Hepatic chemoembolization: Effect of intraarterial lidocaine on pain and postprocedure recovery

Purpose: To determine if intraarterial lidocaine reduces pain during and after chemoembolization, and whether it influences postprocedure recovery. Methods: Two patient cohorts undergoing selective hepatic chemoembolization were compared. Chemoembolization was performed without lidocaine (control group) in 27 patients and intraarterial lidocaine was used (lidocaine group) in 29 similar patients. Objective changes in patient management were assessed. Pain reduction in 31 more procedures with lidocaine (total 60) was assessed and related to tumor type. Results: During chemoembolization, intraarterial lidocaine reduced the need for additional intravenous analgesics from 69% to 19%. After chemoembolization the mean Dilaudid dose in the first 24 hr was reduced from 9.5 mg to 4.15 mg; accordingly, the mean length of hospital stay was reduced from 67.5 to 53.5 hr. During the day of chemoembolization, the mean oral fluid intake increased from 420 ml (control group) to 487 ml (lidocaine group); the percentage of patients taking solid food on the day of chemoembolization increased from 3% to 43%. Conclusion: Intraarterial lidocaine during chemoembolization reduces the severity and duration of pain after chemoembolization resulting in faster recovery thus reducing the length of hospitalization.     

Chemoembolization for hepatocellular carcinoma: effect of intraarterial lidocaine in peri- and post-procedural pain and hospitalization

PURPOSE: To assess the efficacy of intraarterial lidocaine on peri- and post-procedural pain and on length of hospital stay in hepatocellular carcinoma (HCC) patients undergoing chemoembolization. MATERIALS AND METHODS: Twenty-eight patients (19M, 9F, age range 49-76) who underwent hepatic chemoembolization at our Institution between March 2000 and February 2002 were included in the study. Group A consisted of 14 patients who received intraarterial lidocaine immediately before and during chemoembolization, while in the 14 patients of group B lidocaine was substituted with saline solution. The doses of centrally acting narcotics (tramadol) administered periprocedurally and in the three days following the procedure were compared, as were the hospitalization times. Subjective pain was measured using the visual analogue scale. Chemoembolizations were performed with an emulsion of lipiodol, cisplatin and epirubicin followed by embolizing material (gelfoam of Contour particles) in order to achieve complete blood flow stop in the proper hepatic artery. RESULTS: No side effects were noted that could be due to systemic administration of lidocaine. All patients experienced some degree of post-embolization syndrome. Periprocedural, day 1 and day 2 post chemoembolization dosages of tramadol were significantly lower in group A with respect to group B patients. No group A patient required analgesia on day 3. No statistical difference was observed in time persistence of nausea and vomiting, fever and hospitalization time between the two patient groups. CONCLUSIONS: Intraarterial administration of lidocaine before and during chemoembolization is a safe and effective method for preventing or reducing peri- and post-procedural pain and dosage of narcotic analgesics in patients with HCC. Hospitalization times did not differ significantly between the two groups, probably because of the other components of post-embolization syndrome, such as fever, nausea and vomiting.     

Sedations and analgesia in patients undergoing percutaneous transhepatic biliary drainage

AIM: To present our experience using intravenous sedoanalgesia for percutaneous biliary drainage. MATERIALS AND METHODS: This study comprised 100 patients, all of whom were continuously monitored [electrocardiogram (ECG), blood pressure, pulse oxymetry] and received an initial dose of 2mg midazolam followed by 0.02 mg fentanyl. Before every anticipated painful procedure, a maintenance dose of 0.01 mg fentanyl was administered. If the procedure continued and the patient became aware, another 1mg midazolam was given. This was repeated if patients felt pain. A total dose of 0.08 mg fentanyl and 7 mg midazolam was never exceeded. Immediately after the procedure, the nurse was asked to evaluate patients' pain score. The patients were asked 3h later to complete a visual 10-degree pain score scale. RESULTS: The average dose of fentanyl and midazolam was 0.042 mg (0.03-0.08 mg) and 4.28 mg (2-7 mg), respectively. Only one patient recorded the procedure as painful. The scores given by the attending nurse (1-7 points, mean 2.9) correlated well with those given by the patients (1-6 points, mean 2.72). No complications were noted. CONCLUSION: According to our experience, interventional radiologists practising biliary procedures can administer low doses of midazolam and minimize the doses of fentanyl, without loss of adequate sedation and analgesia.     

