A randomized, double-blinded comparison of intrathecal morphine, sufentanil and their combination versus IV morphine patient-controlled analgesia for postthoracotomy pain

We compared the analgesic effect of lumbar intrathecal (IT) 0.5 mg morphine (Group M, n = 10), 50 microg sufentanil (Group S, n = 10), and their combination (Group S-M, n = 10) given before general anesthesia and patient-controlled analgesia with IV morphine (Group C, n = 19) in a randomized, double-blinded study performed in patients undergoing thoracotomy. Pain visual analog scale (VAS) and morphine consumption were assessed for 24 h. In Group S-M the number of patients initially titrated with IV morphine was less than in group C (30 vs 84%, P < 0.05). Morphine requirement was higher in Group C (71 +/- 30 mg) than in Groups S (46 +/- 34 mg, P < 0.05), M (38 +/- 31 mg, P < 0.05) and S-M (23 +/- 16 mg, P < 0.01). VAS scores were significantly decreased during the first 0-11 postoperative h at rest and during the first 0-8 postoperative h on coughing in Groups M and S-M rather than in Group C. The incidence of side effects was infrequent except for urinary retention. Preoperative IT morphine or combined sufentanil and morphine could be given as a booster to achieve rapidly effective analgesia in the immediate postoperative period. Implications: As compared with IV patient-controlled analgesia, intrathecal morphine or combined sufentanil and morphine provided superior postoperative pain relief both at rest (11 h) and on coughing (8 h) than did IV patient-controlled analgesia morphine alone. IV morphine requirement was decreased during the first postoperative day after posterolateral thoracotomy.     

The morphine sparing effect of ketorolac tromethamine

A randomised, double-blind study of patients after upper abdominal surgery was undertaken to assess the analgesic efficacy of ketorolac tromethamine, a new, parenteral non-steroidal anti-inflammatory agent. Postoperatively, patients received a 24-hour intramuscular infusion of either saline (n = 20), ketorolac 1.5 mg/hour (n = 21) or ketorolac 3.0 mg/hour (n = 20). Cumulative morphine requirements were measured using a patient-controlled analgesia system which delivered intravenous increments of morphine on demand. Pain was assessed by visual analogue scores. Arterial blood gas analyses were performed pre-operatively and on the first postoperative day. Patients who received low and high dose ketorolac infusions required less morphine than the control group (p less than 0.05 and p = 0.06, respectively). This was associated with significantly lower pain scores. Patients who received the higher ketorolac dose had significantly less postoperative increase in arterial carbon dioxide tensions than controls. This study suggests that ketorolac tromethamine is a useful analgesic drug with significant morphine sparing properties.     

Mini-dose (0.05 mg) intrathecal morphine provides effective analgesia after transurethral resection of the prostate

PURPOSE: To determine the optimal dose of intrathecal morphine that produces satisfactory analgesia with minimum side effects in elderly patients undergoing transurethral resection of the prostate (TURP). METHODS: In this double-blind prospective study, 42 patients undergoing TURP with spinal anesthesia were allocated to one of three groups. Group A (n = 14) received tetracaine, 10 mg, alone. Group B (n = 13) and Group C (n = 15) received morphine 0.05 mg and 0.10 mg, respectively, in combination with tetracaine. Postoperative pain, nausea and pruritus were evaluated using visual analogue scales (VAS). SpO(2) and respiratory rate were also assessed. RESULTS: At three, five, seven and 24 hr after spinal anesthesia, the VAS scores for pain in Groups B and C were significantly less than in Group A. Group C experienced significantly greater VAS scores for pruritus as compared to Groups A and B. There was no significant difference in the intensity of nausea among the three groups. No patient experienced hypoxemia (SpO(2) < 90%) and respiratory depression (respiratory rate < 10 beats*min(-1)) in any group. CONCLUSION: A dose of 0.05 mg in intrathecal morphine with spinal anesthesia would be optimal for elderly patients undergoing TURP.     

