A randomized controlled trial examining the effect of naproxen on analgesia during the second day after cesarean delivery

Whereas nonsteroidal antiinflammatory drugs augment spinal morphine on Day l, the analgesia gained by simply combining these drugs with conventional "on request" oral regimens on Day 2 is less clear. In this trial, we randomized 80 women undergoing elective cesarean delivery with spinal morphine (0.2 mg) to receive naproxen (500 mg) or placebo every 12 h after surgery. Both groups received conventional therapy with acetaminophen with codeine (on request) and rescue IM opioids. Incision pain on sitting (IPS), incision pain at rest, uterine cramping, and gas pain were evaluated with visual analog scales (0-100). Worst interval pain (0-10), analgesic use, and side effects were measured over 72 h. At 36 h (primary outcome), naproxen use was associated with reductions in IPS (38.2 +/- 26.0 versus 51.4 +/- 25.7; P = 0.05), incision pain at rest, uterine cramping, and worst interval pain scores. Clinically modest, statistically significant reductions in IPS (P = 0.0001) and opioid use were found over time (P < 0.0l). Reductions in the incidence of inadequate analgesia and improvements in overall pain relief (P = 0.0006) on Day l did not persist on Day 2 (overall pain relief, P = 0.057; inadequate analgesia, 24% naproxen versus 27% controls; P = 1.00). The addition of regular doses of naproxen to conventional oral pain therapy after cesarean delivery leads to reductions in IPS at 36 h and pain over Day 2 but does not reduce the incidence of inadequate analgesia. IMPLICATIONS: This randomized trial suggests that adding regular doses of naproxen to conventional "on request" acetaminophen and codeine therapy provides small reductions in pain on the second day after cesarean delivery. The greatest effects occur at 36 h, when pain peaks.     

Systemic adjunct analgesics for cesarean delivery: a narrative review

It is critical to adequately treat postoperative cesarean delivery pain. The use of parenteral or neuraxial opioids has been a mainstay, but opioids have side effects that can be troubling and the opioid crisis in the United States has highlighted the necessity to utilize analgesics other than opioids. Other analgesic options include neuraxial analgesics, nerve blocks such as the transversus abdominis plane block, and non-opioid parenteral and oral medications. The goal of this article is to review non-opioid systemic analgesic adjuncts following cesarean delivery, focusing on their efficacy and side effects as well as their impact on reduction of opioid requirements after surgery.     

Current and developing methods of patient-controlled analgesia

Moderate-to-severe acute postoperative pain is commonly controlled with opioids administered via programmable intravenous (IV) patient-controlled analgesia (PCA) infusion pumps. Intravenously administered opioids provide effective relief of postoperative pain, and IV PCA enables patients to control their level of analgesia, which has advantages over nurse-administered approaches, including more satisfied patients and improved pain relief. Unfortunately, commonly used opioid analgesics can cause significant adverse effects. Furthermore, IV PCA has drawbacks, such as device programming errors, system errors, medication errors, limitations in patient mobility, and potential for IV tubing kinks, clogging, and transmission of infection. The IV route of administration is also characterized by a rapid, high peak in analgesic drug concentration followed by rapidly decreasing concentrations. Consequently, respiratory depression, excessive sedation, and inadequate pain control can occur. Furthermore, the technical assembly of an infusion pump is often complex and time-consuming. PCA modalities that incorporate superior opioid analgesics, such as sufentanil, and novel noninvasive routes of administration offer great promise for enhancing the patient and caregiver experience with the use of postoperative PCA.     

Pain management after major orthopaedic surgery: current strategies and new concepts

Several recently developed analgesic techniques effectively control pain after major orthopaedic surgery. Neuraxial analgesia provided by epidural and spinal administration of local anesthetics and opioids provides the highest level of pain control; however, such therapy is highly invasive and labor intensive. Neuraxial analgesia is contraindicated in patients receiving low-molecular-weight heparin. Continuous plexus and peripheral neural blockades offer excellent analgesia without the side effects associated with neuraxial and parenteral opioids. Intravenous patient-controlled analgesia allows patients to titrate analgesics in amounts proportional to perceived pain stimulus and provide improved analgesic uniformity. Oral sustained-release opioids offer superior pain control and greater convenience than short-duration agents provide. Opioid dose requirements may be reduced by coadministration of COX-2-type nonsteroidal analgesics.     

