The effect of rectal diclofenac on pruritus in patients receiving intrathecal morphine

In this prospective randomised study, pruritus and pain were evaluated in patients undergoing abdominal surgery in which intrathecal morphine was administered. Each patient received intrathecal morphine 0.3 mg prior to induction, followed by a standard anaesthetic. The patients were randomly allocated to one of two groups. One group received 100 mg of rectal diclofenac immediately post-induction. Patients receiving diclofenac had significantly lower pruritus scores at 30 min (p = 0.0076), 2, 4, 8 and 24 h postoperatively, as well as significantly reduced pain scores at each time point (p < 0.0001 at each study interval). Morphine consumption in the first 24 h was also significantly lower in this group. In conclusion, rectal administration of diclofenac significantly reduces the incidence and severity of postoperative pruritus. It also significantly reduces pain and further analgesic requirements postoperatively.     

Tenoxicam 20 mg or 40 mg after thoracotomy: a prospective,randomized, double-blind,placebo-controlled study

Forty-five adults undergoing thoracotomy were randomized to receive placebo, tenoxicam 20 mg or tenoxicam 40 mg IV during chest wall closure. All patients received intraoperative fentanyl and intercostal blocks followed by morphine by patient-controlled analgesia. Patient numbers 13 to 45 also received thoracic epidural analgesia by continuous infusion of bupivacaine 0.125%, patient numbers 25 to 45 having fentanyl 2 microg/ml added to the epidural infusion. Efficacy parameters and adverse reactions were assessed over the first 24 hours postoperatively. On a 100 mm visual analogue scale, mean (SD) pain at rest (adjusted area under curve for hours 1 to 24) was 25.8 (12.5), 17.4 (14.8) and 16.5 (13.3) mm for groups receiving placebo, 20 mg and 40 mg tenoxicam, respectively (ANOVA: P<0.05). There were no significant differences between study groups postoperatively in pain on coughing, opioid consumption, blood gas measurements, nausea, vomiting, sedation, blood loss, haemoglobin or serum creatinine. One patient in each tenoxicam group reported epigastric pain, rated moderate. These data support the inclusion of tenoxicam 20 mg IV in the management of pain at rest for patients undergoing thoracotomy, but do not show additional benefit for a higher dose.     

Pre-emptive efficacy of epidural fentanyl in elective abdominal surgery

BACKGROUND AND AIM: This study determines whether epidural fentanyl given before incision decreases the requirements for opioid analgesia postoperatively, compared with the same dose of epidural fentanyl given after the surgery. METHODS: Forty patients scheduled to undergo elective abdominal surgery were randomly allocated between two groups according to the time of administered of fentanyl. None of the patients in either group received premedication. Prior to induction of general anaesthesia an epidural catheter was inserted at the L2-3 interspace and flushed with 0.9% NaCl. Patients then received 100 micrograms fentanyl in 10 mL 0.9% NaCl through this catheter either 15 min before awaking at the end of the operation (group I), or else the same dose given at an estimated time of 15 min before the start of surgery (group II). Postoperative analgesia consisted of patient-controlled intravenous fentanyl. The amount of fentanyl used by the patients was noted at 2, 4, 8, 12 and 24 h after surgery. Pain scores and sedation scores were assessed at 0, 2, 4, 8, 12 and 24 h postoperatively. RESULTS: The consumption of fentanyl was similar in both groups in all studied periods postoperatively. The mean pain score was lower for patients in group I than group II immediately after operation. There were no statistically significant differences between the mean pain scores of groups at 2, 4, 8, 12 and 24 h after operation. Mean sedation scores were similar in both groups at all times postoperatively. CONCLUSION: This study showed that the dose of fentanyl administered epidurally prior to surgical incision did not produce any clinically useful pre-emptive analgesic effect.     

Does epidural fentanyl decrease the efficacy of epidural morphine after cesarean delivery?

