacaine was below known toxic concentrations in humans, and no patient had symptoms of local anaesthetic toxicity. Health-related quality of life showed improved scores at 3 months after the operation compared with preoperative values, but no differences between the groups were found in any of the parameters.

CONCLUSION: Satisfactory analgesia can be achieved with low doses of levobupivacaine administered intraabdominally, except during the early postoperative period. No advantages were seen in this study when higher doses of levobupivacaine were administered as a continuous infusion for postoperative pain relief.

Place, publisher, year, edition, pages
Lippincott Williams & Wilkins, 2009
National Category
Medical and Health Sciences Anesthesiology and Intensive Care
Research subject
Medicine
Identifiers
urn:nbn:se:oru:diva-12118 (URN)10.1097/EJA.0b013e3283261b53 (DOI)000265561700011 ()19521298 (PubMedID)2-s2.0-70149107139 (Scopus ID)
Available from: 2010-10-07 Created: 2010-10-07 Last updated: 2017-12-12Bibliographically approved
3. Postoperative pain after abdominal hysterectomy: a randomized, doubleblind,controlled trial comparing continuous infusion vs. patient-controlled intraperitoneal injection of local anesthetic
Open this publication in new window or tab >>Postoperative pain after abdominal hysterectomy: a randomized, doubleblind,controlled trial comparing continuous infusion vs. patient-controlled intraperitoneal injection of local anesthetic
Show others...
2014 (English)In: British Journal of Anaesthesia, ISSN 0007-0912, E-ISSN 1471-6771, Vol. 112, no 2, p. 328-336Article in journal (Refereed) Published
Abstract [en]

Background. Local anaesthetics (LA) injected intraperitoneally (i.p.) have been found to decrease postoperative pain. This double-blind randomized study was performed comparing continuous infusion or patient-controlled bolus injection of LA i.p. The primary endpoint was supplemental opioid consumption during the first 24 postoperative hours.

Methods. Two multi-hole catheters were placed i.p. at the end of the surgery in 40 patients undergoing elective abdominal hysterectomy. The patients were randomized into two groups: Group P: patients self-injected 10 ml of levobupivacaine 1.25 mg ml21 via the i.p. catheter as needed, maximum once/hour, and had continuous saline infusion 10 ml h21 into the second catheter. Group C: Patients received a continuous infusion of 10 ml h21 of levobupivacaine 1.25 mg ml21 i.p. through one catheter and 10 ml saline as bolus as needed via the other. Ketobemidone i.v. was administered as rescue medication.

Results. Total ketobemidone consumption during 0–24 hwas lower in Group P compared with Group C, (mean 23.1 vs 35.7 mg, P¼0.04). No differences in the median pain scores were found between the groups. Earlier return of gastrointestinal (GI) function was found in Group P vs Group C (mean 1.5 vs 2.2 days, P,0.01), which also resulted in earlier home-readiness (mean 1.9 vs 2.7 days, P¼0.04).

Conclusions. A statistically significant opioid-sparing effect was found when patientcontrolled levobupivacaine was administered i.p. as needed compared with continuous infusion. This was associated with a faster return of GI function and home-readiness. There was, however, a wide confidence interval in the primary endpoint, opioid consumption.

Place, publisher, year, edition, pages
Oxford University Press, 2014
Keywords
abdominal hysterectomy; local anaesthetics; postoperative pain
National Category
Anesthesiology and Intensive Care
Research subject
Anaesthesiology
Identifiers
urn:nbn:se:oru:diva-32071 (URN)10.1093/bja/aet345 (DOI)000330433400017 ()24185607 (PubMedID)2-s2.0-84892760154 (Scopus ID)
Note

Funding Agency:

Research Committee, Örebro County Council, Örebro, Sweden

Available from: 2013-10-18 Created: 2013-10-18 Last updated: 2018-08-29Bibliographically approved
4. Local anesthetics administered intra-peritoneally have predominant localand not central analgesic effect: a randomized, double blind study
Open this publication in new window or tab >>Local anesthetics administered intra-peritoneally have predominant localand not central analgesic effect: a randomized, double blind study
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background It remains unclear whether the analgesic effect of intraperitoneal local anesthetics (LA) is via local intraperitoneal or central mechanisms. This double blind, randomized study was performed to test the hypothesis that LA given intraperitoneally (IP) are superior to the same dose administered by continuous IV infusion (IV) for treating postoperative pain.

Methods A multi-hole catheter was placed intraperitoneally at the end of the surgery in 60 patients undergoing elective abdominal hysterectomy. The patients were randomized to: Group IV: a continuous infusion of lidocaine 50 mg/h (10 ml) IV and saline 10 ml/h intermittently IP

Group IP: an injection of lidocaine 50 mg/h (10ml) once every hour IP and a continuous infusion of saline 10 ml/h IV. Group P: saline 10 ml/h both as continuous IV infusion and intermittent IP injection. Postoperative morphine consumption, pain intensity, recovery parameters, home discharge and lidocaine concentrations were measured.

Results

Morphine consumption during 0-24h was lower in Group IP vs. Group IV, mean difference - 22.6 mg (95% CI, 11.4 to 33.8, p < 0.01). No difference was seen between Group IV and Group P in analgesic consumption. The total mean plasma concentration of lidocaine in Group IP was significantly lower than in Group IV, 0 - 4.5h postoperatively (p = 0.03). Pain intensity, recovery parameters and time to home discharge were similar between the groups.

Conclusion The lower supplemental morphine consumption coupled with a lower plasma lidocaine concentration following intraperitoneal administration would confirm a predominant local rather than central effect of local anesthetics.

Keywords
local anesthetics, postoperative pain, abdominal hysterectomy
National Category
Anesthesiology and Intensive Care
Research subject
Anaesthesiology
Identifiers
urn:nbn:se:oru:diva-32194 (URN)
Note

Fant F. is said to be one of the authors to this article (in the "Original studies", p.11) in the dissertation. This is most likely an error. 

Available from: 2013-10-29 Created: 2013-10-29 Last updated: 2017-10-17Bibliographically approved

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