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1.
Background. Acetaminophen is commonly used for the managementof perioperative pain. However, there is a marked discrepancybetween the extent to which acetaminophen is used and the availableevidence for an analgesic effect after major surgery. The aimof this systematic review is to determine the morphine-sparingeffect of acetaminophen combined with patient-controlled analgesia(PCA) with morphine and to evaluate its effects on opioid-relatedadverse effects. Methods. MEDLINE and the Cochrane Library were searched to selectrandomized controlled trials which compared PCA morphine alonewith PCA morphine plus acetaminophen administered orally orintravenously. Studies were evaluated for their quality basedon the Oxford Quality Scale. Outcome measures were morphineconsumption over the first 24 h after surgery, patient satisfactionand the incidence of morphine side-effects, including nauseaand vomiting, sedation, urinary retention, pruritus and/or respiratorydepression. Results. Seven prospective randomized controlled trials, including265 patients in the group with PCA morphine plus acetaminophenand 226 patients in the group with PCA morphine alone, wereselected. Acetaminophen administration was not associated witha decrease in the incidence of morphine-related adverse effectsor an increase in patient satisfaction. Adding acetaminophento PCA was associated with a morphine-sparing effect of 20%(mean, –9 mg; CI –15 to –3 mg; P=0.003) overthe first postoperative 24 h. Conclusion. Acetaminophen combined with PCA morphine induceda significant morphine-sparing effect but did not change theincidence of morphine-related adverse effects in the postoperativeperiod.   相似文献   

2.
Background. This review examines the evidence from publisheddata concerning the incidence of moderate-severe and of severepain after major surgery, with three analgesic techniques; intramuscular(i.m.) analgesia, patient controlled analgesia (PCA), and epiduralanalgesia. Methods. A MEDLINE search of the literature was conducted forpublications concerned with the management of postoperativepain. Over 800 original papers and reviews were identified.Of these 212 papers fulfilled the inclusion criteria but only165 provided usable data on pain intensity and pain relief.Pooled data on pain scores obtained from these studies, whichrepresent the experience of a total of nearly 20 000 patients,form the basis of this review. Results. Different pain measurement tools provided comparabledata. When considering a mixture of three analgesic techniques,the overall mean (95% CI) incidence of moderate-severe painand of severe pain was 29.7 (26.4–33.0)% and 10.9 (8.4–13.4)%,respectively. The overall mean (95% CI) incidence of poor painrelief and of fair-to-poor pain relief was 3.5 (2.4–4.6)%and 19.4 (16.4–22.3)%, respectively. For i.m. analgesiathe incidence of moderate-severe pain was 67.2 (58.1–76.2)%and that of severe pain was 29.1 (18.8–39.4)%. For PCA,the incidence of moderate-severe pain was 35.8 (31.4–40.2)%and that of severe pain was 10.4 (8.0–12.8)%. For epiduralanalgesia the incidence of moderate-severe pain was 20.9 (17.8–24.0)%and that of severe pain was 7.8 (6.1–9.5)%. The incidenceof premature catheter dislodgement was 5.7 (4.0–7.4)%.Over the period 1973–1999 there has been a highly significant(P<0.0001) reduction in the incidence of moderate-severepain of 1.9 (1.1–2.7)% per year. Conclusions. These results suggest that the UK Audit Commission(1997) proposed standards of care might be unachievable usingcurrent analgesic techniques. The data may be useful in settingstandards of care for Acute Pain Services. Br J Anaesth 2002; 89: 409–23  相似文献   