Earlier studies have suggested that epidural fentanyl improves intraoperative analgesia during cesarean section, but others have suggested that it worsens postoperative analgesia from epidural morphine. The purpose of this study was to determine whether epidural fentanyl given before epidural morphine improves the quality of intraoperative epidural anesthesia without worsening postoperative analgesia provided by epidural morphine. Sixty patients having epidural anesthesia for cesarean delivery were studied. Epidural anesthesia was established using 2% lidocaine with epinephrine 5 micrograms/mL. After delivery, either fentanyl 100 micrograms/10 mL or normal saline-control 10 mL was injected through the epidural catheter in a randomized, double-blind manner. All patients received 3.5 mg of morphine epidurally after uterine repair. After administration of the epidural study drug, there were no significant differences in the pain responses during surgery between the two groups. Patients in the fentanyl group experienced significantly less nausea and vomiting between delivery and the end of surgery than did patients in the normal saline-control group (P = 0.013). Postoperatively, visual analogue scale scores for pain, pruritus, nausea, and sedation were similar at 1, 2, 4, and 8 h in the two groups. We conclude that fentanyl 100 micrograms administered epidurally during cesarean delivery did not improve intraoperative analgesia, but significantly reduced intraoperative nausea and vomiting without diminishing the efficacy of postoperative analgesia provided by epidural morphine.     

The impact of intraoperative propofol administration in the prevention of postoperative pruritus induced by epidural morphine

BACKGROUND AND OBJECTIVE: We examined the efficacy of intraoperative propofol administration to prevent pruritus induced by epidural morphine. METHODS: Seventy patients ASA I-II undergoing combined epidural and general anaesthesia for hysterectomy were randomly assigned to two groups, Group P where anaesthesia was induced with propofol and fentanyl and maintained with propofol-nitrous oxide and Group S in which anaesthesia was induced with thiopental and fentanyl and maintained with sevoflurane-nitrous oxide. All patients received a ropivacaine epidural bolus with 3 mg morphine 1 h before the end of surgery. The incidence and severity of pruritus were evaluated every 4 h for the first 12 h postoperatively by blinded observers. RESULTS: The total incidence of pruritus was significantly higher (P = 0.024) in Group S (65.6%) compared to Group P (29%) between 4 and 8 h postoperatively. There were also significantly more patients (P = 0.03) reporting severe pruritus in Group S (22%) compared to Group P (0). CONCLUSION: Propofol-based general anaesthesia compared to thiopental-sevoflurane-based anaesthesia reduces the incidence and severity of pruritus induced by a single injection of 3 mg epidural morphine with ropivacaine.     

Ropivacaine 1 mg x ml(-1) does not decrease the need for epidural fentanyl after hip replacement surgery

BACKGROUND: Ropivacaine is a new long-acting local anesthetic. Laboratory trials have demonstrated a synergistic analgesic effect between intrathecal opioids and local anesthetics. We tested the hypothesis that addition of ropivacaine 1 mg x ml(-1) to epidural fentanyl (10 microg x ml(-1)) postoperatively decreases the need for fentanyl, improves the quality of analgesia and decreases the side-effects of fentanyl. METHODS: Forty patients were enrolled in this double-blind, randomized study to receive either fentanyl 10 microg x ml(-1) (group F) alone or fentanyl combined with ropivacaine 1 mg x ml(-1) (group R) for 20 h as an epidural infusion at TH12-L1 or L1-L2 for analgesia after hip replacement surgery. The patients were free to use a patient-controlled epidural analgesia device, which was programmed to infuse 3 ml of the study medication hourly and to allow a 3-ml bolus when needed (maximal hourly dose of fentanyl was 150 microg). The consumption of medication, visual pain scores at rest and on movement, hemodynamic and respiratory parameters, motor and sensory block, nausea, pruritus and sedation were recorded. RESULTS: There were no significant differences between the groups in the total mean fentanyl consumption (1.10+/-0.18 mg in group F, 1.08+/-0.31 mg in group R, 95% CI: -0.14 to 0.19, P = 0.774). The pain scores were similar at rest (median scores < or = 1) and on movement (median scores < or = 3). The adverse effects were similar and of a minor nature, consisting mostly of pruritus and nausea. CONCLUSION: Addition of ropivacaine 1 mg x ml(-1) to epidural fentanyl 10 microg x ml(-1) did not significantly decrease the requirement for fentanyl administered for pain relief after hip replacement surgery.     

Does adrenaline improve epidural bupivacaine and fentanyl analgesia after abdominal surgery?