Drug choices for intravenous and spinal analgesia

Opioids remain at the center of most postoperative pain control therapies. The choice between full agonist opioids should be determined by the time for a given dose to produce its maximum effect (i.e., latency to peak effect), and the duration of action. There is little to choose between different opioids administered by patient-controlled analgesia. Parenterally-administered NSAIDs (e.g., ketorolac) contribute significantly to analgesia and reduce opioid requirements. Morphine may be the opioid of choice for epidural administration. The combination of epidural opioids and local anesthetics provides synergistic analgesia and appears to provide superior analgesia with activity. Several nonopioid receptor agonists are under investigation as neuraxial analgesics.     

Results of a multimodal analgesic trial involving patients with total hip or total knee arthroplasty

The mainstays for pain relief after total hip arthroplasty (THA) and total knee arthroplasty (TKA) have been the opioids, but these medications, though excellent analgesics, have problems limiting their effectiveness. Alternative analgesics have been considered too mild for the pain caused by THA and TKA. These medications have been used in combination, but only in pairs and not in a "stacked modality." Here we report a trial of around-the-clock acetaminophen, rofecoxib, tramadol, and dexamethasone combined with bupivicaine pain pumps and on-demand opioid use (patient-controlled analgesia with morphine). Patients (48 with THA, 54 with TKA) were divided into pain protocol (PP) groups and conventional pain-therapy groups. Important variables were recorded from a chart review. In the PP groups, reductions in opioid use, length of hospital stay (TKA, P=.012), and time on patient-controlled analgesia were significant, as were improvements in pain scores for TKA. In addition, there was a trend in improved pain scores for the PP group with THA. Minor adverse events were similar for the groups, but major medical complications were fewer in the PP group. Preemptive analgesia with multiple non-narcotic medications used in a stacked modality can significantly reduce postoperative pain.     

Monitoring,prevention and treatment of side effects of long-acting neuraxial opioids for post-cesarean analgesia

Long-acting neuraxial opioids such as morphine and diamorphine, administered via spinal or epidural routes, are staple components of a multimodal approach to postoperative analgesia following cesarean delivery. The widespread use of neuraxial opioids is due largely to their significant analgesic efficacy and favorable safety profile. The most common side effects of neuraxial opioids are pruritus, nausea and vomiting. These symptoms appear to be dose-related. The most serious complication of neuraxial opioids is respiratory depression, which occurs in 0–0.9% of cases. Hypothermia has also been reported in association with neuraxial morphine use at cesarean delivery. This article will review recent advances in prophylaxis, treatment and monitoring of the side effects of long-acting neuraxial opioids.     

Intraarticular, epidural, and intravenous analgesia after total knee arthroplasty

BACKGROUND: After total knee arthroplasty, patients regularly suffer from severe pain. It is unclear whether epidural or systemic pain therapy is superior in terms of postoperative pain relief, patients' comfort and side effects. A new therapeutic approach, intraarticular opioids, has been suggested with the detection of opioid receptors in inflamed tissue. This method has proven suitable for clinical use in small operations (e.g. knee arthroscopy). In this study, we compared epidural analgesia and intraarticular application of morphine plus "on-demand" intravenous analgesia to "on-demand" intravenous analgesia alone. METHODS: Thirty-seven patients, scheduled for total knee arthroplasty, were randomly assigned to three treatment groups: in group 1 (EPI) patients received bolus doses of morphine via an epidural catheter; in group 2 (IA) an intraarticular bolus of 1 mg of morphine was applied at the end of the operation with subsequent use of a patient-controlled analgesia (PCA) pump; group 3 (Control), in which only PCA was provided, served as control for both analgesic procedures. Main outcome measures included visual analogue pain scales, total morphine consumption, and stress hormones. RESULTS: No statistically significant differences in visual analogue pain scales could be detected between the three groups. Application of intraarticular morphine did not reduce the amount of analgesics required for postoperative analgesia as compared to intravenous analgesia alone. Application of epidural morphine significantly suppressed beta-endorphine release, but did not significantly influence other stress hormones as compared to the control group. CONCLUSION: Epidural and intravenous analgesia after total knee arthroplasty are equivalent methods of pain relief. In major orthopaedic procedures, application of intraarticular morphine does not reduce analgesic requirements.     