Preoperative droperidol improved postoperative pain relief in patients undergoing rotator-cuff repair during general anesthesia using intravenous morphine

STUDY OBJECTIVE: To demonstrate the effect of preoperative and intraoperative, small-dose intravenous (IV) droperidol on postoperative pain relief in orthopedic patients given general anesthesia with morphine. DESIGN: Randomized, double-blind, prospective study. SETTING: University-affiliated hospital. PATIENTS: 84 ASA physical status I and II patients undergoing shoulder rotator-cuff repair with general anesthesia. INTERVENTIONS: Patients were randomly assigned to one of three groups: Group P (n = 27) wee given droperidol 10 microg/kg IV before skin incision; Group A (n = 30) received droperidol 10 microg/kg IV after skin incision; and Group C (n = 27) served as controls. General anesthesia consisted of sevoflurane and nitrous oxide in oxygen and IV morphine 0.2 mg/kg, which was given before skin incision. MEASUREMENTS: The degree of postoperative pain as assessed by postoperative pain scores and the number of supplemental analgesics given, and the frequency of postoperative nausea and vomiting, nightmares, and respiratory depression were compared among the three groups. A p-value < 0.05 was considered statistically significant. MAIN RESULTS: The postoperative pain score distribution was significantly greater in smaller values in Groups P and A than in Group C (p < 0.01). The number of supplemental analgesics given in the first 18 hours postoperatively was significantly smaller in Group P than in Groups A or C (p < 0.05). CONCLUSIONS: Preoperative IV droperidol resulted in improved postoperative pain relief inpatients undergoing shoulder rotator cuff surgery with general anesthesia using IV morphine.     

Postoperative analgesia after peripheral nerve block for podiatric surgery: clinical efficacy and chemical stability of lidocaine alone versus lidocaine plus ketorolac

BACKGROUND AND OBJECTIVES: The purpose of this study was to determine whether the addition of ketorolac tromethamine to local anesthesia for ankle block alters the quality or duration of analgesia after podiatric surgery. The second aim was to determine the chemical stability of ketorolac tromethamine when added to local anesthetic solutions. METHODS: The study design was double-blinded, placebo-controlled, and randomized. Seventy-nine American Society of Anesthesiologists (ASA) class I or II patients scheduled for bunionectomy or hammer toe repair, or both were randomized to 1 of 4 groups. Group L received plain 1.73% lidocaine for their ankle block. Group K received 1.73% lidocaine with ketorolac (4 mg/mL) added to the local solution. Group Kiv received 1.73% plain lidocaine for ankle block and 20 mg of ketorolac intravenously. Group E received 1.73% lidocaine with .67% ethanol added. The final concentration of lidocaine for all groups was 1.73%. The block performed in each patient was a 5-point ankle block. Beginning at 1 hour after the completion of the block and every 30 minutes thereafter, visual analogue scale (VAS) and verbal pain scores were recorded. The time from performance of the block to the initial pain and time to the first oral pain medication intake were also recorded. The time and amount of postoperative oral analgesics in the first 9 hours after the block were recorded. Adverse events were also recorded for each group. RESULTS: There were significantly lower overall VAS and verbal pain scores for group K compared with groups E and L and group Kiv compared with group E. Group K also had a significantly longer time to the first reported pain and first oral pain medications than groups E and L, but not with Group Kiv. The same group had significantly fewer average doses of pain medications postoperatively than Groups E and L. Group E had significantly shorter times to first report of pain and first pain medications and higher mean dose of postoperative oral analgesics than group K and Group Kiv. There were no untoward side effects reported from any group. Chemical analysis by gas chromatography (GC) and capillary electrophoresis (CE) showed no significant change in composition of the solutions when ketorolac was mixed with lidocaine and/or bupivacaine and stored at 37 degrees C for 1 week. CONCLUSIONS: The addition of ketorolac to lidocaine for ankle block contributed to longer duration and better quality analgesia after foot surgery compared with plain 1.73% lidocaine or 1.73% lidocaine plus intravenous ketorolac. The ethanol vehicle is unlikely responsible for the analgesic effects of ketorolac. Ketorolac retains its chemical stability when placed in local solutions of lidocaine or bupivacaine.     