The alpha-adrenergic agonists have been demonstrated to have synergistic effects with opioids and local anesthetics in animal research. The present study was performed to determine whether the addition of adrenaline improves the analgesic effects of an epidural infusion of a combination of fentanyl and bupivacaine after abdominal surgery. We studied 90 ASA 1 or 2 patients scheduled for abdominal surgery under epidural anaesthesia, with or without general anaesthesia. Patients were randomly divided into two groups to receive a postoperative epidural infusion of fentanyl 5 micrograms/ml in bupivacaine 0.2%, with or without adrenaline 5 micrograms/ml, at a rate of 2 ml/h for more than 48 hours. Postoperative pain relief was assessed using visual analog scales (VAS), both at rest and during coughing, at 2, 24, and 48 hours after surgery. The number of rescue analgesics and side-effects such as nausea, vomiting, pruritus, respiratory depression, headache, muscle weakness, and hypotension were recorded. Patients who received adrenaline (n = 40) reported significantly lower mean VAS scores than those who received no adrenaline (n = 37), both at rest at 24 hours postoperatively and during coughing at 24 and 48 hours. The number of additional analgesics and incidence of side-effects did not differ between groups. In conclusion, the results of the present study demonstrate that the addition of adrenaline to a combination of fentanyl and bupivacaine improves the quality of epidural analgesia after abdominal surgery. Under the conditions of the study, we did not detect any disadvantage from the addition of adrenaline.     

Tenoxicam i.v. in major gynaecological surgery--pharmacokinetic, pain relief and haematological effects

This study compared postoperative analgesic dispensation and measures relating to haemostasis following intravenous administration, in a randomized double-blinded manner, of either placebo or tenoxicam 20 mg to 30 women presenting for major gynaecological oncology surgery under a standardized, combined epidural/general anaesthetic technique. Pharmacokinetic disposition of tenoxicam in this patient cohort was also described. There was no objective or subjective alteration in haemostatic function or increase in blood loss, nor any deviation from the normal range of values. Postoperative analgesia during the first 48 hours was delivered to achieve a VAS endpoint of less than five on leg-raising, by a combination of a nurse-controlled low-dose background epidural infusion and patient-administered epidural bolus. Greater VAS variability was observed during the first four postoperative hours (P = 0.08). The tenoxicam group self-administered significantly fewer epidural bolus doses to maintain satisfactory analgesia compared with the placebo group during the first 24 hours (P = 0.004) and 48 hours (P = 0.01) postoperatively. Similar differences between the groups in the total dose of the epidural bupivacaine/fentanyl mixture delivered were described (4 h: P = 0.148; 24 h: P = 0.033; 48 h: P = 0.001) (Figure 2). Despite surgery, transfusion and the use of a renal protective fluid administration strategy, tenoxicam disposition was not greatly different from that widely described for healthy volunteers. There were no significant side-effects and no adverse events attributable to tenoxicam. In this small study we have shown that tenoxicam administered preoperatively reduced the epidural analgesic requirements during the first 48 hours following major gynaecological surgery. There was no clinical or pathological evidence of haematological impairment following a single i.v. administration of tenoxicam 20 mg.     

Should epidural diamorphine be withheld after caesarean section from women who suffer severe pruritus following intrathecal fentanyl?

Pruritus following neuraxial opioids in 37 women undergoing caesarean section under combined epidural-spinal anaesthesia was investigated. All women received intrathecal fentanyl for intra-operative analgesia followed by epidural diamorphine for postoperative analgesia, when pain returned. Pruritus was assessed using a verbal rating scale at the end of surgery and again 24-36 h postoperatively. There was no relationship between pruritus experienced after intrathecal fentanyl and that experienced after epidural diamorphine. We conclude that there is no reason to withhold epidural diamorphine from women who have previously experienced severe itching after intrathecal fentanyl.     

Comparison of epidural fentanyl with sufentanil

Duration of analgesia and side effects following single bolus doses of epidural fentanyl (100 micrograms) or sufentanil (10, 20, 30 or 50 micrograms) were studied in 50 patients who underwent Caesarean section under epidural anaesthesia. Fewer patients experienced pain peroperatively in the fentanyl group than in a joint group of those given sufentanil 20 or 30 micrograms (p less than 0.05). The combined fentanyl and sufentanil 50 micrograms groups had fewer patients in pain than the sufentanil 10 micrograms group at 3 hours after injection (p less than 0.05). Patients given fentanyl also had a longer pain-free interval than those who received sufentanil 10 micrograms (p less than 0.02). The sufentanil 50 micrograms group had more patients asleep than the 10 micrograms group and also had more patients with pruritus than the 10 micrograms or 30 micrograms groups (p less than 0.02). The patients given sufentanil 30 and 50 micrograms had more emetic sequelae than those who received sufentanil 10 and 20 micrograms or fentanyl 100 micrograms (p less than 0.05). There was no detectable excretion of drug into breast milk and no significant respiratory depression at the time of first postoperative analgesia in the patients who received fentanyl or 30 micrograms or less of sufentanil.     

