[Evaluation of postoperative pain]

Corrugator Muscle Activity Associated with Pressure Pain in Adults with Neck/Shoulder Pain

Background and Objectives: No studies have reported corrugator muscle activity associated with pain in people with pain. This study aimed to develop an objective pain assessment method using corrugator muscle activity with pressure pain stimulation to the skeletal muscle. Methods: Participants were 20 adults (a mean ± SD age of 22.0 ± 3.1 years) with chronic neck/shoulder pain. Surface electromyography (sEMG) of corrugator muscle activity at rest (baseline) and without and with pressure pain stimulation applied to the most painful tender point in the shoulder was recorded. Participants evaluated the intensity of the neck/shoulder pain and the sensory and affective components of pain with pressure stimulation using a visual analogue scale (VAS). The percentages of integrated sEMG (% corrugator activity) without and with pressure pain stimulation to the baseline integrated sEMG were compared, and the relationships between the % corrugator activity and the sensory and affective components of pain VAS scores were evaluated. Results: Without pressure stimulation, an increase in corrugator muscle activity due to chronic neck/shoulder pain was not observed. The % corrugator activity with pressure pain stimulation was significantly higher than that without stimulation (p < 0.01). A significant positive correlation between corrugator muscle activity and the affective components of pain VAS scores with pressure stimulation was found (ρ = 0.465, p = 0.039) and a tendency of positive correlation was found for the sensory component of pain VAS scores (ρ = 0.423, p = 0.063). Conclusions: The increase in corrugator muscle activity with pressure pain stimulation to the tender point in adults with chronic neck/shoulder pain was observed, although increased corrugator muscle activity resulting from the chronic neck/shoulder pain was not. These findings suggest that corrugator muscle activity with pressure pain stimulation can be a useful objective indication for tender point sensitivity assessment in the skeletal muscle with pain.

Evaluating safety, efficacy, and cost-effectiveness of PICC securement by subcutaneously anchored stabilization device

Purpose

In recent years, a large variety of medical devices has become available. Every device must be efficient, safe and cost effective, but it is not enough to use it properly without considering the environment in which it will be employed. We applied this kind of analysis to subcutaneously anchored sutureless devices (SAS).

Methods

This is a one-center prospective observational study on safety, effectiveness and cost effectiveness of an SAS device (SecurAcath, Interrad) for securement of peripherally inserted central catheter (PICC) in 30 adult cancer patients with treatment expected to be >60 days.

Results

During 4963 catheter days and after 709 dressing changes (documented by 373 pictures), the use of SAS was associated with no episode of PICC dislodgement and a lower incidence of complications if compared to traditional securement devices. Insertion, management and removal of SAS were not associated with an increased pain perception by the patients. Cost effectiveness was particularly evident for long dwelling PICCs.

Conclusions

Our study suggests that SAS is a highly effective and cost-effective method for securement of medium- to long-term PICCs with expected duration longer than 30 days. The introduction of SAS had a positive impact on our healthcare organization.

Chest trauma: First 48hours management

Chest trauma remains an issue for health services for both severe and apparently mild trauma management. Severe chest trauma is associated with high mortality and is considered liable for 25% of mortality in multiple traumas. Moreover, mild trauma is also associated with significant morbidity especially in patients with preexisting conditions. Thus, whatever the severity, a fast-acting strategy must be organized. At this time, there are no guidelines available from scientific societies. These expert recommendations aim to establish guidelines for chest trauma management in both prehospital an in hospital settings, for the first 48hours. The "Société française d'anesthésie réanimation" and the "Société française de médecine d'urgence" worked together on the 7 following questions: (1) criteria defining severity and for appropriate hospital referral; (2) diagnosis strategy in both pre- and in-hospital settings; (3) indications and guidelines for ventilatory support; (4) management of analgesia; (5) indications and guidelines for chest tube placement; (6) surgical and endovascular repair indications in blunt chest trauma; (7) definition, medical and surgical specificity of penetrating chest trauma. For each question, prespecified "crucial" (and sometimes also "important") outcomes were identified by the panel of experts because it mattered for patients. We rated evidence across studies for these specific clinical outcomes. After a systematic Grade^® approach, we defined 60 recommendations. Each recommendation has been evaluated by all the experts according to the DELPHI method.

Preemptive Local Anesthesia in Ankle Arthroscopy

BACKGROUND

Complex anesthesia is increasingly used in order to reduce postoperative pain and accelerate rehabilitation. The aim of this study was to evaluate the efficacy and safety of preemptive local anesthesia combined with general or spinal anesthesia in ankle arthroscopy.