Intraarterial lidocaine for pain control after uterine artery embolization for leiomyomata

PURPOSE: To evaluate the effectiveness of intraarterial lidocaine in controlling pain after uterine artery embolization (UAE). MATERIALS AND METHODS: In this double-blind prospective study, patients undergoing UAE received preservative-free 1% lidocaine or saline solution (control) in the uterine arteries before embolization. Postprocedural pain was managed with patient-controlled intravenous morphine. Attempted doses, number of doses received, total morphine dose, and maximum pain numeric rating scale (NRS) score during the postprocedural hospitalization were recorded and compared. Three-month follow-up magnetic resonance (MR) imaging and symptomatic questionnaires were collected and compared. RESULTS: Ten patients received lidocaine and eight patients received placebo. Moderate to severe vasospasm was noted in seven patients after lidocaine injection, whereas no vasospasm was noted in the placebo group (P =.004). Patients in the lidocaine group had lower NRS pain scores than those in the placebo group (P =.012), whereas there was no difference in morphine requirement between treated patients and control subjects. The study was terminated after 18 patients were treated as a result of unexpected vasospasm. CONCLUSIONS: Intraarterial 1% lidocaine is associated with moderate to severe vasospasm. Lidocaine significantly lowers subjective pain, but there is no difference in analgesic requirements. The routine use of intraarterial lidocaine is not recommended for pain control until the long-term effects of vasospasm on outcome is known.     

Sedation and analgesia in adult patients: evaluation of a staged-dose system based on body weight for use in abdominal interventional radiology

PURPOSE: To evaluate the safety and effectiveness of a systematic protocol for sedation and analgesia in interventional radiology. MATERIALS AND METHODS: Ninety-one adult patients underwent 113 abdominal interventional procedures. Fentanyl citrate and midazolam hydrochloride were administered in one to five steps (A, B, C, D, E) until the patient was drowsy and tranquil at the effective loading dose (ELD). Doses per step were as follows: A, fentanyl 1 microg per kilogram of body weight; B, midazolam 0.010-0.035 mg/kg; C, repeat dose in A; D, repeat half the dose in B; and E, midazolam 1-2-mg boluses (maximum, 0.15 mg/kg). RESULTS: The ELD was reached in no procedure after step A, in 70 after B, in 23 after C, and in 18 after D. Step E was needed in two procedures. The mean maximum pain score (scale of 0 to 10) was 3.4; pain scores in 85 (75%) procedures were 4 or less (discomforting). Severe pain occurred in seven (6%) procedures. Hypoxia (oxygen saturation < 90%) occurred in 11 (22%) procedures performed in patients breathing room air and four (6%) performed in those breathing supplemental oxygen (P: =.04). All patients responded to supplemental oxygen. CONCLUSION: This stepwise "ABCDE protocol" allows safe and effective sedation of patients. It is easy to use and may be useful in training radiology residents, staff, and nurses in the techniques of sedation and analgesia. Supplemental oxygen should be used routinely.     