Combining epidural fentanyl and lidocaine for postoperative pain.

Fifteen patients undergoing total hip and total knee replacement were studied prospectively to evaluate postoperative pain relief provided by an epidural infusion of fentanyl citrate, with and without lidocaine hydrochloride, and changes in arterial flow to the lower extremities. The patients were randomly placed in three groups: group 1 received epidural fentanyl, 5 micrograms/mL; group 2 received epidural fentanyl, 5 micrograms/mL with 0.75% solution of lidocaine; and group 3 received epidural fentanyl, 5 micrograms/mL with 1.0% solution of lidocaine. All patients received 1.5% solution of epidural etidocaine hydrochloride with epinephrine 1:200,000 for intraoperative anesthesia. No clinical evidence of deep vein thrombosis, tachyphylactic reaction to lidocaine, orthostatic hypotension, or motor block was demonstrated in any patient. The addition of lidocaine to the epidural fentanyl infusion did not improve pain relief or allow a decrease in the rate of infusion. Patients in all groups had improved arterial flow to the lower extremities 24 hours postoperatively.     

The clinical effectiveness of epidural bupivacaine, bupivacaine with lidocaine, and bupivacaine with fentanyl for labor analgesia

STUDY OBJECTIVE: To examine the efficacy of bupivacaine alone and in combination with lidocaine or fentanyl for epidural analgesia during labor. DESIGN: Randomized, single-blind study. SETTING: Labor and delivery unit at a university medical center. PATIENTS: Forty-five primiparas requesting epidural analgesia. INTERVENTIONS: Following epidural placement at L3-4 interspace, patients received either bupivacaine 0.5% (Group 1, n = 15), bupivacaine 0.25% with lidocaine 1% (Group 2, n = 15), or bupivacaine 0.5% with fentanyl 50 micrograms in 10 ml of saline (Group 3, n = 15). Patients in Groups 1 and 2 received 6 to 10 ml of local anesthetic depending on patient height, while patients in Group 3 received 5 ml of local anesthetic plus 50 micrograms of fentanyl in 10 ml of saline. All solutions contained epinephrine 1:200,000. MEASUREMENTS AND MAIN RESULTS: Patients were assessed at regular intervals following administration of the epidural solution. Visual analog scale (VAS) scores were used to measure onset of analgesia, time to complete pain relief, duration of analgesia, and patient satisfaction with therapy. The frequency of shivering and pruritus and the extent of sensory/motor block also were evaluated. There were no intragroup differences in time to complete pain relief or patient satisfaction. However, patients in Group 3 noted the most rapid onset and longest duration of pain relief. Patients in Group 3 also experienced significantly less shivering and had the lowest degree of motor block. Two patients in Group 3 experienced mild pruritus. CONCLUSIONS: Epidurally administered fentanyl safely extended the duration of labor analgesia while reducing bupivacaine dose requirements and magnitude of motor block. In this setting, the combination of bupivacaine and lidocaine offered no clinical advantage over bupivacaine alone.     

The analgesic efficacy of intravenous tenoxicam as an adjunct to patient-controlled analgesia in total abdominal hysterectomy

Nonsteroidal antiinflammatory drugs may reduce postoperative opioid consumption. We evaluated the analgesic efficacy of preoperatively administered tenoxicam in patients undergoing total abdominal hysterectomy. Patients were randomly assigned to receive IV either normal saline 4 mL (Group NS), tenoxicam 20 mg (Group T20), or tenoxicam 40 mg (Group T40) before the induction of anesthesia in a double-blinded fashion. Patient-controlled analgesia with fentanyl was used to assess postoperative opioid requirements. Pain was evaluated by visual analog scale at 2, 4, 6, 8, and 24 h postoperatively. Intraoperative bleeding as assessed by the surgeon, incidence of nausea, and gastrointestinal symptoms were recorded. No statistically significant difference was identified between groups in fentanyl consumption or pain scores. The incidence of nausea was similar in all groups. Two patients in Group T20 and two in Group T40 exhibited mild gastrointestinal symptoms. Intraoperative oozing was noted in two patients in Group T40. We conclude that patients undergoing total abdominal hysterectomy and receiving fentanyl via patient-controlled analgesia postoperatively do not benefit from tenoxicam pretreatment. On the contrary, the drug may be associated with an increased incidence of side effects. IMPLICATIONS: The preoperative administration of 20 or 40 mg IV tenoxicam does not reduce fentanyl consumption via Patient-Controlled Analgesia, compared with placebo, after total abdominal hysterectomy. Additionally, tenoxicam may increase intraoperative bleeding and gastrointestinal side effects.     