Intramuscular ketorolac following total hip replacement with spinal anaesthesia and intrathecal morphine

We have studied the analgesic and morphine sparing effect of ketorolac tromethamine in 60 patients after total hip replacement under spinal anaesthesia.
In this double blind study 30 patients received ketorolac 30 mg IM 6 hourly postoperatively and the control group received saline. Analgesia was assessed by visual analogue pain scores (VAS) and morphine consumption by patient controlled analgesia (PCA). There was a significantly ( P <0.02) lower morphine consumption in the ketorolac group (7.1 ±8.6 mg; Mean±s.d.) when compared to the saline group (14.2±13.6 mg). Although there was a trend for lower VAS on the first postoperative night this was only significant at 10 hours postoperatively and the next morning at 08:00 hr. The incidence of side effects (emetic sequelae, pruritus and headache) were similar in both groups. It is concluded that ketorolac reduces the consumption of additional morphine in conjunction with intrathecal morphine but had no effects on the side effects.     

The influence of preemptive spinal anesthesia on postoperative pain

STUDY OBJECTIVE: To examine the influence of spinal anesthesia on postoperative pain and postoperative opioid requirements. DESIGN: Prospective randomized study. SETTING: Bnai-Zion Medical Center, Haifa, Israel-a government hospital. MEASUREMENTS AND MAIN RESULTS: 30 ASA physical status I and II unpremedicated women undergoing elective total abdominal hysterectomy were randomly allocated into two groups of 15 patients each using a sealed envelope technique. Patients in Group 1 were given a subarachnoid injection of 12 mg hyperbaric bupivacaine and after 10 minutes general anesthesia was induced. Patients in Group 2 received only general anesthesia. Anesthesia was induced with midazolam and maintained with oxygen, N2O, isoflurane, and pancuronium. No opioids were given intraoperatively. Postoperatively patient-controlled analgesia (PCA) with morphine was initiated in both groups (1 mg x mL(-1), bolus dose 1 mg, lockout interval 10 minutes, and background infusion 1 mg x mL(-1)) at patient first request for analgesic. Pain was assessed over 24 hours by cumulative morphine dose and visual analog score (VAS). Postoperative PCA morphine consumption at 2, 6, and 24 hours following patient first request for analgesic for Groups 1 and 2 were: 3.1 +/- 1 mg versus 7.2 +/- 3 mg (p = 0.04), 13.4 +/- 2 mg versus 17.2 +/- 4 mg (p = 0.03) and 35.9 +/- 8 mg versus 47.7 +/- 8 mg in Group 2 (p = 0.04). VAS scores at 4, 6, 12, and 24 hours postoperatively were not significantly different between the two groups. CONCLUSIONS: Preoperative neural blockade may reduce postoperative analgesic requirements.     

Tramadol 2.5 mg·kg−1 appears to be the optimal intraoperative loading dose before patient-controlled analgesia

PURPOSE: We previously established that a 5 mg x kg(-1) intraoperative dose can reduce the nausea/vomiting associated with tramadol patient-controlled analgesia (PCA). This study was conducted to identify the most appropriate initial dose to improve the quality of tramadol PCA. METHODS: During general anesthesia, 60 patients undergoing knee arthroplasty were randomly allocated to receive 1.25 mg x kg(-1) (Group I), 2.5 mg x kg(-1) (Group II), 3.75 mg x kg(-1) (Group III), or 5 mg x kg(-1) (Group IV) tramadol. The emergence condition was recorded. The titration of additional tramadol 20 mg + metoclopramide 1 mg doses by PCA every five minutes was performed in the postanesthesia care unit (PACU) until the visual analogue scale (VAS) score was < or = 3. An investigator blinded to study group recorded the VAS and side effects every ten minutes. RESULTS: In the PACU, significantly more tramadol (8.4 +/- 3.1 vs 4.3 +/- 2.1, 2.5 +/- 1.8, and 0.4 +/- 0.3, P < 0.05), and a higher incidence (15/15 vs 5/15, 3/15, and 2/15, P < 0.05) of PCA use was observed in Group I compared to Groups II-IV. VAS was significantly higher in Group I than in Groups II-IV at zero and ten minutes (P < 0.05). Unexpected delayed emergence anesthesia (> 30 min) was observed in Group III (n = 1) and in Group IV (n = 2). Sedation was more important in Groups III and IV than in Groups I and II (P < 0.05). CONCLUSION: When considering efficacy and side-effect profile, 2.5 mg x kg(-1) of tramadol is the optimal intraoperative dose of this drug to provide effective postoperative analgesia with minimal sedation.     

