Biomedical subjects

H Kehlet

Publications and source records attributed to H Kehlet.

At least 19 recordsLinked to original sources

PubMed1992

Postoperative morbidity among symptom-free alcohol misusers.

Retrospective studies suggest that there is an increased postoperative morbidity among alcohol misusers. We have prospectively studied the risk of alcohol intake among patients undergoing surgery. We investigated 15 symptom-free subjects who required colorectal surgery and who were drinking at least 60 g of alcohol per day. These patients were matched for sex, nutrition, age, weight, cardiovascular and pulmonary disease, diagnosis, anaesthesia, and surgery to 15 control subjects who were consuming below 25 g of alcohol daily. Those drinking at least 60 g of alcohol per day developed more postoperative complications than controls (67% vs 20%, p less than 0.05) and hospital stay was prolonged (20 vs 12 days, p less than 0.05). Preoperatively, alcohol misusers had reduced left ventricular ejection fraction (median, 54% vs 68%, p less than 0.01). Delayed hypersensitivity responses were smaller in the alcohol group before (53 mm2 vs 78 mm2, p less than 0.05) and after (18 mm2 vs 55 mm2, p less than 0.01) surgery. Alcohol misusers had longer bleeding times during the first postoperative week (p less than 0.01). Surgical stress responses, as assessed by changes in plasma cortisol and catecholamines, were higher among alcoholics (p less than 0.05). Postoperative morbidity is increased in symptom-free alcohol misusers. The mechanism is probably subclinical cardiac insufficiency, immunosuppression, and decreased haemostatic function. Preoperative alcohol consumption may be a more important risk factor than previously thought.

Aged↗

PubMed1992

[Patients' activity and length of stay after hip arthroplasty with balanced analgesia and early mobilization].

Thirteen consecutive patients were submitted to hip-replacement by Müller's method under epidural analgesia and were treated for postoperative pain with balanced analgesia by means of continuous epidural infusion of a mixture of bupivaine (0.625 mg/ml) and morphine (0.05 mg/ml) 4 ml hourly for 96 hours and supplemented by 600 mg ibuprofen every eight hour orally. The analgesic treatment was combined with intensive mobilization regime and altered postoperative care as regards early normalization of daily activities and reduced duration of hospitalization. The patients were found to be effectively relieved of pain during rest and also during mobilization and, together with suitable care and rehabilitation, this had the result that more than half of the patients were mobilized from bed for more than eight hours from the second postoperative day and that all of the patients were able to carry out ordinary everyday functions after the fourth postoperative day, with the assistance of the aids which the hip regimen required. Eleven of the patients were ready for discharge on the sixth postoperative day while two patients were not discharged until the eighth and ninth postoperative days on account of slight surgical complications. All of the patients were discharged to their homes and to outpatient rehabilitation for three weeks. Compared with the usual duration of hospitalization of approximately 13 days in corresponding patients, this pilot investigation appears to show that the analgesic regime employed was extremely effective but that traditional attitudes and routines in the postoperative care and mobilization must be revised if this is to be utilized for more rapid restitution and reduced duration of hospitalization.

Aged↗

PubMed1992

[Treatment of defecation blockade caused by deep recto-vaginal fossa with total pelvic floor reconstruction using a prolene-net].

The causes of severe defaecation blockage resulting from compression of the rectum and deep recto-genital fossa are reviewed and are illustrated by three patients who had previously undergone hysterectomy and who had incapacitating defaecation blockage and abdominal pain requiring morphine in two of the patients. The condition had not been diagnosed despite previous hospital contact for many years in two of the patients. Complete reconstruction of the pelvic floor with prolene net was performed. Subsequent defaecography showed normalization of defaecation without rectal compression and with relief of the abdominal pain and dependence on morphine in two of the patients. Rectal compression resulting from an abnormally deep recto-genital fossa should be included in the differential diagnostic deliberations in patients with severe constipation and defaecation blockage. Complete reconstruction of the pelvic floor with prolene net is considered, in the preliminary findings, to be a reasonable alternative in the treatment of this condition.