3.
Background. Intrathecal clonidine prolongs spinal anaesthesia.We investigated the effect of the addition of clonidine (75µg) to hyperbaric bupivacaine on postoperative morphineconsumption after Caesarean section in a randomized controlleddouble-blind trial. Methods. A group of 106 women received spinal anaesthesia usingeither bupivacaine 0.5% (2.2 ml) heavy with 0.5 ml normal saline0.9% (B) or bupivacaine 0.5% (2.2 ml) heavy with clonidine (75µg) in 0.5 ml normal saline 0.9% (BC). The primary outcomewas the total morphine consumption in the first 24 h after surgery.Secondary outcomes were the duration of postoperative analgesia,postoperative pain scores, the need for alfentanil during surgery,block regression, clonidine side-effects and morphine side-effects. Results. Total morphine consumption was similar in both studygroups. The mean time to the first analgesic request in theBC group was 129 (SD 13.8) min, compared with 55 (14.2) minin the B group [mean difference (95% CI) –75 (–106to –44) min]. In the BC group 22 (42%) patients had acomplete motor block 1 h after surgery compared with 4 (8%)patients in the B group [RR (95% CI) 0.18 (0.07–0.49)].Side-effects of intrathecal clonidine were not detected. Conclusions. The addition of clonidine (75 µg) to hyperbaricbupivacaine prolongs spinal anaesthesia after Caesarean sectionand improves early analgesia, but does not reduce the postoperativemorphine consumption during the first 24 h. No clinically relevantmaternal or neonatal side-effects were detected.  相似文献   

4.
Emetic effects of morphine and piritramide   总被引:3,自引:1,他引:2  
Background. Successful management of postoperative pain requiresthat adequate analgesia is achieved without excessive adverseeffects. Opioid-induced nausea and vomiting is known to impairpatients’ satisfaction, but there are no studies providingsufficient power to test the hypothesis that the incidence ofopioid-induced nausea and vomiting differs between µ-opioidreceptor agonists. Thus, we tested the hypothesis that the incidenceof vomiting and nausea differs between morphine and piritramide. Methods. In a prospective, randomized, double-blind fashion,we administered either morphine (n=250) or piritramide (n=250)by patient-controlled analgesia (PCA) for postoperative painrelief. We used a bolus dose of 1.5 mg with a lockout time of10 min. Incidence and intensity (numerical rating scale) ofpostoperative nausea, vomiting, pain, patient satisfaction (score0–10), side-effects (score 0–3) and drug consumptionwere measured. Results. Mean drug consumption did not differ between the piritramideand morphine groups (30.8 (SD 22.4) mg day–1 vs 28.4 (21.8)mg day–1) during the first postoperative day and therewere no significant differences in the overall incidence ofnausea (30% vs 27%) and vomiting (19% vs 15%). Intensity ofnausea correlated inversely (P=0.01) with morphine consumptionbut not with piritramide consumption. Pain scores both at rest(2.2 (1.9) vs 2.6 (2)) and during movement (4.4 (2.2) vs 4.9(2.3)) were slightly but significantly less with morphine. Conclusions. Opioid-induced emesis was observed in about one-thirdof the patients using morphine and piritramide for PCA and theincidence of vomiting was one-half of that. Potential differencesin the incidence of vomiting during PCA therapy between theseµ-opioid receptor agonists can be excluded. Br J Anaesth 2003; 91: 218–23  相似文献   

5.
Background. Although remifentanil’s short-acting pharmacokineticprofile makes it well suited for procedures during which a briefperiod of intense analgesia is required, setting up an infusionpump for brief procedures is inconvenient. The clinical pharmacologyof remifentanil administered by bolus injection, a more convenientalternative, has not been explored in detail. The primary aimof this study was to examine the safety of single bolus dosesof remifentanil in conscious, healthy, adult volunteers breathingroom air. Secondary aims included the evaluation of remifentanilpharmacokinetics and analgesic effects after bolus injectionand a comparison of these issues in younger vs older adults. Methods. Using a randomized, double-blind, placebo-controlled,dose-escalation, crossover study design, 64 subjects (16 over60 years old) received remifentanil or placebo by bolus injectionin a fixed unit dose separated by a 1 h washout period. Respiratoryeffects were assessed using a respiratory intervention scale.Analgesic effects were assessed using pressure algometry. Apopulation pharmacokinetic model was constructed using non-linear,mixed-effects modelling techniques based on arterial blood samples.Computer simulations were performed to illustrate the clinicalapplication of the pharmacokinetic model. Results. Dose-related increases in both respiratory and analgesiceffects were observed. In general, the respiratory depressionobserved was mild and easily treated with requests to breatheor the administration of oxygen, although the older cohort (andsome younger subjects) experienced more substantial respiratorydepression at lower doses. The pharmacokinetics of bolus-doseremifentanil were adequately described by a two-compartmentmodel. The pharmacokinetic simulations illustrated the potentialutility of bolus-dose remifentanil. Conclusions. Bolus injection could potentially be a safe andeffective means of administering remifentanil in clinical situationsrequiring a brief period of intense analgesia. Because somesubjects, both old and young, experienced significant respiratorydepression even at low doses, careful monitoring of respiratoryfunction is essential. Br J Anaesth 2004; 92: 335–43  相似文献   