Comparison of Opioid Medication Use after Conventional Chemoembolization versus Drug-Eluting Embolic Chemoembolization

PurposeTo assess the use of opioid analgesics and/or antiemetic drugs for pain and nausea following selective chemoembolization with doxorubicin-based conventional (c)-transarterial chemoembolization versus drug-eluting embolic (DEE)-transarterial chemoembolization for hepatocellular carcinoma (HCC).Materials and MethodsFrom October 2014 to 2016, 283 patients underwent 393 selective chemoembolization procedures including 188 patients (48%) who underwent c-transarterial chemoembolization and 205 (52%) who underwent DEE-transarterial chemoembolization. Medical records for all patients were retrospectively reviewed. Administration of postprocedural opioid and/or antiemetic agents were collated. Time of administration was stratified as phase 1 recovery (0–6 hours) and observation (6–24 hours). Logistic regression model was used to investigate the relationship of transarterial chemoembolization type and use of intravenous and/or oral analgesic and antiemetic medications while controlling for other clinical variables.ResultsMore patients treated with DEE-transarterial chemoembolization required intravenous analgesia in the observation (6–24 hours) phase (18.5%) than those treated with c-transarterial chemoembolization (10.6%; P = .033). Similar results were noted for oral analgesic agents (50.2% vs. 31.4%, respectively; P < .001) and antiemetics (17.1% vs. 7.5%, respectively; P = .006) during the observation period. Multivariate regression models identified DEE-transarterial chemoembolization as an independent predictor for oral analgesia (odds ratio [OR], 1.84; P = .011), for intravenous and oral analgesia in opioid-naïve patients (OR, 2.46; P = .029) and for antiemetics (OR, 2.56; P = .011).ConclusionsCompared to c-transarterial chemoembolization, DEE-transarterial chemoembolization required greater amounts of opioid analgesic and antiemetic agents 6–24 hours after the procedure. Surgical data indicate that a persistent opioid habit can develop even after minor surgeries, therefore, caution should be exercised, and a regimen of nonopiate pain medications should be considered to reduce postprocedural pain after transarterial chemoembolization.     

Hepatic Hilar and Celiac Plexus Nerve Blocks as Analgesia for Doxorubicin-Eluting Microsphere Chemoembolization Procedures for Hepatocellular Carcinoma: A Nonblinded Randomized Clinical Trial

PurposeTo investigate whether hepatic hilar and celiac plexus nerve blocks provide safe and effective analgesia to patients undergoing doxorubicin-eluting embolics transarterial chemoembolization (DEE-TACE) for hepatocellular carcinoma.Materials and MethodsIn this prospective, randomized trial, 92 patients undergoing DEE-TACE for hepatocellular carcinoma were enrolled. The control group received standard intraprocedural local anesthetic, intra-arterial lidocaine, and intravenous analgesia; the study group underwent additional hepatic hilar and celiac plexus nerve blocks. Intra-arterial lidocaine, intravenous and oral narcotic and antiemetic requirements after the procedure, pain, patient satisfaction, adverse events, and hospital stay were compared.ResultsThe nerve block group reported less pain during and after the procedure at days 1 and 7 (P < .001), although differences resolved by week 2. The control group received more intra-arterial lidocaine (P < .001) and required approximately double the amount of narcotic analgesia during and after the procedure, extending to 3 weeks after the procedure (P < .001), as well as less antiemetics (P < .001). No differences in adverse events, hospital stay, and overall patient satisfaction were noted.ConclusionsHepatic hilar and celiac plexus nerve blocks before procedures can result in lower pain during and after procedures in patients undergoing DEE-TACE. Furthermore, nerve blocks result in lower opioid consumption and opioid-related complications for 3 weeks following procedures.     