Adult↗

PubMed1992

Effect of combined prednisolone, epidural analgesia, and indomethacin on the systemic response after colonic surgery.

Twenty patients undergoing colonic resection were randomized to either conventional postoperative pain treatment with morphine chloride and acetaminophen (group 1, n = 9) or methylprednisolone sodium succinate 90 minutes before surgery plus intraoperative neural blockade, with a postoperative analgesic regimen with combined bupivacaine hydrochloride-morphine and indomethacin sodium for systemic effect (group 2, n = 11). Assessments of pain, pulmonary function, convalescence, and various injury factors were done several times until 8 days after surgery. Postoperative pain and hyperthermic response were eliminated in group 2. Conventional reduction in pulmonary function measures was improved in group 2, and fatigue and mobility were less pronounced. Prostaglandin E2, interleukin 6, and C-reactive protein levels increased in both groups, but significantly less in group 2. These results suggest that a combined neural and humoral blockade may more effectively inhibit the global stress response to elective surgery than previously observed with neural blockade with or without indomethacin.

Acetaminophen↗

PubMed1992

Circadian variation in unexpected postoperative death.

Unexpected deaths still occur following major surgical procedures. The cause is often unknown but may be cardiac or thromboembolic in nature. Postoperative ischaemia, infarction and sudden cardiac death may be triggered by episodic or constant arterial hypoxaemia, which increases during the night. This study examined the circadian variation of sudden unexpected death following abdominal surgery between 1985 and 1989 inclusive. Deaths were divided into those occurring during the day (08.00-16.00 hours), evening (16.00-24.00 hours) and night (24.00-08.00 hours). Twenty-three deaths were considered to have been totally unexpected. Of 16 such patients undergoing autopsy, pulmonary embolism was the cause of death in five. In the remaining 11 patients, death occurred at night in eight (P < 0.005). Five of the seven patients without an autopsy died at night (P < 0.04); overall, 13 of 18 unexpected deaths occurred at night-time. These results suggest a need for further studies of sleep- and respiration-related effects on postoperative nocturnal cardiac function. The efficacy of monitoring during this apparent high-risk period should be evaluated.

Aged↗

PubMed1992

Effect of oxygen therapy on late postoperative episodic and constant hypoxaemia.

As constant hypoxaemia itself may trigger development of apnoea and periodic breathing, we have studied the effect of oxygen therapy on the occurrence of late postoperative episodic hypoxaemia. Thirty-five patients without cardiopulmonary disease and undergoing elective total hip replacement were monitored with a pulse oximeter on the second night after operation (23:00 to 07:00), receiving either 21% or 37% oxygen by face mask in a randomized double-blind design. Mean oxygen saturation was greater in the group receiving 37% oxygen than in those having 21% oxygen (96% vs 92%, P less than 0.01). There was a weak correlation between mean oxygen saturation and the total number of hypoxaemic episodes (rs = -0.62, P less than 0.001), explained partly by the calculated (non-mechanistic) reduction in mean saturation by the episodes of hypoxaemia. There was no significant difference between the groups in the total number of sudden decreases in oxygen saturation, the duration of the events or number of patients with events to more or less than 80% oxygen saturation, although there was a trend towards fewer patients having events to less than 80% in the 37% oxygen group (nine of 17 patients vs five of 18 patients (ns); 95% confidence limits of median difference: -6 to 56%). We conclude that postoperative oxygen therapy with 37% oxygen by face mask increases mean oxygen saturation, but does not influence the basic mechanism leading to episodic hypoxaemia.

Aged↗

PubMed1992

Effect of pre- vs postoperative inguinal field block on postoperative pain after herniorrhaphy.