METHODS

From January 2014 to February 2016, 80 ankle anterior arthroscopies were performed. Patients were randomly assigned to one of 4 groups, depending on the type of anesthesia: A, general and local preemptive; B, spinal and local preemptive; C, general and placebo; D, spinal and placebo. After general or spinal anesthesia, each patient randomly received an injection of 7 mL of a mixture of local anesthetics or the same amount of normal saline. After 2, 4, 8, 12, 16, 24, 48, and 72 hours following the release of the tourniquet, the pain intensity level was measured with a visual analog scale (VAS). The use of additional analgesics and any adverse effects were also noted.

RESULTS

Preemptive local anesthesia (groups A and B) resulted in a significantly lower level of pain intensity during the first 24 hours after surgery. Until 8 hours after the release of the tourniquet, the pain intensity level was statistically lower in the groups A, B, and D in comparison to C. During hospitalization, none of the patients from groups A and B received on-demand ketoprofen intravenously. No side effects of local anesthetic agents were observed. Two patients had transient numbness and paresthesia in the field of sensory nerve innervation of the dorsal intermediate cutaneous nerve of the foot.

CONCLUSION

Preemptive operative site infiltration with a mixture of local anesthetics performed in ankle arthroscopy was a safe procedure. It reduced the level of intensity of postoperative pain and the amount of analgesics used.

LEVEL OF EVIDENCE

Level I, prospective randomized study.

Assessment of Migraine Severity Using the Migsev Scale: Relationship to Migraine Features and Quality of Life

We have recently developed an instrument to describe and categorize severity of migraine attacks from patient self-report, the MIGSEV questionnaire. We have now performed a large prospective survey using this tool to evaluate migraine severity in 2979 patients consulting for headache in France, included by 1164 general practitioners, 174 neurologists and 82 gynaecologists. The objective of the study was to determine the prevalence of severity grades in a large population who consults for migraine, to test the concordance between severity calculated from physician-derived and patient-derived data, and to test the relevance of the concept of severity as applied to diagnosis, other measures of the burden of migraine, and to health-related quality of life. Severe attacks were reported in around one-fifth of the sample. Physician- and patient-derived data provided concordant estimates of severity in 71% of cases, the discordant cases representing principally an underestimate by the physician of headache severity. Migraine severity was associated with frequent, long-lasting and treatment-resistant attacks, and with poor quality of life. The MIGSEV questionnaire is proposed as a simple measure of severity for the diagnosis and management of migraineurs, suitable for use both by physicians and patients.

Long-term outcome of surgical treatment of chronic postoperative groin pain: a word of caution

PURPOSE

Chronic postoperative groin pain is widely accepted to be a serious clinical condition after inguinal hernia repair and Pfannenstiel incision. Surgical treatment has been reported to be effective, but the long-term outcome following these interventions remains unclear. This retrospective study reports the outcome and investigates patient and intra-operative factors to identify possible predictors of success. A literature review of other outcome studies with more than 1 year follow-up is also presented.

METHODS

A registry of patients who underwent surgery for chronic postoperative groin pain was analyzed. Pain was assessed using DN4-score and VAS-scale. Primary endpoint was successful pain reduction, as defined by the ratio of VASmax (post/pre) and the subjective outcome (better vs. same-worse).

RESULTS

Fifteen patients underwent surgery for chronic postoperative groin pain between December 2000 and April 2010. Overall, significant pain reduction was achieved in 1/3 of patients. There was no significant association between patient or intra-operative factors and favorable outcome. A complete concordance between subjective outcome and the ratio of VASmax (post/pre) was noted.

CONCLUSION

The success of surgery for chronic postoperative groin pain is difficult to predict. In this study, one in three patients benefits from an operative treatment. The ratio of VASmax (post/pre) is suggested as a useful pain assessment tool. A further prospective study of sufficient sample size is necessary to identify possible factors associated with favorable outcome after surgery for chronic groin pain.

Single-port transumbilical laparoscopic cholecystectomy: A prospective randomised comparison of clinical results of 140 cases

INTRODUCTION

A novel single port access (SPA) cholecystectomy approach is described in this study. We have designed a randomised comparative study in order to elucidate any possible differences between the standard treatment and this novel technique.

MATERIALS AND METHODS

Between July 2009 and March 2010, 140 adult patients with gallbladder pathologies were enrolled in this multicentre study. Two surgeons (RV and UB) randomised patients to either a standard laparoscopic (SL) approach group or to an SPA cholecystectomy group. Two types of trocars were used for this study: the TriPort™ and the SILS™ Port. Outcomes including blood loss, operative time, complications, length of stay and pain were recorded.

