2017-18 HSC Section 3 Green Book
E.
Boselli
et
al.
/ Anaesth
Crit
Care
Pain Med
35
(2016)
31–36
scores groups,
were
observed
between
the
saline
and
levobupivacaine
whereas
NRS plus
scores
were
lower
at
30 min
and
1 h
in
the
tramadol
group.
However,
67%
of
patients
levobupivacaine
septoplasty
and
only
33%
underwent
rhinoplasty, which
underwent
in part why no differences were observed
in NRS scores.
might explain
there
is a
lack of prospective
studies assessing early
Indeed, although
pain
after
rhinoplasty
or
rhinoseptoplasty,
it
is
well
postoperative
that
rhinoplasty
is much more
painful
than
septoplasty
[2] .
known
Our
study
presents
certain
limitations.
First,
our
primary
comprised
the LB,
intraoperative
dose
of morphine, which
outcome
null
in
Group
whereas
patients
in
the
control
group
was
before
the
end
of
surgery.
This was
due
to
the and
received morphine
of
remifentanil,
a
short-acting
opioid
with
a
fast
choice
recovery
suitable
for
outpatient
surgery
but
requiring
predictable
morphine
administration
for
painful
procedures
intraoperative
The
use
of
a
control
group
receiving
no morphine may
have was
[20] . been
more
suitable
for
avoiding
interpretation
bias,
but
for ethical reasons.
Indeed,
it has been shown
however not possible
Fig. 5. Comparison of mean 0–10 numerical
rating
scale
(NRS) pain
scores between
almost
30%
of
patients
undergoing
rhinoplasty may therefore, patients
experi-
that
over
time
(ANOVA
for
repeated measures).
Error
bars
represent
standard
groups
(NRS
6);
in
the
ence severe postoperative pain
deviations.
group
received
morphine
as
part
of
their
multimodal
control
using
an
extraoral
approach
and
infratrochlear blocks) with 0.25%
in
anticipation
of
postoperative
pain
[1] .
Hence,
our
analgesia
provide
a
statistically
significant
reduction
in
may
therefore
not
be
generalisable
to
any
general
levobupivacaine
results
(during both
the
intraoperative
procedures
using
opioids
other
than
remifentanil,
total perioperative morphine doses
anaesthesia
and
in
the
PACU)
after
desflurane/remifentanil
general
administered only postoperatively.
Second,
senso-
period
with morphine
for outpatient
rhinoseptoplasty. The
time
spent
in
the
facial nerve blocks
anaesthesia
ry testing was not possible prior to surgery since
and
the
outpatient ward was
also
significantly
reduced.
performed
under
general
anaesthesia. We
use
an
extraoral
PACU
were
surgery
in
adults study
for
infraorbital nerve blocks
in our practice because of
its
The use of bilateral nerve blocks during nasal
technique simplicity, successful
reported
in
two
studies
[6,7] .
In
the first
but
it
is
still
possible
that not
all
injections
resulted
in
has been previously
on
40
patients
undergoing
outpatient
nasal
surgery,
a
analgesia
[8] .
Indeed,
4
patients
(24%)
receiving
facial
conducted
infraorbital
nerve
block
using
an
intraoral
approach
levobupivacaine
experienced
severe pain
bilateral
nerve blocks with 0.25%
0.5%
bupivacaine
immediately
following
anaes-
6) at arousal
from general anaesthesia. The use of maxillary
performed with
(NRS
induction provided a small but significant reduction
inmean
including
the
nasopalatin
and
infraorbital
branches
of
the
thesia
blocks,
confidence
interval]
pain
scores
in
the
PACU
reported
on
a
nerve, may
have
been
chosen
for
septum,
cartilage
and
nose
[95%
V2
in comparison with
isotonic saline
(–11
analgesia,
potentially
associated
with
a
nasociliate
nerve
0–100 visual analogic scale
bone block,
0],
P = 0.047)
[6] .
Both
bupivacaine
and
saline
groups
a
branch
of
the
ophthalmic
(V1) nerve
[5,21] .
This
block
is,
[–21,
similar doses of
intraoperative
fentanyl and no difference
however, more profound infraorbital nerve block and some authors have suggested the use of neurostimulation using the blink reflex to enhance nerve localisation [21] . The use of ultrasound- guidance for infraorbital nerve blocks has been recently described using a skull model and may increase the efficacy and the safety of the procedure [22] . However, no data on ultrasound-guided infraorbital nerve blocks during nose surgery is currently available and this technique is not routinely used in our unit. Moreover, a bilateral infratrochlear block was systematically associated to provide analgesia in the superior part of the nose, but its usefulness during rhinoseptoplasty remains to be demonstrated since no data is available on this subject. Last, since patients in the control group received bilateral facial blocks using isotonic saline as a placebo, the complications following regional anaesthesia (haematoma, oedema) should be interpreted with caution and might have been different if no injection had been performed. However, the use of a placebo for facial nerve blocks was justified by the fact that it is minimally invasive with a risk of only minor complications (Grade 2 on the Serious Harm And Morbidity [SHAM] scale) [23] . than an
received
observed
in
the mean
SD
dose 1 mg,
of
postoperative
hydromor-
was
(0.4
0.8 mg
versus
0.8
respectively,
P = 0.095).
No SD
phone
significant difference was observed between groups in
the mean
room duration
(131
61 min
versus 131
58 min,
respec-
recovery
P = 0.77).
These
discrepancies
with
our
results
might
be
tively,
by
the
fact
that
fentanyl,
exhibiting
long-acting
analgesic
explained
used
in
the Mariano
et
al.
study, while
short-acting the Mariano home when
properties, was
in ours. Moreover,
the patients
in to
remifentanil was used
al.
study were
discharged
directly
from
the
PACU
et
achieved
a
score
19
out
of
21
on
a modified
Aldrete
scale
they
individual
items
for
vital
signs,
activity
and
mental might
incorporating
pain,
PONV,
bleeding,
and
intake/output
[18] .
This
status,
the Mariano
et
al.
study
found
no
difference
for
PACU
explain why
whereas
a
reduction
in
PACU
time
was
observed
in
the
duration,
study
in
patients
receiving
bilateral
facial
blocks
before
current
to
the
outpatient ward.
discharge
More
recently,
the
effect
of
0.25%
levobupivacaine
and
a
of
levobupivacaine
and
tramadol was
compared
to
combination
in
45
patients
undergoing
nasal
surgery
with
general
placebo
and
bilateral
infraorbital
nerve
blocks
using
an
anaesthesia
5. Conclusion
[7] . The authors observed a
significant
increase patients
intraoral approach
the
mean
SD
time
to
first
analgesic
requirement
in
in
In
levobupivacaine
in
comparison with
saline
(240
96 min
conclusion,
this
study
demonstrates
that
bilateral
extraoral
receiving versus 143
77 min, respectively, P = 0.03) and a significant decrease
and infratrochlear nerve blocks performed with 0.25%
infraorbital
the
mean
SD
total
meperidine
requirement
in
the
PACU effects
during
general
anaesthesia
combining
remifen-
in
levobupivacaine
16 mg
versus 32
13 mg,
respectively,
P = 0.01).
These
and
desflurane
reduce
the
perioperative
dose
of morphine
(17
tanil
pronounced when
tramadol was
added.
The
authors
did
and adult patients undergoing outpatient rhinoseptoplasty. Our data support the use of routine bilateral facial blocks in this indication. Further the time spent in the PACU and the outpatient ward in
were more
report
the
duration
of
PACU
stays.
Although
no
intraoperative
not
administered
during
the
procedures,
similar NRS
pain
opioids were
250
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