Beruflich Dokumente
Kultur Dokumente
doi:10.1111/j.1365-2044.2007.05142.x
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In a randomised double blind prospective study, we tested the hypothesis that postoperative pain is
lower in patients who receive an ProSeal LMATM laryngeal mask airway compared with a tracheal
tube. One hundred consecutive female patients (ASA III, 1875 years) undergoing laparoscopic
gynaecological surgery were divided into two equal-sized groups for airway management with the
ProSeal LMA or tracheal tube. Anaesthesia management was identical for both groups and included
induction of anaesthesia using propofol fentanyl, and maintenance with propofol remifentanil,
muscle relaxation with rocuronium, positive pressure ventilation, gastric tube insertion, dexamethasone tropisetron for anti-emetic prophylaxis, and diclofenac for pain prophylaxis. All types
of postoperative pain were treated using intravenous patient-controlled analgesia (PCA) morphine.
Patients and postoperative staff were unaware of the airway device used. Data were collected by a
single blinded observer. We found that pain scores were lower for the ProSeal LMA at 2 h and 6 h
but not at 24 h. Morphine requirements were lower for the ProSeal LMA by 30.4%, 30.6%
and 23.3% at 2, 6 and 24 h, respectively. Nausea was less common with the ProSeal LMA than
with the tracheal tube at 2 h and 6 h but not at 24 h. There were no differences in the frequency of
vomiting, sore throat, dysphonia or dysphagia. We conclude that postoperative pain is lower for
the ProSeal LMA than the tracheal tube in females undergoing gynaecological laparoscopic surgery.
. ......................................................................................................
M. Hohlrieder et al.
Analgesia requirements after gynaecological laparoscopic surgery
Anaesthesia, 2007, 62, pages 913918
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Methods
Tracheal tube
n
50
Age; year
37.2 (10.2)
Height; cm
166.4 (5.7)
Weight; kg
66.5 (11.2)
BMI; kg.m)2
24.1 (4.1)
ASA I II; n
45 5
Laparoscopic procedures; n
diagnostic
6
ovarian cyst resection
16
uni- and bilateral ovarian resection
13
endometriosis resection
4
fibroidectomy
11
Anaesthesia induction and maintenance drugs
Propofol; mg
194.2 (23.7) (50)
Fentanyl; mg
0.18 (0.04) (50)
Cumulative remifentanil; lg
1161 (608) (50)
Cumulative propofol; mg
508 (293) (50)
Cumulative intra-operative crystalloids; ml
1110 (368) (50)
Cumulative intra-operative colloids; ml
0
Anaesthesia time; min
82 (37)
Surgical time; min
55 (36)
Insertion attempt; n
First
50
Second
0
Blood detected on laryngoscope; n
1
Blood detected on TT or PLMA; n
1
66 (8)
Heart rate; beats.min)1
Heart rate < 40 or > 100 beats.min)1; n
0
Systolic blood pressure; mmHg
106 (8)
Systolic blood pressure < 80 mmHg; n
1
98.1 (0.8)
SpO2; %
SpO2 < 90%; n
0
Total residual gastric volume; ml
16.2 (18.1)
Post anaesthesia care unit time; min
92 (29)
Post anaesthesia care unit droperidol*; mg
0.625 (0) (10)
ProSeal LMA
50
38.4 (9.9)
166.2 (6.2)
65.5 (12.7)
23.7 (4.3)
45 5
8
18
11
4
9
189.6 (24.2) (50)
0.17 (0.06) (50)
1083 (400) (50)
471 (176) (50)
1080 (325) (50)
0
81 (26)
54 (24)
50
0
0
0
66 (8)
0
105 (9)
1
98.2 (0.8)
0
18.7 (15.5)
91 (26)
0.625 (0) (2)
p value
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
915
M. Hohlrieder et al.
Analgesia requirements after gynaecological laparoscopic surgery
Anaesthesia, 2007, 62, pages 913918
. ....................................................................................................................................................................................................................
