Post-Operative Manipulations In Patients’ Recovery Essay

Post operative hand off to recovery room refers to the follow-up care that a patient receives after undergoing a surgical procedure or after being in the Intensive Care Unit (ICU). This entails my patient-centered problem that I wish to expound in my project. Post operative care often entails wound care and pain management undertaken by the ICU nurses. It begins immediately after the surgery session and lasts until the patient has fully recovered.

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My proposal on addressing the problemIt is crystal clear that post hand off to recovery is an immense problem that if not controlled could result in adverse effects such as the death of the patient, infection of other diseases and many others. As a nurse and this being one of my fields of work, I would propose various ways which can be used to address the problem and if possible eliminate it completely. In order to enhance the recovery process, I can propose that all patients be educated thoroughly about the process of surgery, what to expect as the outcome and also how to cooperate with the nurses after the process before they undergo the surgery. This would reduce resistances by the patients during the care and therefore fasten the process of healing. Another suggestion would be to regularly check on the nurses in order to take them through the counselling process. This can ensure that they are always version with their roles during the postoperative recovery process and this can minimize adverse effects like complications. Post-Operative Manipulations In Patients’ Recovery Essay

There are ethical issues which are concerned with post operative recovery, which are put in place to ensure adherence by both the patients and the nurses and to determine what is right or wrong. The code of ethics governing this process requires that the nurses handle the patients with utmost care leaving behind personal issues. It is ethical for the nurses to dress appropriately and use courteous language to address the patients regardless of the resistance by the latter. The code of ethics also puts emphasis on the fact that it is crucial for the nurses to critically follow guidelines and all the policies on postoperative care (McGrath, 2012). They should also maintain patient safety and proficiency by often updating their knowledge and understanding. Another ethical behavior that ought to be observed comprises of recording all vital observations, signs and any assessments performed. Post-Operative Manipulations In Patients’ Recovery Essay

According to the American Nurses Association (ANA), there are various legal rules and regulations that govern the postoperative recovery process. These comprise of the rule of Autonomy which entails freedom to implement a plan or decision my nurses, respect for others and a complete understanding of the patient. Justice: this comprises of equitable, fair and appropriate treatment of all the patients under the recovery process. Fidelity: this ensures that the nurses remain faithful to the ANA code of ethics for nurses and to ethical principles while keeping promises and commitments in their work (McGrath, 2012). Veracity: entails telling the truth by either the nurses or the patients and has an added advantage of enhancing trust between the nurse and the patient. In the rules and regulations act also, there should exist the principle of accountability that encompasses the responsibility concept that is being answerable to oneself as well as to others for ones actions. The law also requires the nurses to do no harm either intentionally or unintentionally to their patients. Another requirement is that the nurses should act in the best interest of others that is to contribute to the well being of the patients by preventing or removing any harm that might be associated with the recovery process. Post-Operative Manipulations In Patients’ Recovery Essay

Why I chose the topic

The postoperative recovery process in most of our hospitals seems to be really forgotten and given no attention at all. I felt the need to deeply undertake a research on it since I felt that it ought to be treated with the seriousness it deserves. This is so because it is a section that could lead to deadly moments in hospitals if not accorded the best services. It is a process that could lead to death of patients even after maneuvering with the surgeries,it could result into wounds that might never heal among many other adverse effects. Therefore, postoperative recovery process ought to be accorded the utmost seriousness in order to enhance the healing process for the patients thereby preventing and eliminating after surgery effects (Parsons, 2001). Post-Operative Manipulations In Patients’ Recovery Essay

References

McGrath.B(2012): Postoperative recovery and discharge. New York: Springer Publishing Company Aldrete, J.(2010). A postanesthetic recovery score. New York: Harper Collins PressParsons, R. (2001). The ethics of professional practice. California: SAGE Press Post-Operative Manipulations In Patients’ Recovery Essay