The analgesic effects of an identical inguinal field block, performed before or immediately after inguinal herniorrhaphy, were evaluated in 32 healthy patients in a double-blind, randomized study. During surgery, all patients received a light general anaesthesia with thiopentone, alfentanil and nitrous oxide in oxygen. After induction of general anaesthesia, patients were allocated randomly to receive an inguinal field block with lignocaine, either 15 min before operation or immediately after operation, after closure of the surgical wound, but before the patients were awake. Pain score on a visual analogue scale and on a verbal scale at rest, during mobilization from supine into sitting position and during cough was assessed 1, 2, 4, 6, 8 and 24 h, and 7 days after operation. No significant differences between the groups were observed in VAS scores or verbal pain scores during rest or ambulation at any time. There was no significant difference in time to first request for morphine or total morphine consumption. These results do not show pre-emptive analgesia with a conventional inguinal field block to be of clinical importance compared with a similar block administered after operation.

Adult↗

PubMed1992

Influence of timing on the effect of continuous extradural analgesia with bupivacaine and morphine after major abdominal surgery.

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 7.5 mg 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 2.5 mg ml-1 plus morphine 0.05 mg ml-1, 4 ml 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.

Aged↗

PubMed1992

Pain sensation and nociceptive reflex excitability in surgical patients and human volunteers.

Pain threshold, nociceptive flexion reflex (NFR) threshold and responses to suprathreshold stimulation were investigated in 15 female patients (mean age 32 yr (range 22-48 yr)) before and 68 (range 48-96) h after gynaecological laparotomy. Control measurements were performed in 17 healthy human volunteers (five males, age 30 yr (range 24-41 yr)). In the surgical patients, pain threshold decreased and pain to suprathreshold stimulation increased significantly (P = 0.006 and P = 0.04, respectively) from before to after surgery. A corresponding trend was demonstrated in neurophysiological measurements, although the decrease in NFR threshold and increase in NFR amplitude to suprathreshold stimulation were not significant (P = 0.08 and P = 0.24, respectively). The correlations between the relative change in pain and reflex thresholds, and time from surgery, were statistically significant (pain threshold: rs = 0.53, P = 0.04; NFR thresholds: rs = 0.54, P = 0.04). In the healthy volunteers, no significant differences in thresholds and responses to suprathreshold stimulation were observed between two recordings with an interval of at least 48 h. The allodynia and hyperalgesia observed in postsurgical patients may be related to postoperative sensitization of central neurones.

Adult↗

PubMed1992

Effects of lidocaine aerosol on postoperative pain and wound tenderness following minor gynaecological laparotomy.

Twenty-four female patients undergoing sterilization through a minor lower laparotomy received, in a double-blind, randomized study, either lidocaine spray 200 mg or placebo in the surgical wound. Postoperative pain intensity was evaluated on a verbal and a visual analogue scale and wound tenderness with an algometer. During mobilisation from the supine to the sitting position, VAS-score was lower (P less than 0.05) in the lidocaine group 2 h postoperatively, but not 4, 6 and 8 h postoperatively (P greater than 0.05). No significant differences were found in VAS-scores at rest or during cough, or in verbal scale ratings during rest, cough or mobilisation, and postoperative consumption of morphine was similar in the two groups. Pressure pain thresholds were higher (P less than 0.05) 2 h postoperatively in the lidocaine group, but not 4, 6 and 8 h postoperatively. In conclusion, topically applied lidocaine aerosol in the surgical wound leads to very short and clinically insignificant relief of postoperative pain.

Aerosols↗

PubMed1992

Effect of thoracic epidural etidocaine 1.5% on somatosensory evoked potentials, cortisol and glucose during cholecystectomy.