RESULTS

There were 69 patients in the SPA group and 71 patients in the SL group. The mean age of the patients was 43.2 (17-77) for the SPA group and 42.6 (19-70) for the SL group. The mean operative time was 63.9 min in the SPA group and 58.4 min in the SL group. For one patient, the SPA procedure was converted to a standard laparoscopic technique and to open approach in the SL group. Complications occurred in eight patients: Five seromas (two in the SPA group) and three hernias (one in the SPA group).The mean hospital stay was 38.5 h in the SPA group and 24.1 h in the SL group. Pain was evaluated and was 2 in the SPA and 2.9 in the SL group, according to the visual analogue scale (VAS) after 24 h (P<0.001). The degree of satisfaction was higher in the SPA group (8.3 versus 6.7). Similar results were found for the aesthetic result (8.8 versus 7.5). (P<0.001).

CONCLUSION

Single-port transumbilical laparoscopic cholecystectomy can be feasible and safe. When technical difficulties arise, early conversion to a standard laparoscopic technique is advised to avoid serious complications. The SPA approach can be undertaken without the expense of additional operative time and provides patients with minimal scarring. The cosmetic results and the degree of satisfaction appear to be significant for the SPA approach.

Single-port transumbilical laparoscopic appendectomy: a preliminary multicentric comparative study in 87 patients with acute appendicitis

Introduction. Laparoscopic appendectomy (LA) has been performed in many approaches such as open, laparoscopic and recently Single Port Access (SPAA). In order to elucidate its potential advantages, we compared the two laparoscopic approaches. Methods. 87 patients were included in a multicentric study for suspected appendicitis in order to perform (SPAA) appendectomy or laparoscopic appendectomy (LA). All outcomes, including blood loss, operative time, complications, and length of stay and pain were recorded prospectively. Results. There were 46 patients in the SPAA group and 41 in the LAG with a mean operative time of 40,4 minutes in the SPAA group and 35,0 minutes in the LA group. Only one patient was converted to an open approach. We described only 2 complications. Pain was graded 2,8 in the SPAA group and 2,9 in the LA group, according to the AVS after 24 hours. Patients in the SPAA Group were more satisfied (7,5 versus 6,9) (P < 0.05). Same results were found for the cosmetic result (8,6 versus 7,4) (P < 0.05). Conclusion. Using the single port approach feasible and safe. The true benefit of the technique should be assessed by new randomised controlled trials.

Ultrasound assessment of haemoperitoneum in ectopic pregnancy: derivation of a prediction model

Background

To derive an ultrasound-based prediction model for the quantification of haemoperitoneum in ectopic pregnancy (EP).

Methods

Retrospective study of 89 patients operated upon EP between January 1999 and March 2003 in a French Gynaecology and Obstetrics department in a university hospital. Transvaginal sonograms, clinical and biological variables from patients with haemoperitoneum ≥ 300 ml at surgery were compared with those from patients with haemoperitoneum < 300 ml or no haemoperitoneum. Sensitivity, specificity, positive and negative likelihood ratios were calculated for each parameter after appropriate dichotomization. Multiple logistic regression analysis was used to select the best combination at predicting haemoperitoneum ≥ 300 ml.

Results

Three parameters predicted haemoperitoneum ≥ 300 ml independently: moderate to severe spontaneous pelvic pain, fluid above the uterine fundus or around the ovary at transvaginal ultrasound, and serum haemoglobin concentration < 10 g/dL. A woman with none of these three criteria would have a probability of 5.3% for haemoperitoneum ≥ 300 ml. When two or more criterias were present, the probability for haemoperitoneum ≥ 300 ml reached 92.6%.

Conclusion

The proposed model accurately predicted significant haemoperitoneum in patients diagnosed to have EP.

Can we implant cardioverter defibrillator under minimal sedation?

Aim In a prospective study, we tested the feasibility of implantable cardioverter-defibrillator (ICD) implantation under local anaesthesia (LA) with minimal sedation (MS) vs. short general anaesthesia (SGA) for defibrillation test (DT).