The successes of society in terms of education, urbanization, industrialization and innovation, not in the least in healthcare, have led to an increasing elderly population [1]. This still expanding generation of the elderly should be able to participate in society for as long as possible. However, with an increasing age their adaptive capacity gradually decreases [2], which makes the elderly vulnerable to reduced functioning and societal participation [3] due to gradually diminishing physical activity [4,5], stereotypical ‘to be old is to be ill’ and ‘let it be’ beliefs [6,7]. Major life events like hospitalization and surgery can further compromise their functional status and activities of daily living [8]. This decrease in adaptive capacity of (vulnerable) elderly can be reduced by recent medical innovations and can be reduced more or possibly even prevented by therapeutic physical exercise training and maintaining physical activity in the course of an event; enabling the elderly to remain independent and live independently for a longer period of time after the event [4,9,10]. Post-Operative Manipulations In Patients’ Recovery Essay

In case of elective surgery, exercise therapy could be initiated preoperatively in patients at risk for unsatisfactory surgical outcomes [11], and be continued during the early and late postoperative period [12] until maximal recovery of physical function and societal participation is achieved. This article provides the latest insights and evidence into pre and postoperative therapeutic exercise training to counterbalance the detrimental effects of hospitalization combined with either cardiovascular, abdominal, thoracic, or orthopedic surgery. Post-Operative Manipulations In Patients’ Recovery Essay

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EFFECTS OF HOSPITALIZATION AND SURGERY IN OLDER PATIENTS
Temporary functional decline among the elderly as a result of decreased physical activity is a common side-effect before, during, and after hospitalization and major surgery [13,14▪▪]. Already before admission, up to 50% of the elderly patients experience loss of functioning [14▪▪]. Some hospitalized patients spend around 80% of the hospital stay lying in bed, generally without medical reason [15▪]. This bed rest leads to a marked and rapid loss of lower extremity strength, power and aerobic capacity [16], particularly in those with distinct risk profiles [17]. Surgery is known to augment this muscle wasting due to surgical stress [18], which may even lead to more serious or even life-threatening conditions as is the case with patients undergoing surgical manipulations close to the diaphragm. Here, the muscular component of the diaphragm suffers an additional degradation by reflex inhibition of phrenic nerve output and/or mechanical ventilation, further compromising the diaphragmatic function thereby increasing the risk of serious pulmonary complications [16]. Apart from decreased inpatient physical activity and temporary sedentary behavior, the so-called, surgical stress syndrome, is a physiological contributor to functional decline. This surgical stress response includes a wide range of physiological effects that directly impair cardiopulmonary, muscle and neurological function [19], and contribute to an accelerated loss of lean tissue [20]. Aforementioned consequences of hospitalization and surgery lead to protracted functional decline, which can be considered an iatrogenic process in elderly patients, as it leads to a higher risk of postoperative complications and mortality, a prolonged hospital stay and/or readmissions, and/or a prolonged and sometimes even permanent loss of mobility and activities of daily living. Post-Operative Manipulations In Patients’ Recovery Essay

NOW

We depicted these phenomena in Fig. 1, in which preoperative functional status plays a key role in the adaptive responses from hospitalization and surgery [21]. We define functional status as part of patients’ health and consider health a dynamic property [22]. Thus, a physically healthy person has the capacity to cope with physiological stress (including surgical stress) and to restore the body’s physiological balance, a process called allostasis [2].