Postoperative analgesia: opioid infusions in infants and children

The purpose of this review is to emphasise the ineffectiveness of traditional analgesic therapy in paediatric patients after surgery, to examine the sensation of pain in infants and children, and to describe the use of intravenous opioids for postoperative analgesia. The management of acute postoperative pain in the paediatric surgical population has been poor. This is despite the knowledge that infants and children have sufficient neurological development at birth to sense pain, and that the same hormonal and metabolic responses to nociceptive stimuli that occur in adult also occur in the neonate. Physicians frequently order analgesics in inappropriate doses, nurses are reluctant to administer opioids, and children themselves frequently compound the problem by refusing injections. The sophisticated techniques for providing postoperative analgesia which have been used so successfully in adults can also be used in paediatric patients. Two of these, continuous intravenous opioid infusion and patient-controlled analgesia, have proved to be very successful. Children older than six months can receive either modality safely with regular monitoring by qualified nursing staff. Infants younger than six months receiving continuous opioid infusions should be monitored in high-dependency units.     

Current concepts and practice in postoperative pain management: need for a change?

Despite a growing trend in acute pain management, many deficiencies still account for the high incidence of moderate to severe postoperative pain to date. Patients nowadays continue to receive inadequate doses of analgesics, but additionally the identification and treatment of those patients with pain still remains a significant health care problem. Advanced techniques are available including epidural or intrathecal administration of local anaesthetics and opioids, various opioid administration techniques such as patient-controlled analgesia and infusions via sublingual, oral-transmucosal, nasal, intra-articular and rectal routes. Nonopioid analgesics such as nonsteroidal anti-inflammatory drugs and newer nonopioid drugs such as alpha2-adrenergic agonists, calcium channel antagonists and various combinations of the above are possible. However, the solution to the problem of inadequate pain relief lies not so much in the development of new drugs and new techniques, but in the effective strategy of delivering these to patients through the introduction of acute pain management services on surgical wards.     

Analgesia in labour: inhalational and parenteral

Inhalational analgesia and parenteral opioids are the most widely used analgesics for labour pain because of their availability, simplicity of administration, and cost. However, their analgesic efficacy is limited compared with regional analgesia. Nitrous oxide in oxygen (Entonox) provides moderate pain relief and is safe for use in labour. Low-dose isoflurane (e.g. 0.25%) with Entonox gives superior pain relief compared with Entonox alone. The more recently introduced inhalational agent, sevoflurane, at a concentration of 0.8% also seems to provide superior pain relief compared with Entonox. Sedation scores tend to be increased with inhalational analgesia. Pethidine is the most widely used opioid for labour despite its side effects and lack of analgesia. Diamorphine is being increasingly used in the UK. There is no good evidence to distinguish analgesic efficacy amongst the standard parenteral opioids and opioid partial agonists and antagonists. Fentanyl patient-controlled analgesia (PCA), with a bolus dose of 20 μg and lockout of 5 minutes, seems to be efficacious but accumulates over time. Close maternal, fetal and neonatal monitoring is required. Parenteral remifentanil PCA, at a dose of 0.25–0.5μg/kg with a lockout time of 1–2 minutes, has a rapid onset and offset without accumulative effects, which makes it ideal for use in labour with improved analgesic efficacy. However, more sophisticated modes of drug delivery and careful titration and monitoring of the parturient are required when sevoflurane and remifentanil are used.     

Postoperative Analgesia in Morbid Obesity

Morbidly obese patients due to high incidence of obstructive sleep apnea (OSA) are predisposed to opioid induced airway obstruction and thus frontline high ceiling analgesics (opioids) have concerns based on safety in their liberal use. Although surgical techniques over the last two decades have seen a paradigm shift from open to laparoscopic procedures for morbidly obese patients; optimally titrated yet safe analgesic management still remains a challenge. The present review sums up the analgesic options available for management of morbidly obese patients undergoing surgery. We highlight the utility of multimodal approach for analgesia with combinations of agents to decrease opioids requirements. Pre-emptive analgesia may be additionally used to improve the efficacy of postoperative pain relief while allowing further reductions in opioid requirements.     