6.
Background. Peripheral neural blockade appears to provide effectiveanalgesia with potentially less morbidity than central neuraxialtechniques. We compared the relative benefits of combined femoral(3-in-1) and sciatic nerve block with epidural blockade forpostoperative knee arthroplasty analgesia. Methods. Sixty patients, ASA I–III, undergoing unilateralknee replacement were prospectively randomized to receive eithera lumbar epidural infusion or combined single-shot femoral (3-in-1)and sciatic blocks (combined blocks). All patients receivedstandard general anaesthesia. Visual analogue pain scores andrescue opioid requirements were recorded at four time pointspostoperatively. Patient satisfaction, morbidity, block insertiontime, perioperative blood loss and rehabilitation indices werealso assessed. Results. In both groups, pain on movement was well controlledat discharge from recovery and 6 h postoperatively but increasedat 24 and 48 h. Median (95% CI) analogue scale scores were 0(0–0), 15 (0–30), 55 (38–75) and 54 (30–67)mm for epidural block and 0.5 (0–22), 21.5 (10–28),40 (20–50) and 34.5 (21–55) mm for combined block.VAS pain scores with the combined blocks were significantlylower at 24 h (P=0.004). Total morphine usage was low in bothgroups: median epidural group 17 mg (8–32) versus combinedblocks 13 mg (7.8–27.5). Patient satisfaction was highin both groups with median (95% CI) scores of 100 (85–100),83 (70–100) and 82 (57–90) mm for epidural and 90(73–100), 100 (77–100) and 97 (80–100) mmfor combined blocks (not significant). Perioperative blood lossand rehabilitation indices were also similar. Conclusions. Combined femoral (3-in-1) and sciatic blocks offera practical alternative to epidural analgesia for unilateralknee replacements.   相似文献   

7.
Background. Fluid depletion during the perioperative periodis associated with poorer outcome. Non-invasive measurementof total body water by bioimpedance may enable preoperativefluid depletion and its influence on perioperative outcome tobe assessed. Methods. Weight and foot bioimpedance were recorded under standardizedconditions in patients undergoing bowel preparation (n=43) orday surgery (n=44). Fifteen volunteers also followed standardnil-by-mouth instructions on two separate occasions to assessthe variabilities of weight and bioimpedance over time. Results. Body weight fell by 1.27 kg (95% CI 1.03–1.50kg; P<0.0001) and foot bioimpedance increased by 51 ohm afterbowel preparation (95% CI 36–66; P<0.0001). Weightchange after the nil-by-mouth period in day-surgery patients(mean –0.22 kg, 95% CI –0.05 to –0.47 kg;P=0.07) correlated (r=–0.46; P=0.005) with an increasein bioimpedance (16 ohms, 95% CI 5–27 ohms; P=0.01). Nodifference between two separate bioimpedance measurements wasseen in the volunteer group. Conclusions. Further work is warranted to determine if bioimpedancechanges may serve as a useful indicator of perioperative fluiddepletion. Br J Anaesth 2004; 92: 134–6  相似文献   