Brachial plexus anesthesia with verapamil and/or morphine

Calcium channel blockers potentiate the analgesic properties of both local anesthetics and opioids. We examined the analgesic effects of administering morphine, verapamil, or its combination into the brachial plexus sheath with lidocaine in 75 patients undergoing upper extremity orthopedic surgery. All patients received brachial plexus anesthesia with 40 mL of 1.5% lidocaine and epinephrine 5 microg/mL. In addition, patients were randomized to 1 of 5 groups: Group 1 received IV saline; Group 2 received IV verapamil 2.5 mg and morphine 5 mg; Group 3 received IV verapamil 2.5 mg and morphine 5 mg was added to the lidocaine solution; Group 4 received IV morphine 5 mg and verapamil 2.5 mg was added to the lidocaine solution; and Group 5 received verapamil 2.5 mg and morphine 5 mg were added to the lidocaine solution. Postoperatively, patients rated their pain (0-10) at 1, 6, 12, and 24 h. Patients were instructed to take 1 acetaminophen 325 mg/oxycodone 5 mg tablet every 3 h whenever the pain score exceeded 3. Analgesic duration was significantly increased in those patients receiving brachial plexus blocks with morphine (Groups 3 and 5) (P < 0.005). The total 24 h acetaminophen/oxycodone use was also less in Groups 3 and 5 (P < 0. 03). Duration of anesthesia (time of abolition of pinprick response) was significantly increased in those patients receiving brachial plexus blocks with verapamil (Groups 4 and 5) (P = 0.002). We conclude that the addition of verapamil to brachial plexus block with lidocaine can prolong the duration of sensory anesthesia, but it had no effect on analgesic duration of 24 h analgesic use. Implications: The addition of verapamil to brachial plexus block with lidocaine and morphine prolongs the duration of sensory anesthesia, but has no effect on analgesic duration or 24 h analgesic use.     

Postoperative pain following knee arthroscopy: the effects of intra-articular ketorolac and/or morphine.

BACKGROUND AND OBJECTIVES: Morphine and nonsteroidal antiinflammatory drugs (NSAID) have been found to be effective in relieving postoperative pain. The goal of this study was to determine whether ketorolac alone or in combination with morphine provides superior pain relief following arthroscopy performed with local anesthesia (LA). METHODS: This was a randomized, double-blind, prospective, study in 100 healthy patients from 15 to 60 years of age. Knee arthroscopy was performed with LA using 40 mL prilocaine (5 mg/mL) with adrenaline (4 microg/mL). At the end of the operation, a catheter was inserted intra-articularly, and one of the following solutions diluted to a total volume of 40 mL was injected: group P (40 mL normal saline), group M (3 mg morphine), group K30 (30 mg ketorolac), group K60 (60 mg ketorolac), and group KM (3 mg morphine + 30 mg ketorolac). Visual analog scale (VAS) pain scores (0-100 mm) were measured preoperative and at 30, 60, 90, 120 minutes postoperative and thereafter 4, 8, 24, and 48 hours at rest and on movement of the knee. The total number of distalgesic tablets (325 mg paracetamol + 32.5 mg dextropropoxyphene) consumed during the 48 hours postoperative was recorded. RESULTS: Significant differences in VAS pain scores were seen between group P and group KM at 4, 8, and 24 hours (P < .05) and between group M and group KM at 4, 8, 24, and 48 hours (P < .01) after the operation at rest. During mobilization of the knee, a significant difference in VAS pain score was found between group P and group KM at 8, 24, and 48 hours (P < .05) and between group P and group K60 at 24 and 48 hours (P < .05). The total consumption of distalgesic tablets did not differ among the groups. CONCLUSIONS: The combination of 3 mg morphine plus 30 mg ketorolac provided significantly better analgesia than either placebo alone or morphine alone. This result could be a synergistic effect.     