Higher sensory levels of spinal anesthesia (T6–T4) are required for lower abdominal surgeries such as hysterectomy. However, patients may perceive an unpleasant discomfort associated with the surgical traction on the peritoneum or abdominal viscera. Perioperative pain control depends mainly on multimodal therapy to minimize the need for opioids. The overprescribing of opioids has reached a critical level worldwide,[1] and surgery may be the trigger for long-term opioid use in many patients.[2],[3] Post-Operative Manipulations In Patients’ Recovery Essay

Combined spinal-epidural anesthesia (CSEA) offers excellent analgesia, with low incidence of postoperative nausea and vomiting.[4] During spinal anesthesia, manipulation of the viscera and peritoneum produces dragging abdominal pain that sometimes necessitates induction of general anesthesia.[5] Pain management for oncology patient is important for early mobilization, tuning the immune system, and attenuation of the serious immune suppression mediated by the surgically stimulated network of neuro-immune-endocrine interactions.[6]

Postoperative opioid analgesia was associated with increased risk of biochemical cancer recurrence after open radical prostatectomy when compared with epidural nonopioid analgesia.[7] Furthermore, opioid dose reduction may improve pain control,[8] others advised avoiding opioid use for postoperative cancer pain.[9] Post-Operative Manipulations In Patients’ Recovery Essay

Rawal et al.[10] animal study documented the safety of intrathecal injection of nalbuphine was proved to be nontoxic nonharmful in a dose more than 1 mg despite that the use of intrathecal nalbuphine in anesthesia was restricted to a narrow sector of publications despite the strong analgesic kappa agonistic criteria of that drug and has been used in the concept of reducing the morphine-related adverse effects after epidural morphine.[11] Peripheral kappa opioid receptors are important modulator of visceral pain,[12] kappa receptor agonists reduced visceral pain and have less adverse effects on gastrointestinal motility than Mu agonists.[13] Multiple neurotransmitters, channels, and receptors are responsible for abdominal pain, so analgesics combinations are anticipated to be better than single analgesic.[14]

Dexamethasone is a high potency, long-acting glucocorticoid with little mineralocorticoid effect that has been used for prophylaxis of postoperative nausea.[15] Single doses of dexamethasone and other glucocorticoids have also reported to improve analgesia after various operations, whether oral or intravenous (IV).[16] Epidural dexamethasone had almost the same analgesic potency as fentanyl when added to local anesthetic (LA) bupivacaine avoiding opioid side effects in addition to its antiemetic effect.[17] In addition, preoperative epidural dexamethasone with or without bupivacaine was reported to reduce postoperative pain and opioid consumption.[18] Moreover, epidural dexamethasone in a dose 8 mg is probably more effective than lower doses to control moderate-to-severe postoperative pain without associated increase in glucose level or delayed wound healing.[19] Post-Operative Manipulations In Patients’ Recovery Essay

Hence, goal-directed better perioperative analgesia that avoids Mu opioid analgesics use in cancer patients,[1],[2],[3] the combined epidural steroid with intrathecal Kappa opioid analgesic utilizing CSEA technique would prevent intraoperative dragging pain due to surgical viscera manipulation (Kappa agonist effect),[13] reduce the postoperative rescue analgesic use and as a result side effects in cancer patients and improve surgeon satisfaction with CSEA anesthesia as a sole technique in lower abdominal oncology surgery.[1],[7],[8],[9] Hence, the present study was designed to evaluate the efficacy of epidural steroid combined with intrathecal nalbuphine in patients subjected to lower abdominal oncology operations. Post-Operative Manipulations In Patients’ Recovery Essay

Patients And Methods Top

The present study was carried out after approved by Institutional Research Board (R1704127). Thirty-four patients with physical status American Society of Anesthesiologists (ASA) Classes I and II of both genders, aged 18–65 years scheduled for lower abdominal (below the umbilicus) such as hysterectomy, open prostatectomy, oophorectomy, rectal mass excision, and pelvic exploration surgery were included in this study after obtaining informed written consents from all of them. Patients refused, with body mass index >35, hypersensitivity to amide LA, fentanyl, nalbuphine, or dexamethasone were excluded from the study. Moreover, failed cases who were shifted to general anesthesia, excluded from the study and reported. General contraindications to spinal anesthesia, surgeon total refusal (surgeon who totally refuse regional anesthesia as a sole anesthesia technique in lower abdominal operations), cardiac, hepatic, renal or respiratory failure or difficult communication with the patient (psychological or deafness) all were also excluded from the current study. Post-Operative Manipulations In Patients’ Recovery Essay