METHODS AND RESULTS

We implanted ICDs in 118 patients between October 2002 and November 2003. Surgery was performed under LA with MS. Depending on the day of admission, patients had DT without SGA with a shock delivered when patient is unconscious (MS group, n = 73) or with short general anaesthesia (SGA group, n = 45). The patients were asked to rate the intensity of pain on a 10-point visual analogue scale (VAS) at the end of the implantation procedure and for the patient of MS group just after DT (VAS-DT). Visual analogue scale was not influenced by the type of anaesthesia (MS vs. SGA). Univariate analysis showed that NYHA >III, 3 leads implanted and an incomplete understanding of the explanation on the procedure were risk factors of VAS >4. Only understanding of the explanation on the procedure has an influence on pain in multivariate analysis.

CONCLUSION

ICD implantation under MS even for DT is feasible and acceptable for the patient.

Influence de l’indice de masse corporelle sur la réalisation d’une prothèse totale de hanche par voie d’abord antérieure réduite

PURPOSE OF THE STUDY

The purpose of this prospective study was to evaluate the influence of the BMI on the feasibility of minimally invasive total hip arthroplasty (THA).

MATERIAL AND METHODS

This prospective study included 86 patients (88 THA) operated on via a single minimally invasive incision (7 cm) using an anterior approach on Judet's orthopedic table. Mean age was 63.7 years and mean BMI was 58.8. Forty-one patients were classified in group I (BMI<25) and 46 in group II (BMI >=25). Perioperative data, pain, postoperative blood loss, duration of the procedure, and length of the incision were noted. All patients were reviewed at three months and radiographic analysis was performed to asses the position of the socket and the quality of the cementation.

RESULTS

BMI did not appear to be a strict contraindication for a minimally invasive procedure. Nevertheless, bleeding and operative duration were statistically correlated with BMI (epsilon=4.28 and epsilon=2.66). Extension of the wound noted at the end of the procedure in patients with BMI > =25 (t=5.01) may have resulted from greater pressure on the skin and soft tissue due to stronger traction and more abrasion of the skin edges by reamers and rasps. Such damage may lead to more wound complications even though in our experience there was no statistical difference. On the other hand, socket position and cementation did not appear to be correlated with BMI.

DISCUSSION

Results concerning duration of procedure, bleeding, hospital stay and rate of complications are contradictory in the literature. At the same time, criteria for patient selection remain unclear. It thus appeared to be of interest to determine whether BMI was a good criterion to determine the feasibility of THA via a minimally invasive procedure.

CONCLUSION

BMI appears to be a good criterion to evaluate the risk of wound complications after minimally invasive surgery. On the other hand, other criteria must be found since BMI does not evaluate muscle mass which seems to be of major concern in minimally invasive procedures.

[Pain management in subarachnoid haemorrhage: a survey of French analgesic practices]

OBJECTIVE

Pain management in patients having a subarachnoid haemorrhage was assessed in French intensive care unit of neurosurgical centres.

STUDY DESIGN

Nationwide survey.

METHODS

A standardized postal questionnaire was sent to senior doctor of every neurosurgical centres in France inquiring pain scores assessment, analgesics used and their routes of administration, centre's opinion about efficacy of pain management.

RESULTS

Of the 34 centres, 24 returned completed questionnaires. Fifty four per cent of the centres evaluated pain intensity with a non valid pain score. In the case of patients in the comatose, pain was not evaluated in fifty four per cent of the centres. Paracetamol and morphine were the most currently used analgesics drugs. Morphine was administered subcutaneously by 75% of the centres. Six centres used also PCA. Thirty-seven percent of the centres were reluctant to use opioids and 75% to use NSAIDS.

CONCLUSION

The majority of the centres considered pain management in patient suffering from subarachnoid haemorrhage (SAH) was not optimal and stressed the need to establish a well validated pain rating scale dedicated to SAH patients.

Assessment of peri-extubation pain by visual analogue scale in the adult intensive care unit: a prospective observational study

OBJECTIVE

This prospective observational study was undertaken in order to assess pain experienced by intensive care unit patients at the time of extubation and to identify factors associated with pain of at least moderate intensity.

DESIGN

Prospective observational study.

SETTING

Intensive care unit at a university hospital.

PATIENTS

During a 1-year period the presence, severity and clinical predictors of orofacial and/or chest pain among patients undergoing removal of endotracheal tubes was assessed.

MEASUREMENTS AND RESULTS

Pain was evaluated using a visual analogue scale (VAS). Of 332 extubated patients, 203 could be evaluated. During the peri-extubation period, pain was significantly associated with a SAPS II score more than 36 ( p=0.03) and duration of mechanical ventilation (MV) of 6 days or more ( p=0.002), whereas intubation in the operating room was associated with less pain ( p=0.001). Pain of at least moderate intensity (VAS score >30 mm) was reported by 73% of patients and pain of severe intensity (VAS score >50 mm) was reported by 45% of patients. MV duration of 6 days or more was the only independent risk factor for pain of at least moderate intensity (OR 2.4, 95% CI 1.03-5.4, p=0.04). We also observed that pain had resolved 1 h after extubation in the majority of patients.