Analgesic and antiemetic effect of ketorolac vs. betamethasone or dexamethasone after ambulatory surgery

BACKGROUND: Glucocorticoids are known to provide slower onset and more prolonged duration of analgesic effect than ketorolac. In the present study, we wanted to evaluate the effect over time from a single dose of either intravenous (i.v.) dexamethasone or an intramuscular (i.m.) depot formulation of betamethasone compared with i.v. ketorolac. MATERIALS AND METHODS: One hundred and seventy-nine patients admitted for mixed ambulatory surgery were included in the study. After induction of general i.v. anaesthesia, the patients were randomized to receive double-blindly either dexamethasone 4 mg i.v. (Group D) or betamethasone depot formulation 12 mg i.m. (Group B) or ketorolac 30 mg i.v. (Group K). Fentanyl was used for rescue analgesic medication in the post-operative care unit (PACU) and codeine with paracetamol after discharge, for a study period of 3 days. RESULTS: There was significantly less post-operative pain in the ketorolac group during the stay in the unit (88% with minor or less pain in Group K vs. 74% and 67% in Groups D and B, respectively, P < 0.05), significantly less need for rescue medication (P < 0.05) and significantly less nausea or vomiting (12% in Group K vs. 30% in the other groups pooled, P < 0.05). The ketorolac patients were significantly faster for ready discharge, median 165 min vs. 192 min and 203 min in Groups D and B, respectively (P < 0.01). There were no differences between the groups in perceived pain, nausea, vomiting or rescue analgesic consumption in the 4- to 72-h period. CONCLUSION: Dexamethasone 4 mg or bethamethasone 12 mg did not provide prolonged post-operative analgesic effect compared with ketorolac 30 mg, which was superior for analgesia and antiemesis in the PACU.     

Postoperative analgesia with morphine with or without diclofenac after shoulder surgery

Balanced analgesia using a narcotic and a nonsteroidal anti-inflammatory drug has been successfully tested for postoperative analgesia. This study was designed to examine the efficacy of such combination therapy after shoulder surgeries. Twenty ASA physical status I or II patients, scheduled for shoulder surgeries under general anesthesia, were randomly assigned to either morphine (M) group (n = 10), who received IV morphine patient-controlled analgesia (PCA) alone (2 mg as a bolus, lock-out interval of 10-minutes, and 10 mg as 1-hour limit for 48 hours), or morphine + diclofenac (M + D) group (n = 10), who received, in addition to morphine PCA, diclofenac suppositories 50 mg.8 h-1 starting immediately before surgical incision for 48 hours. Postoperative analgesic profiles, such as visual analog scale (VAS) at rest and on movement, and cumulative morphine consumption, the incidence and extent of side effects (nausea, vomiting, and time till the first bowel movement), and other complications were recorded. The two groups were similar demographically. Patients in the M + D group required 15.1 +/- 9.0 mg of morphine within 48 hours after surgery, while those in the M group required 30.5 +/- 21.0 mg of morphine (P < 0.05). No significant differences in VAS at rest and on movement were observed between the two groups. The time till the first bowel movement was significantly shorter in the M + D group. Our data suggest that diclofenac suppositories 50 mg.8 h-1 starting immediately before surgery for 48 h are effective adjuvant in reducing post-shoulder surgery morphine requirement and retardation of bowel movement.     

Wound instillation with 0.25% bupivacaine as continuous infusion following hysterectomy