Randomization and blinding patients

Patients were randomly assigned to either Group P (epidural placebo saline control group) (n = 17) and = Group D (epidural dexamethasone study Group) (n = 17). A person not involved in the data collection or in patient care randomly assigned the patients using Research Randomizer Program[20] into two blocks each of block size 17 patient was also randomized using two lists of random numbers. Block size and randomization codes were not revealed to the investigators until all measurements and calculations had been entered into the database for all patients. Each patient, the investigators, and all medical caregivers were blinded to group allocation. One hour before the CSE block procedure of an enrolled patient, a nurse, not otherwise participating in the study, opened a sealed opaque envelope containing group allocation. The nurse then filled size 20 mL syringe containing (15 mL sterile normal saline) labeled “control medicine” or size 20 mL syringe (15 mL sterile normal saline containing 8 mg dexamethasone) labeled “study medicine.” All data were entered into the database before entering the randomization codes. Post-Operative Manipulations In Patients’ Recovery Essay

Combined spinal epidural block technique

Preoperative patient and drug preparation

After patient clinical examination and consultation about any comorbidities and explanation of the anesthetic procedure, the consent was taken after clarification of the visual analog score (VAS). Then, 20 gauge IV catheter and preloading by 1000 mL ringers solution over 30 min before anesthesia. After attaching 5 L oxygen face mask, all standard monitors pulse oximeter probe, noninvasive blood pressure cuff, and electrocardiogram, and recording basal data. Post-Operative Manipulations In Patients’ Recovery Essay

Technique

Using needle-through-needle CSE technique, (18-gauge Tuohy needle, 25 mm × 120 mm gauge/length spinal needle), at level below L2 (L2–3, or L3–4) interspace with the patient in the sitting position skin disinfection with complete aseptic technique, skin infiltration with LA lidocaine 0.5 mL at the preselected intervertebral space below L2, the epidural (18-gauge Tuohy needle) was inserted and the epidural space identified using “air-loss of resistance technique” then, 25 mm × 120 mm gauge/length spinal needle was introduced through the epidural needle and advanced until the tip of the spinal needle is felt to penetrate the dura “dural click” confirmed by free flow or aspiration of cerebrospinal fluid (CSF), then the appropriate preprepared dose of fentanyl or nalbuphine followed by LA bupivacaine was injected according to the protocol sequence of drug injection in both groups then spinal needle was withdrawn and Tuohy needle was rotated 180°[21],[22],[23](site of the spinal needle dural puncture is away), followed by epidural needle position confirmation by aspiration for excluding blood or CSF aspiration then loss of resistance recheck to document that the Tuohy needle still in the epidural space,[24] after that epidural bolus volume of placebo or dexamethasone to be injected according to the randomization protocol in both groups: Post-Operative Manipulations In Patients’ Recovery Essay

First group: Epidural placebo control group (Group P)

Intrathecal injection of preservative-free 20 μg fentanyl (Fentanyl Hameln 100 μg/2 mL ampoule, Sunny Pharmaceutical, 100Acre Industrial zone, Badr City, Egypt under license of Hameln Pharmaceutical, Germany). 100 μg fentanyl ampoule will be diluted up to 5 mL sterile saline 0.9% to get 20 μg/mL concentration then using a sterile 3 mL syringe to take 1 mL to be injected intrathecally followed by intrathecal injection of 3 mL (15 mg) of hyperbaric bupivacaine 0.5% (Marcaine spinal heavy 0.5% by Astra Zeneca, Buyukdere Cad. Yapi Kredi Plaza B Blok Kat: 3-4 Levent, Istanbul, Turkey), then epidural injection of placebo 15 mL volume of sterile saline 0.9%.