阿片类药物依赖患者的术后镇痛

背景 阿片类药物是术后镇痛的主要药物,但长期使用阿片类药物的患者因对阿片类药物产生耐受而难以得到较理想的临床术后镇痛效果.目的 讨论如何采用不同的镇痛技术和药物来更好地为这些患者提供良好镇痛.内容 介绍阿片类药物依赖的流行病学及术后镇痛特点,如何对阿片类药物依赖规范合理使用阿片类药物及辅助类镇痛药物,麻醉医生擅长的神经阻滞技术在该类患者应有独特的地位.趋向 在阿片类药物依赖患者,通过使用阿片类药物、局麻药和辅助性镇痛药,将不同作用机制的药物或方法联合使用,发挥药物的相加或协同作用的平衡镇痛及多模式镇痛将是术后镇痛技术的主要发展方向.     

阿片类药物依赖患者的术后镇痛

背景 阿片类药物是术后镇痛的主要药物,但长期使用阿片类药物的患者因对阿片类药物产生耐受而难以得到较理想的临床术后镇痛效果.目的 讨论如何采用不同的镇痛技术和药物来更好地为这些患者提供良好镇痛.内容 介绍阿片类药物依赖的流行病学及术后镇痛特点,如何对阿片类药物依赖规范合理使用阿片类药物及辅助类镇痛药物,麻醉医生擅长的神经...     

Postoperative Pain Management in Total Knee Arthroplasty

Total knee arthroplasty (TKA) is one of the most common surgeries performed to relieve joint pain in patients with end‐stage osteoarthritis or rheumatic arthritis of the knee. However, TKA is followed by moderate to severe postoperative pain that affects postoperative rehabilitation, patient satisfaction, and overall outcomes. Historically, opioids have been widely used for perioperative pain management of TKA. However, opioids are associated with undesirable adverse effects, such as nausea, respiratory depression, and retention of urine, which limit their application in daily clinical practice. The aim of this review was to discuss the current postoperative pain management regimens for TKA. Our review of the literature demonstrated that multimodal analgesia is considered the optimal regimen for perioperative pain management of TKA and improves clinical outcomes and patient satisfaction, through a combination of several types of medications and delivery routes, including preemptive analgesia, neuraxial anesthesia, peripheral nerve blockade, patient‐controlled analgesia and local infiltration analgesia, and oral opioid/nonopioid medications. Multimodal analgesia provides superior pain relief, promotes recovery of the knee, and reduces opioid consumption and related adverse effects in patients undergoing TKA.     

Perioperative hypothermia and postoperative opioid requirements.

BACKGROUND AND OBJECTIVE: Hypothermia may alter the disposition of opioids. Because opioids are commonly used as analgesics in the postoperative period, it is of clinical interest to clarify whether perioperatively developed hypothermia affects postoperative opioid requirements. METHODS: Fifty-nine patients undergoing subtotal hysterectomy were prospectively randomized and either treated intraoperatively with forced air warming, or served as controls covered with conventional blankets without active warming. Both groups received postoperative patient-controlled analgesia with the opioid ketobemidone. Total analgesic requirements, demands, analgesic requirements over 6-h intervals and pain scores were measured for 48 h. Core temperature at the tympanic membrane and ambient room temperature were measured during the perioperative period. RESULTS: There were no postoperative differences in analgesic requirements or pain intensity between normothermic and hypothermic patients. Patients treated with warm air had an up to 1 degree C higher core temperature from 0.5 h after anaesthesia induction until almost 2 h postoperatively. The actively warmed patients also had a lower intraoperative blood loss than the hypothermic patients (186 +/- 27 mL vs. 308 +/- 47 mL; P < 0.05). CONCLUSION: In a clinical setting, opioid requirements do not seem to be affected by mild postoperative hypothermia after lower abdominal surgery.     

Nalbuphin in der Kinderanästhesie

Efficient and safe pediatric perioperative pain therapy in the context of a multimodal pain therapy concept requires a slight to moderate opioid analgesic. Nalbuphine is a nearly ideal opioid for this purpose due to its unique pharmacological properties as a μ-receptor antagonist/κ-receptor agonist and a high safety profile. Nalbuphine is used clinically primarily in postoperative pain therapy administered as a bolus, continuous infusion and patient-controlled analgesia. Furthermore, it is administered in different regimens for pediatric diagnostic and interventional sedation.     