The effect of thoracic (T7-8) epidural etidocaine 1.5%, 9 ml, and continuous per- and postoperative epidural infusion of etidocaine 1.5%, 4 ml/h, on early (less than 500 ms) somatosensory evoked potentials (SEPs), and cortisol and glucose in plasma during cholecystectomy, was examined in ten patients. Spread of analgesia (pin-prick) was T3 (T1-T3) to L2 (T11-L3) 35 min after injection of etidocaine, and T3 (T2-T4) to T12 (T8-L4) 3 h after surgical incision (median (range)). Before operation, epidural etidocaine had no significant effects on peak-to-peak amplitude of SEPs to electrical stimulation at the L1, T10 or T6 dermatomal level (P greater than 0.09). SEPs were abolished in only two patients at T6, and no patient had SEPs abolished at T10 or L1. The plasma concentrations of cortisol and glucose were significantly increased 20 min after surgical incision and remained increased throughout the study. No correlation was found between the block-induced decrease in the peak-to-peak amplitude at T6 or T10 and increase in plasma cortisol, except for a negative correlation at T10 and the initial increase in cortisol (Rs = 0.72, P = 0.03). In conclusion, thoracic epidural administration of 9 ml of etidocaine 1.5% does not provide total afferent somatic blockade assessed by SEP and the stress response to cholecystectomy.

Adult↗

PubMed1992

Continuous coeliac plexus blockade plus intermittent wound infiltration with bupivacaine following upper abdominal surgery: a double-blind randomised study.

In this double-blind trial, we observed the effect of intermittent wound infiltration with local anaesthetic plus continuous coeliac plexus blockade on postoperative pain relief, pulmonary function, the neuroendocrine and acute phase protein response following upper abdominal surgery. In Group A (n = 10) patients received bupivacaine intermittently into the wound and continuously into the coeliac plexus following an initial bolus. A total of 862.5 mg of bupivacaine was used over 12 h with no observed toxicity. Group B (n = 10) received equal volumes of saline. Although pain relief was poor in both groups, the bupivacaine group used less morphine postoperatively and had lower pain scores than the saline group 4 h after operation (P less than 0.05). Pulmonary function was significantly reduced in both groups with no statistical difference between the two. Significant reductions in serum glucose and cortisol were achieved (P less than 0.05), suggesting that afferent neural blockade was partially effective in attenuating the neuroendocrine response. However, the postoperative rise in interleukin-6 was not affected by this technique. It is concluded that total afferent neural blockade cannot be achieved with peripheral wound and coeliac plexus administration of relatively large doses of local anaesthetic during upper abdominal surgery.

Abdomen↗

PubMed1992

Effect of piroxicam in addition to continuous thoracic epidural bupivacaine and morphine on postoperative pain and lung function after thoracotomy.

Twenty-eight patients scheduled for lung resection with lateral thoracotomy and postoperative chest drains during combined thoracic epidural bupivacaine plus morphine and general anaesthesia were studied. Postoperative pain treatment was continuous epidural infusion of bupivacaine 0.25% 5 ml h-1 plus morphine 0.2 mg h-1 for 48 h and, in addition, the patients received rectal piroxicam 40 mg randomly and double-blind 12 h and 1 h before surgery and 20 mg 24 h-1 postoperatively or placebo. Pain was evaluated at rest, during cough and mobilisation, together with pulmonary function (FEV1, FVC, PEFR) and sensory level of analgesia repeatedly for 48 h. The results showed efficient pain relief, but without differences in pain scores or need for supplementary analgesics between the two groups. Pulmonary function decreased similarly in the two groups. Thus we were unable to show enhanced analgesia by supplementing an otherwise effective low-dose epidural bupivacaine and morphine treatment with piroxicam after thoracic surgery with chest drains.

Administration, Rectal↗

PubMed1992

Duration of postoperative immunosuppression assessed by repeated delayed type hypersensitivity skin tests.