Second group: Epidural dexamethasone study group (Group D)

Intrathecal injection of preservative-free 0.6 mg nalbuphine (Nalbuphine 20 mg/2mL ampoule; SERB, Paris, France). 20 mg ampoule will be diluted up to 20 mL sterile saline 0.9% to get 1 mg/mL dilution then using an insulin syringe to take 0.6 mL and complete it to 1 mL volume with sterile saline 0.9% to be injected intrathecally followed by 3 mL (15 mg) of hyperbaric bupivacaine 0.5% intrathecal injection, Then epidural injection of 8 mg dexamethasone sodium phosphate (dexamethasone 8 mg/2 mL ampoule; Amriya Pharmaceuticals, Alexandria, Egypt) in 15 mL total volume using sterile saline 0.9%. Post-Operative Manipulations In Patients’ Recovery Essay

Anesthesia technique precautions

Epidural bolus injection time should never exceed the range of 30 seconds to avoid intrathecal saddling and low fixation of the LA. After drugs injection, patients were immediately placed in the supine 5°–10° trendelenburg position, at 2-min intervals the spread of sensory analgesia to pinprick was done
If at 4 min analgesia level had not reached the 8th thoracic dermatome, the Trendelenburg tilt to be increased further to an approximately 20° head down position so as to extend the sensory block to the fourth thoracic segment, patients in whom a T4 level of pinprick anesthesia could not be achieved were excluded, motor function was also assessed at 2-min intervals with use of the modified bromage scale. Post-Operative Manipulations In Patients’ Recovery Essay

Surgeons team included three senior surgeons

Charged in this present study for (a) assigning expert surgeons in lower abdominal oncology operations, (b) exclude surgeons who refuse sole regional anesthesia technique for lower abdominal operations, (c) collect surgeons opinion about the CSEA technique at the end of surgery according to the surgeon satisfaction score (0 = unsatisfied, 1 = satisfied, 2 = fully satisfied) assigned for this study.

Intraoperative complications management

Intraoperative irritability

Propofol IV infusion of 25 μg/kg/min (targeting conscious sedation).

Abdominal dragging pain

Surgical manipulation that unaccepted by the patient managed soon using multimodal analgesia regimen including; ketorolac slow injection in an IV bolus of 0.5 mg/kg plus bolus of nalbuphine of 0.1 mg/kg and number of patients that had this pain was recorded. If still in pain, general anesthesia to be induced and case to be excluded from the study replaced from the enrolled randomized cases and recorded as a number of patients with failed technique. Post-Operative Manipulations In Patients’ Recovery Essay

Nausea and vomiting

Treated by metoclopramide 10 mg, if resistant IV bolus ondansetron 4 mg, with the treatment of hypotension if present.

Hypotension

Mean arterial blood pressure (MAP) <65 mmHg, will be managed using ephedrine bolus doses of 6 mg, fluids and blood transfusion according to events and requirements.

Bradycardia

Heart rate (HR) <60 beat/min will be managed by atropine bolus of 0.5 mg.

Desaturation (SaO2<90%) will be managed by increase oxygen face mask flow up to 10 L/s and dealing with the airway according to the situation targeting a patient airway with breathing comfort and O2 saturation >94%. In case of any respiratory depression, emergency airway equipment’s and drugs for resuscitation for airway management and ventilation were kept ready. Post-Operative Manipulations In Patients’ Recovery Essay

Postoperative management

Postoperative pain will be assessed by VAS every1 h 1st 4 readings then at 6 h, 12 h, 18 h, and 24 h and managed by background IV ketorolac 0.5 mg/kg with maximum bolus dose of 30 mg within 6 h, plus IV nalbuphine 10 mg bolus dose on need if (VAS ≥ 3) after ketorolac injection, postoperative vomiting managed by IV boluses of metoclopramide (10 mg/dose), then IV bolus ondansetron (4 mg/dose) if resistant vomiting to metoclopramide. Postoperative hypotension, bradycardia, and desaturation to be managed same as intraoperative method.