8.
Background. Morphine-6-glucuronide (M6G) is a metabolite ofmorphine with potent analgesic properties. The influence ofM6G on respiratory and antinociceptive responses was investigatedin mice lacking the µ-opioid receptor (MOR) and comparedwith morphine. Methods. Experiments were performed in mice lacking exon 2 ofthe MOR (n=18) and their wild type (WT) littermates (n=20).The influence of M6G and morphine on respiration was measuredusing whole body plethysmography during three elevations ofinspired carbon dioxide. Antinociception was assessed usingtail flick and hotplate tests. Results. In WT but not null mutant mice, a dose-dependent depressionof the slope of the ventilatory carbon dioxide response wasobserved after M6G and morphine. Similarly, both opioids weredevoid of antinociceptive effects in null mutant mice, but showedpotent dose-dependent analgesia in WT animals. Potency differencesbetween M6G and morphine in WT mice were of the same order ofmagnitude for analgesia and respiration. Conclusions. The data indicate that the desired (antinociceptive)and undesired (respiratory depression) effects of M6G and morphineare linked to the same gene product; that is the MOR. Otheropioid- and non-opioid-receptor systems may play a minor rolein the actions of M6Gs and morphine. The clinical implicationsof our findings are that any agent acting at the MOR will invariablycause (potent) analgesia in combination with (variable) respiratorydepression. Br J Anaesth 2003; 91: 862–70  相似文献   

9.
Background. It has been reported that ropivacaine produces vasoconstrictionin contrast to vasodilation produced by bupivacaine. It is possiblethat additives to ropivacaine can provide further analgesicadvantages compared with bupivacaine. We thus evaluated whetherthe addition of fentanyl to ropivacaine prolonged the durationof analgesia after a single shot caudal block. Methods. A total of 36 children undergoing surgical proceduresbelow the umbilicus were randomly allocated to one of two groups:Group F received ropivacaine 0.2%, 1 ml kg–1 with fentanyl1 µg kg–1 and Group S received ropivacaine 0.2%,1 ml kg–1 with saline. The analgesic effect of the caudalblock was evaluated using the Children's Hospital of EasternOntario Pain Scale (CHEOPS) and sedation was assessed usingthe Steward score at 30 min after extubation and at 1, 2, 4,6, 12 and 24 h. The first analgesic requirement time and side-effectsin a 24 h period were also recorded. Results. There were no differences in characteristics betweenthe groups. The end-tidal concentration of sevoflurane at extubationin Group F was significantly lower than in Group S. However,there was no significant difference in time from discontinuationof the volatile anaesthetics to tracheal extubation. No statisticaldifferences were found in the CHEOPS and Steward score, andthe time to first analgesia. The incidence of postoperativevomiting was not significantly different. Conclusion. We found that the addition of fentanyl 1 µgkg–1 to ropivacaine 0.2% for caudal analgesia providesno further analgesic advantages over ropivacaine 0.2% alone.  相似文献   

10.
Background. Opioid analgesics are commonly added to intrathecalbupivacaine to improve patient comfort during Caesarean sectionunder spinal anaesthesia, and provide post-operative pain relief.We sought to discover if the addition of diamorphine influencedblock height when given with 0.5% w/v hyperbaric bupivacaine. Method. Eighty ASA I and II women of at least 37 weeks gestationand planned for elective Caesarean section under combined spinal–epiduralanaesthesia were recruited. They were randomized into two groupsto receive intrathecal hyperbaric bupivacaine 0.5% at an initialdose of 13 mg, with the next dose determined by the responseof the previous patient (dose interval 1 mg). One group alsoreceived diamorphine 400 µg intrathecally. If a blockheight of T5 to blunt light touch had been achieved after 20min, the block was deemed effective. A difference in the ED50for hyperbaric bupivacaine between the groups would indicatethat diamorphine influenced block height. Intraoperative patientdiscomfort and need for analgesic supplementation was noted. Results. The median effective dose (ED50) to achieve a T5 blockto light touch for Caesarean section using hyperbaric bupivacaine0.5% was 9.95 mg [95% confidence interval (CI) 9.0–10.90]and with the addition of diamorphine it was 9.3 mg (95% CI 8.15–10.40),while the ED95 was 13.55 mg (95% CI 10.10–17.0) and 13.6mg (95% CI 9.15–18.05), respectively. Five women who hadreceived intrathecal diamorphine and 13 who had not receiveddiamorphine needed intraoperative supplementation (not significant). Conclusion. The addition of intrathecal diamorphine does notappear to influence block height.  相似文献   

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