硬膜外注射新克痛宁用于术后镇痛的效果观察

目的　观察硬膜外腔注入新克痛宁用于术后镇痛的效果。方法　 72例胫腓骨骨折病人在连续硬膜外阻滞麻醉下行切开复位内固定术 ,术后随机分为四组 (每组 18例 )向硬膜外腔一次注入容量为 10ml药物 :A组新克痛宁 0 .2 5U/kg ;B组新克痛宁 0 .12 5U/kg加 0 .5 %利多卡因液 10ml;C组吗啡 2mg ;D组吗啡 1mg加 0 .5 %利多卡因液 10ml。按WHO标准 ,术后疼痛程度达Ⅱ级时按组别注药。结果　A组与B组镇痛作用完全 ,镇痛维持时间A组与B组明显延长 ,A组与B组分别为 (4 12± 2 5 )min和 (34 5± 2 8)min ,与C组 [(2 0 7± 2 3)min]和D组 [(16 5± 10 .3)min]比较 ,差异显著(P <0 .0 5 )。注药后 30～ 12 0min患肢足背皮肤温度 ,A组与B组均高于C组与D组 (P <0 .0 5 )。结论　新克痛宁注入硬膜外腔用于术后镇痛 ,维持时间较长 ,镇痛作用完全 ,无不良反应     

Superior hypogastric nerve block for pain control in outpatient uterine artery embolization

PURPOSE: To assess the efficacy of the superior hypogastric nerve block (SHNB) in permitting uterine artery embolization (UAE) to be performed as a routine outpatient procedure. MATERIALS AND METHODS: One hundred thirty-nine patients who underwent UAE in a prospective single-arm clinical trial in an academic institution underwent SHNB from an anterior abdominal approach to control acute postprocedural pain, in addition to conventional conscious sedation. They were discharged and prescribed one of two drug combinations started during the in-hospital recovery period. Regimen A included short-acting morphine tablets and indomethacin rectal suppositories and regimen B included long-acting morphine tablets for baseline pain supplemented with short-acting morphine tablets for breakthrough pain, and naproxen rectal suppositories. All patients were contacted by phone on the third and fifth postprocedural days and their peak pain experience was recorded on a scale of 0 to 10. RESULTS: All patients were able to be discharged the day of the procedure. Seven patients (5%) returned to the hospital because of pain. One was discharged after undergoing a second SHNB and four were discharged after receiving intravenous analgesics; two required longer admission for intravenous analgesia. The mean (+/-SD) peak pain score in the first 5 days after the procedure for all patients was 4.8 +/- 2.6. There was a significant difference between regimens A (mean pain score, 5.7 +/- 2.2) and B (mean pain score, 2.7 +/- 2.5; Mann-Whitney, 5.94; P < .01). CONCLUSION: The addition of SHNB to the more conventional post-UAE pain management methodology enhances pain control, enabling the procedure to be offered with minimum pain on a routine outpatient basis.     

Thoracic paravertebral block for percutaneous transhepatic biliary drainage

Percutaneous transhepatic biliary drainage is a painful procedure most commonly performed after intravenous sedation. Despite systemic opiates and benzodiazepines, most patients experience significant pain during the procedure and in the recovery period. Paravertebral blocks allow the spinal nerve roots and sympathetic chain in the paravertebral space to be anesthetized, and their role in providing analgesia for thoracic and upper abdominal surgical procedures is well-established. Herein a case is described in which thoracic paravertebral blockade dramatically reduced standard intra- and postprocedural analgesic needs and provided superior pain control.     

The postoperative analgesic effects of intra-articular levobupivacaine in elective day-case arthroscopy of the knee: a prospective, randomized, double-blind clinical study

Purpose: Pain and emesis are the two major complaints after day surgery. Local anesthesia has become an important part of optimizing perioperative pain treatment. The aim of the present study was to study two different concentrations of levobupivacaines effect on postoperative pain following elective arthroscopy of the knee with lidocaine 10 mg/ml with adrenaline as active control. Type of study: Prospective, randomized double-blind study with lidocaine as active control but without placebo. Methods: One hundred and twenty patients were studied comparing levobupivacaine 2.5 mg/ml, levobupivacaine 5 mg/ml, and lidocaine 10 mg/ml with adrenaline given intra-articularly at the end of day-case operative elective arthroscopy of the knee done in light general anesthesia. Primary study endpoint was the need for any analgesics during the first 24 postoperative hours. Results: Levobupivacaine 5 mg/ml was associated with a reduced need for any analgesia during the entire 24-h study period (p = 0.013) as compared to both 2.5 mg/ml levobupivacaine and lidocaine with adrenaline. Levobupivacine 2.5 mg/ml was inferior to lidocaine with regard to pain relief with an increase in need for oral analgesia already during stay in the recovery unit (p < 0.001). Conclusions: Levobupivacaine 5 mg/ml was found to be an effective local anesthetic in day-case operative arthroscopy of the knee providing superior postoperative analgesia as compared to lidocaine with adrenaline or a lower concentration of levobupivacaine. Level of evidence: Level I: Prospective, randomized double-blind study without placebo.     