Postoperative pain relief was assessed by the effects of local anesthetic wound instillation on 100 patients who had undergone total abdominal hysterectomy with bilateral salpingo oophorectomy (TAH with BSO). Patients were divided into four groups of wound and non-wound instillation: Wound instillation Group A1 received diclofenac IM. Group A2 received diclofenac suppository. Non-wound instillation Group B1 received diclofenac IM. Group B2 received diclofenac suppository. A standard general anesthesia technique was administered. For would instillation, a multiholed (1 cm apart) 18G epidural catheter was placed above rectus sheath. This was connected to a pediatric regulated drip set with "Dial-a flo" to deliver 0.25% bupivacaine 10 ml/hour for 6 hours after a basal bolus of 10 ml. During first 6 hours after surgery rescue pentazocine 15 mg was administered to achieve VAS score < or = 30. Thereafter, rescue diclofenac was administered to patients. The requirement of rescue analgesic (pentazocine) was significantly less (P < 0.001) in wound instillation Groups A1 (13.80 mg +/- 13.64) and A2 (12.00 mg +/- 12.25) in comparison to non wound instillation Groups B1 (35.60 mg +/- 14.02) and B2 (31.80 mg +/- 15.80). Rescue diclofenac was not required in wound instillation groups as compared to 30 mg (B1) and 36 mg (B2) in non wound instillation groups. Nausea and vomiting was less in wound instillation groups. VAS score supine from 4th to 12th hours, VAS coughing during all time interval and VAS leg raising from 3rd to 12th hours was significantly lower (P < 0.001) in wound instillation group (A1, A2) in comparison to non wound instillation groups (B1, B2). We conclude that basal bolus infusion followed by continuous wound instillation of bupivacaine decreases analgesic requirement and pain scores in first 24 hours of postoperative period after TAH with BSO.     

肩关节手术后关节内应用酮洛酸、吗啡、罗哌卡因联合患者自控关节内镇痛对疼痛缓解影响的随机双盲研究

背景本研究评估关节内镇痛对手术后疼痛和镇痛药物需要量的影响。方法51例接受肩关节手术（Bankart）的患者纳入本随机双盲研究。手术结束后在关节内置入导管,随机分为3组分别注射下述药物：组1,罗哌卡因90mg（9ml）、吗啡4mg（10ml）、酮洛酸30mg（1ml）（总量20ml）;组2和组3,生理盐水（20ml）。此外,组1和组3的患者静脉注射1ml生理盐水;组2则静脉注射酮洛酸30mg（1ml）。手术后,组1通过关节内导管应用10ml 0．5％的罗哌卡因按需行手术后镇痛,而组2和组3应用生理盐水。组3是对照组。结果在最初的30和120分钟内,组1患者较组2和组3患者手术后静息和运动状态的疼痛减轻。组1患者较组2和组3手术后首次需要应用局麻药的时间延长（P〈0．001）。手术后最初24小时内,组1和组2患者的平均吗啡用量小于组3（P〈0．001）。组1和组2患者镇痛药物用量差异无显著性。与组2（P〈0．05）和组3（P〈0．001）相比,组1患者的平均满意度较高。结论与对照组相比,关节内联合应用罗哌卡因、吗啡、酮洛酸,随后按需间断应用罗哌卡因可以达到更好的疼痛缓解效果,较少的吗啡用量以及更高的患者满意度。与对照组患者相比,静脉注射酮洛酸组患者吗啡用量减少,并且治疗满意度也较高。     

Comparison of postoperative analgesic effects of preemptively used epidural ketamine and neostigmine

STUDY OBJECTIVE: To compare the analgesic and side effects of preemptively used epidural ketamine +bupivacaine, neostigmine +bupivacaine, and bupivacaine alone on postoperative analgesia after major abdominal surgery. DESIGN: Randomized, controlled study. SETTING: Inpatient anesthesia at the department of surgery of a metropolitan hospital. PATIENTS: 30 ASA physical status I, II, and III patients scheduled for abdominal surgery. INTERVENTIONS: Group K received 1 mL (50 mg) ketamine and 5 mL (25 mg) bupivacaine epidurally, Group N received 1 mL (0.5 mg) neostigmine and 5 mL (25 mg) bupivacaine epidurally, and Group B received 1 mL saline and 5 mL (25 mg) bupivacaine epidurally 30 minutes before operation. All patients underwent anesthesia induction with thiopental and vecuronium; anesthesia was maintained with isoflorane and vecuronium. For postoperative analgesia, all patients received epidural morphine for 48 hours postoperatively. MEASUREMENTS AND MAIN RESULTS: Standard monitoring included: 48 hours of analgesic requirement, visual analog scale (VAS), mean arterial pressure (MAP), and heart rate (HR) in the 1st, 2nd, 6th, 12th, 24th, and 48th hours. Data were analyzed using Kruskall-Wallis and Mann Whitney U tests, with a p < 0.05 considered statistically significant. No significant differences were observed regarding MAP and HR among the groups during the study period. In Group N, VAS was significantly lower than Group K and Group B. The total opioid consumption in Group N was significantly lower than in Groups K and B in the first 48 hours after the operation. CONCLUSIONS: Preemptive neostigmine can be a good choice for postoperative analgesia.     