Effect of postoperative pain treatment on outcome—current status and future strategies

Background and aims The effect of postoperative pain relief on morbidity and hospital stay is reviewed.Results Beneficial effects of postoperative pain relief by patient-controlled analgesia (PCA) opioids on morbidity and hospital stay have not been documented. The clinical outcome effects of the 20%–30% opioid sparing by non-steroidal anti-inflammatory agents have not been defined, but recent data suggest hastened recovery in cholecystectomy and knee surgery. The effect of continuous epidural analgesia on morbidity and hospital stay remains controversial except for improved pulmonary outcome. However, existing randomised trials on continuous epidural analgesia have insufficient design due to predominantly opioid-based epidural analgesia and the lack of a revision of perioperative care programmes to take advantage of the beneficial physiological effects of balanced epidural analgesia.Conclusion The effects of pain relief on outcome remains debatable, despite beneficial effects of pathophysiological responses. Future outcome studies are required where optimised dynamic pain relief is integrated with a multimodal rehabilitation programme.     

Patient-controlled epidural analgesia (PCEA) for postoperative pain control after lumbar spine surgery

Spine surgery remains one of the most common procedures for patients with a wide variety of spine disorders. Postoperative pain after major spine surgery is moderate to severe. We retrospectively reviewed 245 medical records of adult patients undergoing major spine surgery who received either patient-controlled epidural analgesia based on local anesthetics and opioids or patient-controlled intravenous analgesia as postoperative pain management. Several outcomes were analyzed including pain intensity, opioid consumption, time to endotracheal extubation, the incidence of deep venous thrombosis, and length of stay in the hospital. We found that the use of patient-controlled epidural analgesia provided better postoperative analgesia [median (quartiles) verbal analog scale score of 4 (3, 5) vs. 5 (3, 6)] and decreased the amount of opioid consumption postoperatively [median of 0 mg (0, 3) vs. 35 mg (0, 150)] compared with patient-controlled intravenous analgesia. Also, a substantially higher number of patients in the patient-controlled intravenous group required opioids as rescue analgesia. Incidences of deep venous thrombosis, operating room extubation, and length of stay in the hospital were not associated with the analgesic technique. The results of this study suggest that the use of neuroaxial analgesia for the management of postoperative pain associated with major spine surgery may have some beneficial properties over intravenous analgesia. The use of a reduced amount of opioids by patients with epidural analgesia may be relevant because of potential fewer side effects mainly in elderly patients. Several limitations related to the retrospective nature of the study are described. Prospective randomized-controlled trials are needed to understand and elucidate the optimum regimen of postoperative pain management after major spine surgery.     

Intra-operative ketorolac 15 mg versus 30 mg for analgesia following cesarean delivery: a retrospective study

BackgroundKetorolac is a nonsteroidal anti-inflammatory drug used as part of multimodal analgesia in women undergoing cesarean delivery. The lowest effective dose of ketorolac that best optimizes analgesia without increasing side effects is unclear. We performed this retrospective study to compare the analgesic efficacy of 15 mg or 30 mg ketorolac administered intra-operatively to our obstetric population.MethodsWe included patients who underwent cesarean delivery under neuraxial anesthesia and received 15 mg or 30 mg of ketorolac intra-operatively. Our multimodal analgesic regimen is standardized and includes 150 µg spinal or 3 mg epidural morphine, 975 mg rectal acetaminophen, and 15–30 mg intravenous ketorolac within 15 min of surgery completion. The primary outcome was opioid use in the first 6 h after surgery. Secondary outcomes were opioid use at 24 and 48 h, opioid dose, pain scores, breastfeeding, postoperative serum creatinine and need for rescue anti-emetics.ResultsOne-thousand-three-hundred and forty-nine patients were analyzed (15 mg ketorolac n=999; 30 mg n=350). There was no difference between the two groups in patient demographics or intra-operative characteristics. There was no significant difference between groups for opioid use at 6 h after surgery (50.3% vs 52.0%, odds ratio [95% confidence interval] 1.13 [0.87 to 1.47]). There were also no significant differences between the groups for secondary outcomes.ConclusionsThere was no difference in opioid use between patients receiving either a 15 mg or a 30 mg dose of ketorolac given intra-operatively for postoperative analgesia following cesarean delivery.