Outcome variables and data recording

Primary outcome

Time to 1st analgesic request (minutes).

Secondary outcome

Postoperative VAS[25] every every1 h 1st 4 readings then at 6 h, 12 h, 18 h, and 24 h. T4 sensory blockade time (time taken from the end of injection to loss of pinprick sensation at T4 dermatome-nipple level), S1 sensory regression time (time taken for sensory block to regress to S1 dermatome level), time to modified bromage Score 0 (time required for motor blockade return to modified bromage Grade 0 from the time of onset of motor blockade).[26] Total IV dose of rescue analgesic nalbuphine in milligram during first postoperative 24 h. Nausea and vomiting incidence. Number of patients that had abdominal dragging pain. Number of failed cases in each group (due to persistent intraoperative abdominal pain, nausea, and vomiting despite all analgesics or excess IV boluses of sedation which compromise the conscious level of the patient indicating failure of this anesthesia technique and shift to general anesthesia and consequently case cancelled from this study reported, and replaced by another one). Hemodynamics (HR and mean arterial pressure MAP]) were recorded basal then every 1 h intraoperative then every 6 h for the postoperative 24 h. Patient satisfaction score using four graded scale (poor, fair, good, and excellent) was recorded. Surgeon satisfaction score (0 = unsatisfied, 1 = satisfied, 2 = fully satisfied) recorded at the end of the operation by head surgeons in charge. Post-Operative Manipulations In Patients’ Recovery Essay

Sample size calculation

According to a previous study[27] with a mean time to 1st analgesic request in intrathecal nalbuphine group (259.20 ± 23.2 min) compared to intrathecal fentanyl group (235.1 ± 15.15 min) was statistically significant between groups (P < 0.05), we will need to study 15 experimental individuals and 15 controls to detect this difference. Considering Type I error of 0.05 and Type II error 0.05 and power 0.95 and drop out of 10%, so we needed 17 subjects in each group having a total sample size = 34. Post-Operative Manipulations In Patients’ Recovery Essay

Statistical analysis

The collected data were coded, processed, and analyzed using SPSS program statistical package version 16 (IBM Corporation, Armonk, NY). The normality of distribution was tested for normality by two-sample Kolmogorov–Smirnov test, Shapiro–Wilk nonparametric tests and histograms. Normally distributed numerical data were presented as mean and standard deviation and their comparison in both groups was performed using Student’s t-test. Nonparametric data presented as median and range, or number and percent, categorical data presented as frequency and percentage will be compared using crosstab Chi-square test. All data will be considered statistically significant if P < 0.05.

Results Top

Fifty patients were enrolled for the present study. Seven patients declined the study, three patients with physical status ASA Class III, five patients their surgeons refused regional anesthesia, and one patient had elevated liver enzymes with coagulopathy. All of these patients were removed from the study. The remaining 34 patients were allocated into the groups of this study and their results were analyzed [Figure 1]. The patient’s demographic characteristics and operative duration showed no significant differences between both studied groups [Table 1].
Figure 1: The flow diagram of patient progress through the randomized trial

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Table 1: Patient’s demographic characteristics and operative duration

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Regarding hemodynamics, neither HR nor MAP recorded any significant difference between both groups all over the study time points whether basal, intraoperative or postoperative.

As regards CSEA block characteristics, time to sensory block to T4 was significantly shorter with Group D (P = 0.029), there were significantly longer times to sensory regression to S1 (P <0.0001), modified bromage Score 0 (P = 0.002), and 1st analgesic request (P < 0.0001) in Group D compared to Group P [Table 2]. Moreover, postoperative VAS recorded significant decrease in the 1st 4 h values with Group D compared to Group P (P < 0.05) while 6 h, 12 h, 18 h and 24 h recorded no significant differences between both groups [Table 3]. IN addition, the total IV nalbuphine dose in 1st postoperative 24 h was significantly lower in D Group (P = 0.007) with the incidence of nausea and vomiting was also significantly lower in that group (P = 0.026). The number of patients had intraoperative abdominal dragging pain was significantly higher with Group P (P = 0.034) [Table 4].
Table 2: Combined spinal epidural anesthesia block characteristics