Pain control requirements for percutaneous ablation of renal tumors: cryoablation versus radiofrequency ablation--initial observations

PURPOSE: To retrospectively compare the pain control requirements of patients undergoing computed tomography (CT)-guided percutaneous radiofrequency (RF) ablation with those of patients undergoing CT-guided percutaneous cryoablation of small (< or = 4-cm) renal tumors. MATERIALS AND METHODS: The study was HIPAA compliant and received institutional review board exemption; informed consent was not required. Medical and procedure records of patients who underwent RF ablation and cryoablation of renal tumors from June 19, 2003, to February 28, 2004, were retrospectively reviewed for clinical data, tumor characteristics, and anesthesia information. During the study period, 10 men (mean age, 66.5 years) underwent cryoablation of 11 renal lesions, and 14 patients (11 men, four women; mean age, 68.1 years) underwent RF ablation of 15 renal tumors. Analgesic and sedative requirements during the procedure were compared. Standard anesthesia consisted of 5 mL of 1% lidocaine injected locally, and conscious sedation consisted of 50 microg of fentanyl and 1 mg of midazolam administered intravenously. The Fisher exact test and Student t test were used to compare clinical factors and drug requirements between the two groups. RESULTS: There was no difference in terms of patient demographics, tumor diameter, or distribution of central versus noncentral lesions between the two groups. Cryoablation was associated with a significantly lower dose of fentanyl (165.0 microg [RF group] vs 75.0 microg [cryoablation group]; P < .001) and midazolam (2.9 mg [RF group] vs 1.6 mg [cryoablation group]; P = .026). In the RF group, one patient required general anesthesia, one patient required supplemental narcotics (5 mg of oxycodone) and sedatives (1 mg lorezapam), and one patient became apneic for a brief interval after receiving additional narcotics for pain during the procedure. An additional RF session was terminated early in one patient because of pain, and further medication could not be administered owing to bradycardia. No patients in the cryoablation group required any additional or alternate anesthetics. CONCLUSION: Image-guided percutaneous cryoablation of small (< or = 4-cm) renal lesions appears to require less analgesia than RF ablation. Prospective trials with validated pain scales are needed to examine this further.     

Nitrous oxide: effective analgesic for vascular and interventional procedures

During a 2 year period nitrous oxide was used as a sole or supplementary analgesic during 173 vascular or interventional procedures including peripheral angiography and endourologic and endobiliary procedures. The decision to administer nitrous oxide to a given patient was a matter of physician preference. Patients with bowel obstruction, pneumothorax, or chronic obstructive pulmonary disease were excluded from this method of analgesia. The nitrous oxide was administered by a radiology nurse under the supervision of an attending radiologist. Nitrous oxide was used without premedication for 39 procedures and with premedication (usually meperidine 1 mg/kg, promethazine 0.3 mg/kg, or atropine 0.01 mg/kg) in 134 procedures. In 74% of nonpremedicated individuals analgesia was adequate with nitrous oxide alone; 26% required supplemental intravenous medication. In 61% of premedicated individuals pain relief was adequate with nitrous oxide; 39% required supplemental intravenous medication. Complications, including nausea, vomiting, and agitation, occurred in eight patients, but were minor and easily reversed by decreasing the concentration of nitrous oxide. Nasally administered nitrous oxide is a safe, easily used, and effective analgesic.     