CONCLUSION

Our results suggest that, in intensive care unit patients, peri-extubation pain is frequent and should be considered for treatment, especially in patients with longer intubation.

[Ovarian puncture in fertilization in vitro: what analgesia?]

We compared two techniques of local anesthesia used in transvaginal ultrasound guided oocyte recovery in in vitro fertilization: paracervical lidocaïne block versus vaginal application of Emla, a topical anesthesic cream.

STUDY DESIGN

The study included 103 patients divided in two groups. Pain was evaluated by visual analog scale and questionnaire.

RESULTS

Univariate analysis showed that the patients were satisfied with neither of the two protocols. Multivariate analysis revealed paracervical lidocaïne block to be superior. The premedication appeared inadequate.

CONCLUSION

We decide to use paracervical lidocaïne block and to improve the premedication. Indications for general and locoregional anesthesia were also enlarged. A new study showed a significantly greater patient satisfaction. One variable analysis indicated that no one of these protocols satisfied our patients.

Preinsertion local anesthesia at the trocar site improves perioperative pain and decreases costs of laparoscopic cholecystectomy

BACKGROUND

Local anesthesia at the trocar site in laparoscopic cholecystectomy is expected to decrease postoperative pain and hence expedite recovery. The aims of this prospective randomized study were to investigate the effect of local anesthesia and to discover whether it is cost effective.

METHODS

For this study, 100 patients undergoing laparoscopic cholecystectomy were randomized into two groups. The 43 study patients were injected with 0.5% bupivacaine hydrochloride at the trocar site before the trocars were inserted. They then were compared with 41 control patients who received no local anesthesia. The remaining 16 patients were excluded from the study. The postoperative pain was evaluated at the standard four trocar sites at 4 h and 24 h after surgery on a scale 1 (the mildest pain the patient had ever experienced) to 10 (the most severe pain the patient had ever experienced). Postoperative pain medications and their cost were evaluated.

RESULTS

There was no difference between the two groups with regard to gender, age, weight, operative time, estimated operative blood loss, and bile culture. The patients who received bupivacaine at the trocar site clinically had less pain (p < 0.001 for all four sites) both at 4 and 24 h after surgery. The treatment group patients used less mepiridine and promethzine than the control group (p = 0.001 and 0.002, respectively) postoperatively. Overall, the patients who had local anesthesia used less postoperative pain and antiemetic medication than the control patients (p = 0.02). This afforded a significant decrease in the costs and charges of these medications (p = 0.004 and 0.005, respectively). Three patients in the study group were discharged from the hospital the day of surgery.

CONCLUSION

Preinsertion of local anesthesia at the trocar site in laparoscopic cholecystectomy significantly reduces postoperative pain and decreases medication usage costs.

[Quality assurance program for postoperative pain management: impact of the Consensus Conference of the French Society of Anesthesiology and Intensive Care]

OBJECTIVE

To assess the impact of a pain management quality assurance program (PQAP) after abdominal surgery. The means used were mainly based on the French Society of anaesthesiology's pain management guidelines.

STUDY DESIGN

Prospective evaluation using a before after study design: two audits among surgical patients: a first one in 1997 before implementation of PQAP, and a second one year later.

PATIENTS AND METHODS

First, standards were defined including objectives about pain relief and patient satisfaction. After analysis of discrepancy observed between these objectives and the data of the first audit, a pain management program was introduced that included education of physicians, nurses and patients, systematic assessment of pain, organized pain relief protocols and implementation of modern analgesic technologies.

RESULTS

201 consecutive inpatients were evaluated in the first audit, and 117 in the second one. Comparing the second audit with baseline, the visual analog pain scores decreased during the five postoperative days, and the rate of very satisfied patients increased (36% versus 26%). 43% of the patients were given a regular analgesic medication in 1998 versus 15% in 1997. 65% of medications were administered with an effective interval between doses versus 47% in 1997. Patient-controlled techniques were used in 28% of the cases in 1998 versus 9% in 1997.

CONCLUSION

The PQAP provided an improvement in efficacy of postoperative pain management in our unit, with the help of the overall ward staff, but without requiring personnel specially qualified.