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Table 3: Postoperative visual analogue scale

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Table 4: Complications, total postoperative nalbuphine dosage, incidence of patients had intraoperative abdominal dragging pain Post-Operative Manipulations In Patients’ Recovery Essay

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There was no significant difference between both groups regarding the incidence of headache (P = 0.545). No reported case in either group had failed block [Table 4]. The patient satisfaction score was significantly higher with Group D (P = 0.024) [Table 5]. The surgeon satisfaction was significantly higher with Group D compared to Group P (P = 0.043) [Figure 2].
Table 5: Patient satisfaction score

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Figure 2: Group P = Epidural placebo control group. Group D = Epidural dexamethasone study group. Surgeon satisfaction was significantly higher with Group D compared with Group P (P = 0.043)

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Discussion Top

In this present study, CSEA utilizing intrathecal nalbuphine with epidural dexamethasone as adjuvant analgesics to the LA bupivacaine 0.5% has improved the blockade criteria, duration, with lower number of patients who had dragging abdominal pain and resulted in significant prolongation of time to 1st analgesic request with significant decrease in VAS during 1st four postoperative hours. Moreover, Group D recorded a lower incidence of nausea and vomiting and the postoperative rescue analgesic nalbuphine utilization was reduced, all of these outcomes were reflected on significant increase in both patient and surgeon satisfaction that was significantly higher with Group D compared to Group P, simultaneously there were hemodynamic stability and acceptable comparable postoperative side effects as headache in between groups. Post-Operative Manipulations In Patients’ Recovery Essay

Visceral pain due to peritoneal traction during surgical manipulation even if still only pain without hemodynamic drawbacks sometimes necessitate sedation and even induction of general anesthesia.[5] A fact that surgical manipulation on abdominal contents, visceral ligaments, and peritoneum produces abdominal visceral pain that may be associated with sever vagal stimulation that would produce reflex bradycardia and hypotension.[28] Culebras et al.[11] documented that intrathecal nalbuphine 0.8 mg provides good intraoperative and early postoperative analgesia without side effects. Epidural volume injection (even if placebo saline) after intrathecal LA injection would increase the upward spread of the intrathecal LA and explain by that increased volume within the extradural space leads to decrease in CSF volume in the caudal subarachnoid space with cephalic shift of LA within the CSF.[29]

The explanation for significant increase in time to 1st analgesic request with significant decrease in the postoperative 1st 4 h VAS in Group D in comparison to Group P is that the combination of epidural 8 mg dexamethasone in 15 mL volume, with optimized dose of intrathecal 0.6 mg nalbuphine kappa opioid receptor agonist potentiated bupivacaine intraoperative analgesia via preventing dragging visceral pain transmission (kappa opioid receptor analgesic role in visceral pain prevention[12]) during surgical manipulations. Another cornerstone point is that the epidural 15 mL volume injection after spinal bupivacaine nalbuphine injection would augment the cephalic spread of the spinal anesthesia dermatome coverage,[30] in line with this explanation Culebras et al.[11] documented that intrathecal nalbuphine 0.8 mg provides good intraoperative and early postoperative analgesia without side effects. Added to the epidural steroid dexamethasone analgesia level and quality improvement. Epidural 8 mg dexamethasone dose is probably more effective than lower doses to control moderate to severe postoperative pain, this dose is surgically safe neither produced delayed wound healing nor elevated blood glucose level.[19] In accordance to our result as regard analgesia, Thomas and Beevi[18] revealed that epidural dexamethasone is significantly more effective than IV dexamethasone to reduce postoperative pain and morphine consumption. Post-Operative Manipulations In Patients’ Recovery Essay