Analgesic effect of intra-articular ketorolac in knee arthroscopy: comparison of morphine and bupivacaine

This prospective study assessed the postoperative analgesic effect of intra-articular ketorolac, morphine, and bupivacaine during arthroscopic outpatient partial meniscectomy. Group 1 patients (n=20) received postoperative injection of 60 mg intra-articular ketorolac, group 2 patients (n=20) 10 cc intra-articular bupivacaine 0.25%, group 3 patients (n=20) 1 mg intra-articular morphine diluted in 10 cc saline, and group 4 patients (n=20, controls) only 10 cc saline. We evaluated the postoperative analgesic effect (period measured from the end of the surgery until further analgesia was demanded), the level of postoperative pain (by visual analog scale 1, 2, 3, 12, and 24 h after surgery), and the need for additional pain medication (during the first 24 h after surgery). The best analgesic effect was in patients treated with intra-articular ketorolac, and this was statistically significant in: postoperative analgesic effect and the need for additional pain medication immediately after surgery, and after 24 h. No complications were found related to the intra-articular treatment. We conclude that 60 mg intra-articular ketorolac provides better analgesic effect than 10 cc intra-articular bupivacaine 0.25% or 1 mg intra-articular morphine.     

Spinal Wada test

Various doses of pentobarbital (1.25-20 mg) and lidocaine (2.5-20 mg) were injected selectively into the artery of Adamkiewicz and anterior spinal artery of 11 monkeys. Pentobarbital produced an acute paraplegia; lidocaine caused a transient paraplegia followed by hyper-reflexia and muscular fasciculation. Duration of effect varied from 5 to 60 minutes with both drugs and was dose related. Effects were totally reversible. The use of intraarterially administered barbiturates and lidocaine may be more sensitive than angiography for predicting cord blood supply during arteriography for spinal arteriovenous malformations or embolization of critical vessels, such as the right bronchial artery.     

Comparison of analgesic effects of intra-articular tenoxicam and morphine in anterior cruciate ligament reconstruction

This study compared the analgesic effect of intra-articular injection of tenoxicam with that of morphine on postoperative pain after anterior cruciate ligament (ACL) reconstruction. Forty-two patients undergoing arthroscopically ACL reconstructions using hamstring tendons underwent the same anesthetic protocol. The patients were randomized to receive 25 ml normal saline, 20 mg tenoxicam in 25 ml normal saline, or 2 mg morphine in 25 ml normal saline. Postoperative pain was assessed using a visual analogue scale and measuring analgesic requirements. We found both that both intra-articular tenoxicam and intra-articular morphine provided better analgesia than that in the control group. Although pain scores were similar between tenoxicam and morphine groups 30 min postoperative, the analgesic requirements in with tenoxicam were significantly lower than those with morphine group 3-6 h postoperatively.     

Music during interventional radiological procedures, effect on sedation, pain and anxiety: a randomised controlled trial

Objective

: To assess the effects of playing patient-selected music during interventional procedures on (1) the doses of sedation and analgesia and (2) anxiety levels.

Methods

: Patients undergoing interventional radiological procedures were randomised to either the intervention (music) or the control (no music) group. Patients in the intervention group had music of their choice played via headphones during the procedure. The primary outcomes were reductions in the doses of drugs for sedation (midazolam) and analgesia (fentanyl). Anxiety levels were assessed both before and after the procedure using the validated State Anxiety Inventory. Mean pulse rate and average of mean blood pressures were also recorded before and during the procedures as surrogate indicators of anxiety levels.

Results

: 100 patients were randomised in a 1:1 ratio. There were 58 males and 42 females, with a mean age of 58 years. Sedation was required in 21 (42%) patients in the music group compared with 30 (60%) patients in the control group (p=0.046). The mean [standard deviation (SD)] midazolam dose was 2.1 mg (2.3 mg) in the control group and 1.3 mg (2.2 mg) in the music group (p=0.027). The mean (SD) fentanyl dose was 29 mg (40 mg) in the control group and 18 mg (34 mg) in the music group (p=0.055). There was no significant effect of music on the change from baseline in anxiety levels (p=0.74), pulse rate (p=0.56) or blood pressure (p=0.34).