A background infusion of morphine does not enhance postoperative analgesia after cardiac surgery

PURPOSE: To compare the effects of patient-controlled analgesia (PCA), with or without a background infusion of morphine on postoperative pain relief and stress response after cardiac anesthesia. METHODS: With University Ethics approval, 35 consenting adults undergoing elective open-heart surgery were randomly assigned preoperatively in a double-blind fashion to receive either morphine PCA alone (Group I, n = 15) or morphine PCA plus a continuous basal infusion (Group II, n = 14) for 44 hr postoperatively. Pain scores with visual analogue scale (VAS) at rest, deep inspiration and with cough, sedation scores, stress hormone levels [cortisol, adrenocorticotropin (ACTH) and growth hormone (GH)] and morphine consumption were assessed, and serum morphine levels were measured at four, 20, 28 and 44 hr after surgery. Adverse effects including nausea, vomiting, constipation, urinary retention and pruritus were noted. Total blood, fluid requirements, drainage and urinary output were recorded. RESULTS: Postoperative morphine consumption at 44 hr was less in Group I (29.43 +/- 12.57 mg) than in Group II (50.14 +/- 16.44 mg), P = 0.0006. There was no significant difference between groups in VAS scores, GH levels, blood levels of morphine and adverse effects. While VAS scores, ACTH and GH levels decreased significantly in both groups, plasma cortisol levels increased significantly in Group I only at four hours. In Group II, ACTH and cortisol were higher at four and 44 hr respectively. CONCLUSION: PCA with morphine effectively controlled postoperative pain after cardiac surgery. The addition of a background infusion of morphine did not enhance analgesia and increased morphine consumption.     

Intraoperative infusion of dexmedetomidine reduces perioperative analgesic requirements

PURPOSE: This prospective, randomized, double-blind study was designed to assess whether intraoperative infusion of dexmedetomidine provides effective postoperative analgesia. Postoperative pain scores and morphine consumption were compared in a treated group and a placebo group, both of which received patient-controlled morphine after total abdominal hysterectomy. METHODS: Fifty women were randomly assigned to two groups. Group D (n = 25) received a loading dose of dexmedetomidine 1 mug.kg(-1) iv during induction of anesthesia, followed by a continuous infusion at a rate of 0.5 mug.kg(-1).hr(-1) throughout the operation. Group P (n = 25) received a volume-matched bolus and infusion of placebo (0.9% saline). For each case, heart rate, peripheral oxygen saturation, and systolic and diastolic blood pressure were recorded intraoperatively and for 48 hr postoperatively. Patients used a patient-controlled analgesia device to receive bolus doses of morphine after surgery. Total morphine consumption, pain scores, and sedation scores were recorded for the first 48 hr (two hours in the postanesthesia care unit and 46 hr on the ward). RESULTS: The groups were similar with respect to mean times to extubation of the trachea. Pain and sedation scores were also similar between groups at all corresponding times throughout the 48-hr period of observation. Group D patients consumed significantly less morphine in the postanesthesia care unit and on the ward (P < 0.05 and P < 0.01, respectively). Fewer patients in Group D experienced itching or nausea/vomiting (P < 0.05). CONCLUSION: Continuous iv dexmedetomidine during abdominal surgery provides effective postoperative analgesia, and reduces postoperative morphine requirements without increasing the incidence of side effects.     

Dextromethorphan premedication reduced postoperative analgesic consumption in patients after oral surgery.