The duration of postoperative impairment in cell-mediated immunity was assessed by repeated skin testing with seven delayed type common antigens in 15 patients undergoing major elective abdominal surgery compared to a similar testing regimen in 10 healthy volunteers. All were skin tested four times, with 72-hour intervals, and in the surgical patients the first test was applied 2 days before surgery, followed by tests on postoperative days 1, 4 and 7. The tests were read after 48 h. Postoperatively, the skin test area decreased on day 3 (p less than 0.01) and recurred to preoperative levels on day 9. In contrast, the skin test area in the volunteers increased from test to test (p less than 0.001) during the study, confirming a previous finding of a vaccination effect. These results suggest that the postoperative immunosuppression is maintained for about 6-9 days.

Female↗

PubMed1992

Differential analgesic effects of low-dose epidural morphine and morphine-bupivacaine at rest and during mobilization after major abdominal surgery.

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.

Abdomen↗

PubMed1992

Systemic piroxicam as an adjunct to combined epidural bupivacaine and morphine for postoperative pain relief--a double-blind study.

In a randomized, double-blind, placebo-controlled trial, we assessed the value of adding rectal piroxicam to a low-dose epidural regimen for postoperative pain relief. Forty-four patients scheduled for major upper abdominal surgery during combined thoracic epidural (bupivacaine + morphine) and general anesthesia were studied. Postoperative analgesia was achieved by using epidural bupivacaine (10 mg/h) plus morphine (0.2 mg/h) for 72 h. In addition, the patients randomly received a placebo or rectal piroxicam (40 mg 12 h before surgery, 20 mg with premedication, and 20 mg every 24 h for 72 h). Pain was evaluated every 4 h at rest, during coughing on demand, and during mobilization. The sensory level of analgesia was evaluated by pinprick. We found no significant difference between piroxicam and placebo with regard to postoperative pain scores or need for supplementary analgesics. Thus, we were unable to demonstrate enhanced analgesia by adding piroxicam to an otherwise very effective low-dose epidural bupivacaine and morphine treatment after upper abdominal surgery.

Abdomen↗

PubMed1992

Epidural clonidine enhances postoperative analgesia from a combined low-dose epidural bupivacaine and morphine regimen.

In a randomized, double-blind, placebo-controlled trial, the value of adding clonidine to a low-dose epidural regimen for postoperative pain treatment was assessed. Twenty-four patients scheduled for hysterectomy during combined thoracic epidural (bupivacaine and morphine) and general anesthesia were studied. Postoperative analgesia consisted of epidural bupivacaine (5 mg/h) and morphine (0.1 mg/h) for 12 h. In addition, the patients randomly received clonidine (75 micrograms), followed by an infusion of 18.75 micrograms/h or saline solution (placebo) epidurally. Pain was evaluated at rest, during cough, and during mobilization every hour. Sensory level of analgesia was evaluated by pinprick. We found no significant difference in pain scores at rest between the clonidine and placebo groups but an enhanced analgesic effect by clonidine during cough and mobilization (P less than 0.05). Arterial blood pressure decreased significantly during clonidine infusion and remained lower than in the control group throughout the study. We conclude that a continuous low-dose epidural clonidine infusion enhances analgesia from a combined low-dose epidural bupivacaine and morphine regimen after hysterectomy; however, the concomitant decrease in arterial blood pressure during epidural clonidine deserves further study before such a regimen can be recommended.

Adult↗

PubMed1992

Are perioperative nonsteroidal anti-inflammatory drugs ulcerogenic in the short term?

It is well documented that long term treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) increases the risk of peptic ulcer and that gastroduodenal mucosal erosions can be demonstrated in volunteers within 1 week of treatment initiation. However, long term studies in nonsurgical patients have not documented gastroduodenal complications within the first week of treatment. Cumulative data from controlled studies of perioperative (> or = 48 hours and < or = 7 days) treatment with NSAIDs do not suggest an increased risk of gastroduodenal complications (such as bleeding/perforation) within this time frame. We conclude that the otherwise well documented gastrointestinal side effects of prolonged treatment with NSAIDs should not hinder short term NSAID treatment for improved analgesia after surgery.

Anti-Inflammatory Agents, Non-Steroidal↗