Conclusion

: Sedation requirements are significantly reduced by playing self-selected music to the patient during interventional radiology procedures. By lowering sedation during interventional radiology, music makes the procedure safer. It also contributes favourably to the overall patient experience.An increasing number of radiological interventional (IR) procedures, both vascular and non-vascular, are being performed worldwide. Most IR procedures are performed under local anaesthesia with a varying need for conscious sedation [1]. Conscious sedation carries small risks that are occasionally life threatening, e.g. respiratory depression [2]. Therefore the dose and need for conscious sedation should be minimised without compromising patient comfort during the procedure.Patients experience varying levels of anxiety before and during these procedures [3]. Factors known to reduce anxiety and analgesic requirements during procedures include adequate pre-operative information, with a pre-operative visit, and familiarity with the personnel involved. A meta-analysis of randomised trials concluded that music reduces anxiety and analgesic requirements during endoscopy [4].Playing music during the procedure is common practice in some IR radiology departments. This may not be directly for the patient''s benefit and they are often not consulted on the choice of music or offered headphones. One might expect a more patient-focused approach to reduce patient anxiety and pain. To our knowledge, the effect of music during IR procedures has not been investigated. The aim of this randomised study was to assess the effect of per-operative patient-selected music during IR procedures on:

1. dose of sedation and analgesic drugs
2. anxiety levels.

     

Pre- and postoperative intra-articular analgesia for arthroscopic surgery of the knee and arthroscopy-assisted anterior cruciate ligament reconstruction A double-blind randomized, prospective study

We tested the effectiveness of different intra-articular analgesics and of pre-emptive intra-articular analgesia for arthroscopy-assisted anterior cruciate ligament reconstruction (ACLR) and for operative knee arthroscopy. Eighty-two patients underwent operative knee arthroscopy under selective subarachnoid anaesthesia (group A), and 60 patients underwent arthroscopy-assisted ACLR under general anaesthesia (group B). Patients were randomly assigned to intra-articular analgesic treatment as follows. Group A: 1, morphine 2 mg; 2, preoperative morphine 2 mg; 3, morphine 5 mg; 4, preoperative morphine 5 mg; 5, bupivacaine 0.25% 20 ml; 6, bupivacaine 0.25% 20 ml + morphine 2 mg; 7, saline solution 20 ml. Group B: 1, morphine 2 mg; 2, morphine 5 mg; 3, preoperative morphine 5 mg; 4, bupivacaine 0.25% 20 ml; 5, bupivacaine 0.25% 20 ml + morphine 2 mg; 6, saline solution 20 ml. All opioids were diluted in 20 ml of saline solution. After postoperative administration the tourniquet was left in place for 10 min. After preoperative administration the intra-articular surgical procedure was delayed for about 5–10 min. In the postoperative period we recorded: total consumption of ketoprofen given i.v. on demand as rescue analgesic treatment; pain scores before surgery and at 1st, 3rd, 6th, 12th and 24th h; occurrence of local anaesthetic or opioid side-effects. Group A (operative knee arthroscopy): all morphine groups (A1, A2, A3, A4) and the bupivacaine group (A5) did not require ketoprofen postoperatively (P < 0.01 vs both groups A6 and A7). Pain scores did not differ significantly among groups. The percentage of patients reporting higher pain scores than before surgery was larger in control group A7 and in bupivacaine groups A5, A6 (83%, 40%, 60%, respectively) and lower in morphine groups A1, A2, A3, A4 (25%, 16%, 27%, 23%, respectively). Group B (ACLR): total consumption of ketoprofen was lowest in groups B2 and B3 (P < 0.001 vs all other treatments and vs control group). The percentage of patients who did not require any rescue analgesic was 60% in group B3, 50% in group B2, 32% in group B5 and 0% in all other groups. No-side effects occurred in any patient. Intra-articular analgesia is safe and effective for arthroscopic knee surgery. Morphine provides a better pain control both in operative knee arthroscopy patients and in ACLR. A 2 mg dose is adequate for operative knee arthroscopy but not for ACLR, where higher dosages are required (5 mg). Pre-emptive intra-articular morphine provides better analgesia than postoperative administration. Received: 25 May 1996 Accepted: 28 April 1997     