Intrathecal anesthesia blockade quality in this present study showed a significant increase in both sensory and motor recovery from the block in Group D in comparison to Group P, this could be attributed to the combined epidural 8 mg dexamethasone in 15 mL volume with intrathecal nalbuphine analgesia effect that potentate and fasten the LA bupivacaine blockade up spread and potency. In line with this Hefni et al.[19] proved that single 8 mg bolus dose of epidural dexamethasone is probably more effective than lower dose to control moderate to severe postoperative pain. Furthermore, this dose is not associated with increased glucose level or delayed wound healing, also Viscusi et al.[31] documented that higher doses of the epidurally injected dexamethasone leads to decreased rate of drug mobilization from the epidural space and allow for more effective dexamethasone tissue concentration leading to more prolonged effective postoperative pain control. In line with this, Naghipour et al.[32] proved that dexamethasone added to bupivacaine prolongs the duration of epidural analgesia. Waldron et al.[33] documented that single IV perioperative dose of dexamethasone had small but statistically significant analgesic benefits. Post-Operative Manipulations In Patients’ Recovery Essay

Postoperative side effects such as headache, hypotension, and bradycardia in the present study were comparable in between both groups with lower incidence of nausea and vomiting in Group D, this can be explained by the epidural antiemetic dexamethasone, simultaneously with intrathecal kappa opioid agonist Mu antagonist “nalbuphine” has its antiemetic effect and signs about the use of Mu-opioid analgesics such as morphine, sufentanil, fentanyl which are documented to be dose-dependent emesis inducing drugs. Epidural administration of drugs leads to rapid vascular uptake that provides access to the chemoreceptive trigger zone through the bloodstream. Peak plasma concentrations may be achieved within 5–15 min and systemic concentrations often approach those obtained after a similar intramuscular dose.[34] In accordance to our result, Wang et al.[35] documented a long time back that IV administration of dexamethasone 8 mg may be valuable for preventing epidural morphine-related postoperative vomiting. Another supporting opinion, epidural dexamethasone had almost the same analgesic potency as fentanyl when added to LA bupivacaine with opioid-sparing and antiemetic effects.[17] Nalbuphine affinity to k-opioid receptors results in analgesia, sedation, and cardiovascular stability with minimal respiratory depression. Nalbuphine improves the quality of perioperative analgesia and provides reasonably potent analgesia for visceral nociception.[36],[37] Post-Operative Manipulations In Patients’ Recovery Essay

Why nalbuphine and its (0.6 mg intrathecal dose) specifically in this present study?

Answer is for the fact that kappa receptor agonist reduced visceral pain.[13] Mukherjee et al.[38] recommend 0.4 mg as the optimal dose of nalbuphine if used intrathecally along with 12.5 mg 0.5% hyperbaric bupivacaine in patients undergoing lower limb orthopedic surgeries, which requires lower level of spinal anesthesia blockade than lower abdominal and pelvic surgery as in our study, so our higher dosing protocol of both nalbuphine and bupivacaine (0.6 mg nalbuphine and 15 mg 0.5% bupivacaine) are both logic to be suitable for attaining a perfect T4 anesthesia to cover the abdominal peritoneal traction induced visceral pain and also 0.8 mg intrathecal nalbuphine[10] was documented to produce more side effects with the same analgesic outcome equal for both doses. In opposition to Mukherjee et al.[38] long time back Culebras et al.[11] documented that intrathecal nalbuphine 0.8 mg provides good intraoperative and early postoperative analgesia without side effects.

The current study had some limitations. First, no patient-controlled analgesia machine available to be used as controlled rescue postoperative analgesia. Second, coagulopathy and thrombocytopenia in cancer patient is frequent, hinders CSE technique inapplicable. Third, the small sample size of the study. We recommend these limitations to be considered in the future. Post-Operative Manipulations In Patients’ Recovery Essay

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