OBJECTIVE: N-methyl-D-aspartate (NMDA) receptor antagonist premedication reduces postoperative pain. In this study, we examined if NMDA antagonist premedication might reduce postoperative pain after oral surgery, testing dextromethorphen. STUDY DESIGN: One hundred eleven patients undergoing mandibular third molar extraction under local anesthesia were included. Patients were randomly allocated into 3 groups. Group A (n = 37), B (n = 38), and C (n = 36) patients were emphasis-placed on dextromethorphan 30 mg, diclofenac 25 mg, or placebo orally before surgery, respectively. Postoperatively, patients were allowed to use oral diclofenac, 25 mg, for postoperative pain relief. Postoperative pain was evaluated the 1st, 7th, and 14th day after surgery, respectively, by using a visual analog scale (VAS) and the number of diclofenac consumed. VAS score and the number of diclofenac consumption were compared among the groups. RESULTS: VAS score was similar among the 3 groups during the study period. Total postoperative diclofenac consumption was significantly less in group A than in group C (P < 0.05). CONCLUSION: Dextromethorphan premedication reduced postoperative analgesic consumption after oral surgery.     

Analgesic transition after remifentanil-based anesthesia in neurosurgery. A comparison of sufentanil and tramadol

AIM: Transition from the end of remifentanil infusion and postoperative analgesia must be planned carefully owing to remifentanil's (R) rapid offset. Intraoperative morphine has been used for the transition to postoperative analgesia following remifentanil-based anesthesia. Sufentanil (S) is a very potent opioid with high micro-receptor affinity, a much wider therapeutic index and a lower fractional receptor occupancy. These pharmacological and dynamics features make sufentanil an interesting alternative to morphine for immediate postoperative analgesia. METHODS: Experimental design: perspective, randomized, single blinded and comparative study. Institution: neurosurgical operating theatre at University. Patients: 96 patients, aging from 25 to 67 years, ASA class I-III, undergoing neurosurgical operations, were studied. Interventions and Measurements: the anesthetic management was: premedication: atropine 0.01 microg kg(-1) + remifentanil 0.20 microg kg(-1) min(-1); induction: propofol 2.0 microg kg(-1) + cisatracurium 0.15 microg kg(-1); maintenance: sevoflurane 0.8% + remifentanil (titrated infusion) cisatracurium. All patients received ketorolac 30 mg i.v. 1 hour before the end of surgery and ketorolac (60-90 mg) + tramadol (200-300 mg) by elastomeric pump; patients were divided into 2 groups: group T receiving tramadol 100 mg and group S receiving a bolus dose of sufentanil 0.10 microg kg(-1), 30 and 15 minutes before the end of surgery respectively. Recovery time, postoperative analgesia evaluated by VAS, cardiocirculatory parameters and side effects like nausea, vomiting, shivering, muscle rigidity, sedation and respiratory depression were recorded. RESULTS: VAS was significantly lower in Group S. Recovery time was shorter in Group T than in Group S (8.8 +/- 3.6 vs 11.6 +/- 4.6 min), no statistically significant differences between groups as regards nausea, vomiting and shivering. Short-lasting respiratory depression was detected in 3 cases in Group S. CONCLUSION: At the emergence much better control of the transition phase in patients treated with sufentanil: smooth recovery with better tolerability of the endotracheal tube; efficacious analgesia along with cardiocirculatory stability.     

Femoral nerve block for total knee arthroplasty patients: a method to control postoperative pain

This study was designed to determine the effects of a single-injection femoral nerve block (FNB) using 30 mL of 0.5% bupivacaine with epinephrine 1:200,000, on pain control following total knee arthroplasty (TKA). Forty patients were randomly distributed into 2 groups: Group A received general anesthesia plus a FNB (n = 19), whereas Group B received general anesthesia plus a FNB with 30 mL of preservative-free saline (n = 21). The amount of morphine used, sedation, and average pain perception were measured for the first 24 hours and daily postoperatively. Group A used significantly less morphine (48.1 mg) compared with Group B, which used 76.2 mg during the first 24 hours after surgery (P = 0.003). Group A's sedation scale was significantly less than group B's (2.26 vs 2.67) (P = 0.045). The average pain perception was significantly different (P =.002). Postoperative management of pain following TKA can be improved through a preoperative single-injection FNB with 0.5% bupivacaine plus epinephrine 1:200,000. The cost is minimal, risks appear acceptable, and the procedure is efficacious.