2h
p value
6h
PCA morphine; mg
Tracheal tube
7.9 (3.9)
13.4 (7.0)
ProSeal LMA
5.5 (3.5)*
9.3 (6.2 )*
Pain VAS at rest; cm
Tracheal tube
4.0 (1.5
3.0 (1.4)
ProSeal LMA
3.3 (1.2)*
2.4 (1.2)*
Nausea (VAS > 3); n
Tracheal tube
10
8
ProSeal LMA
2*
1*
Vomiting; n
Tracheal tube
6
4
ProSeal LMA
1
1
Sore throat; n
Tracheal tube
4
4
ProSeal LMA
2
1
Dysphonia; n
Tracheal tube
0
0
ProSeal LMA
0
0
Dysphagia; n
Tracheal tube
1
1
ProSeal LMA
0
0
Location of main pain (abdomen incision shoulder airway others); n
Tracheal tube
50 0 0 0 0
48 2 0 0 0
ProSeal LMA
49 1 0 0 0
49 1 0 0 0
24 h
Time
effect
Group
effect
< 0.0001
0.006
< 0.0001
0.038
0.027
NS
NS
NS
NS
NS
16.7 (8.8)
12.8 (7.9)*
1.5 (1.0)
1.4 (0.9)
1
0
0
0
2
1
0
0
0
0
16 0 34 0 0
14 0 36 0 0
*Significantly different by uncorrected post hoc group comparison (p < 0.05); significantly different by Bonferroni-Holm-corrected post hoc
group comparison (p < 0.016).
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Time, h
2h
PCA Morphine; mg
Tracheal tube
ProSeal LMA
Pain VAS at rest; cm
Tracheal tube
ProSeal LMA
Nausea (VAS > 3); n
Tracheal tube
ProSeal LMA
Vomiting; n
Tracheal tube
ProSeal LMA
p value
6h
24 h
7.9 (3.8)
5.5 (3.4)*
13.4 (7.0)
9.4 (6.4)*
16.9 (8.7)
12.8 (8.0)*
4.0 (1.6)
3.3 (1.2)*
3.0 (1.4)
2.3 (1.2)*
1.5 (1.0)
1.4 (0.9)
8
1*
1
0
4
1
0
0
10
2*
6
1
Time
effect
Group
effect
< 0.0001
0.008
< 0.0001
0.032
0.014
NS
No sore throat, dysphonia or dysphagia. n = 46 for tracheal tube; n = 48 for ProSeal LMA.
*Significantly different by uncorrected post hoc group comparison (p < 0.05); significantly different by Bonferroni-Holm-corrected post hoc group comparison (p < 0.016).
for laryngeal mask devices than the tracheal tube [4, 5]:
Cork et al. [4], in a study of 44 patients for peripheral
orthopaedic surgery; and Buniatian & Dolbneva [5] in a
study of 146 patients for laparoscopic cholecystectomy.
The current study also showed that nausea was less
frequent with the ProSeal LMA, confirming our previous
findings [6].
The combined findings of these studies suggest that
laryngeal mask devices are associated with lower pain
scores than is the tracheal tube. The presence of a cuff
in the pharynx is much less stimulating than a cuff in
the trachea [3]. We postulate that the pain centres are
stimulated to a lesser extent by extraglottic than by
subglottic airway devices during surgery, resulting in
higher pain thresholds after surgery. The mechanism is
perhaps similar to the pre-emptive analgesic effect
occurring at the spinal level during spinal anaesthesia
[1]. An alternative explanation is that analgesic requirements were lower with the ProSeal LMA as there was a
trend for lower airway morbidity; however, analysis of
the subpopulation with no airway morbidity yielded the
same findings. Also, the main location of pain was always
the abdomen (early) or shoulder tip (late) and never the
airway. Our previous study also showed that the reduction in postoperative pain was unrelated to airway
morbidity [6].
Our study has two limitations. Firstly, our data may
not apply to other patient populations undergoing other
surgical procedures. However, as other studies have
detected a pre-emptive analgesic effect in orthopaedic
surgery [4], laparoscopic cholecystectomy [5] and breast
surgery [6], as well as gynaecological laparoscopy [6], it is
likely that our findings are widely applicable. Secondly,
the ProSeal LMA was inserted by an experienced
2007 The Authors
Journal compilation 2007 The Association of Anaesthetists of Great Britain and Ireland
917
M. Hohlrieder et al.
Analgesia requirements after gynaecological laparoscopic surgery
Anaesthesia, 2007, 62, pages 913918
. ....................................................................................................................................................................................................................
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