小剂量硫酸镁复合芬太尼术后静脉镇痛

目的比较小剂量硫酸镁联合芬太尼与单纯芬太尼术后静脉镇痛的临床效应。方法选择行上腹部手术后患者90例,随机均分为三组,每组30例,以一次性静脉镇痛泵(2m l/h)分别行静脉术后镇痛,F组:单纯芬太尼镇痛,0.2μg/(kg.h)芬太尼+5 mg氟哌利多,MF1组:硫酸镁联合芬太尼镇痛,0.2μg/(kg.h)芬太尼+0.5 mg/(kg.h)硫酸镁+5 mg氟哌利多,MF2组:硫酸镁联合芬太尼镇痛,0.2μg/(kg.h)芬太尼+1 mg/(kg.h)硫酸镁+5 mg氟哌利多,各组镇痛泵中药物均用医用盐水稀释至100 m l,观察各组患者镇痛48 h内的静息镇痛评分(VAS方法),恶心呕吐,皮肤瘙痒和尿潴留的发生情况。结果三组患者的静息镇痛评分在12 h内MF1组和MF2组明显低于F组(P<0.05),而在12 h后没有明显差别(P>0.05);恶心呕吐,皮肤瘙痒和尿潴留发生率MF1组和MF2组显著低于F组(P<0.01)。MF1组和MF2组之间在静息镇痛评分和并发症发生方面没有明显差别。结论小剂量硫酸镁用于术后静脉镇痛可明显减少芬太尼的剂量,使恶心呕吐,皮肤瘙痒和尿潴留发生率降低,镇痛效果明显优于单纯芬太尼术后静脉镇痛。     

Postoperative analgesic effects of intra-articular bupivacaine and morphine after arthroscopic cruciate ligament surgery

Intra-articular administration of local anaesthetics such as bupivacaine can produce short-term postoperative analgesia in patients undergoing diagnostic arthroscopy or arthroscopic meniscectomy. A peripheral anti-nociceptive effect may also be induced by the administration of intra-articular opiates interacting with local opioid receptors in inflamed peripheral tissue. In the present study we aimed to study the analgesic effects of intraarticularly given bupivacaine and morphine sulphate (as well as the combination of both drugs) on postoperative pain. In a prospective, randomized, double-blind manner 40 patients received one of the following: (a) morphine (1 mg in 20 ml NaCl), (b) bupivacaine (20 ml, 0.375%), (c) combination of both or (d) saline (20 ml, control group) intra-articularly at the end of arthroscopic anterior cruciate ligament (ACL) reconstruction. The postoperative pain was assessed via a visual analogue scale (VAS) during the first 48 h after surgery, and supplemental analgesic requirements were noted. All comparisons were made versus the control group receiving saline. The pain scores were significantly lower in the morphine group at 24 and 48 h, and in the bupivacaine group at 2, 4 and 6 h after surgery. In the group that received a combination of both bupivacaine and morphine, the pain scores were significantly reduced throughout the whole postoperative observation period. No side-effects or complications from therapy were seen in any of the groups. The conclusion of this study is that intra-articular morphine is effective in the postoperative period after arthroscopic ACL reconstruction. The combination of bupivacaine and morphine was the most effective postoperative analgesic regimen and resulted in significant analgesia throughout the whole 48-h period following surgery. Patients receiving the combination of bupivacaine and morphine had a significantly shorter hospital stay than the control group.