Epidural fentanyl in the management of postoperative pain

Epidural fentanyl (Sublimaze; Janssen) in the management of postoperative pain, with particular attention to efficacy and safety, was investigated. A treatment group (group 1) of 31 patients and a control group (group 2) of 30 patients were used. Group 1 received epidural fentanyl 100 micrograms postoperatively, while in the control group pain was treated with intramuscular pethidine 1.5 mg/kg 4-6-hourly as required during the 11 hours in the recovery room. Epidural fentanyl started working within 20 minutes and provided excellent analgesia for 8 hours or more postoperatively, comparable to repeated doses of intramuscular pethidine. Of the patients in group 1 13% experienced tolerable pruritus and the incidence of nausea and vomiting was small relative to that recorded in group 2.     

Transdermal clonidine: does it affect pain after abdominal hysterectomy?

Clonidine has analgesic properties. We evaluated the analgesic effect of clonidine perioperatively. Forty patients undergoing abdominal hysterectomy received randomly the evening before surgery transdermal clonidine covered with overlay (CLO group) or the overlay alone (CTL group). Ten min before induction they received i.v. clonidine 1 microgram.kg-1 (CLO) or normal saline (CTL). Induction was accomplished with fentanyl 5 micrograms.kg-1, thiopentone 5 mg.kg-1, cis-atracurium 0.15 mg.kg-1 and maintenance with sevoflurane 2% in 70% N2O. Hemodynamic parameters were recorded intraoperatively. Pain was assessed by VAS at rest and movement 2, 4, 6, 8, 24, 48, 72 h and 30 days, postoperatively. During the first 8 h postoperatively all patients received controlled analgesia with fentanyl followed by morphine i.m. 0.15 mg.kg-1 and paracetamol. From 24-72 h postoperatively, patients received 75 mg propoxyphene and 600 mg paracetamol i.m., on demand. Arterial blood pressure was lower in the CLO group 0, 3, 10 min after intubation. There was no difference in pain or fentanyl consumption 8 h postoperatively. The CLO group required less analgesics 24 h postoperatively (p = 0.023). The two groups did not differ in pain or analgesic requirements 72 h and 30 days postoperatively. Clonidine had a weak opioid sparing effect 24 h post-operatively, but did not affect pain in long term.     

Tramadol or fentanyl analgesia for ambulatory knee arthroscopy

In a double-blind, randomized, controlled study, 61 patients who received a standardized anaesthetic for day case arthroscopic knee surgery were studied. Group T (n = 31) received tramadol 1.5 mg kg-1, and group F (n = 30) received fentanyl 1.5 micrograms kg-1 at the induction of anaesthesia. All patients also received 20 mL of intra-articular bupivacaine 0.5% at the end of surgery. Assessments were made of pain at rest and on movement, analgesic requirements and side-effects at hourly intervals up to 6 h and by means of a postal questionnaire at 24 h and 48 h post-operatively. Group F had higher pain scores than group T at 4 h only [VAS 3.3 (1.6-5.5) vs. 2.4 (1-4), P = 0.039, respectively; median (interquartile range)]. There were no other significant differences between the groups in terms of pain scores, supplemental analgesic requirements or incidence of side-effects. We conclude that tramadol offers little benefit clinically compared with fentanyl when used at induction of anaesthesia for day case arthroscopic knee surgery. Further studies are indicated in patients with more severe pain to determine the role of tramadol in post-operative analgesia.     

A comparison of epidural ropivacaine infusion alone and in combination with 1, 2, and 4 microg/mL fentanyl for seventy-two hours of postoperative analgesia after major abdominal surgery

Our aim in this prospective, randomized, double-blinded study was to compare the analgesic effectiveness and side effects of epidural infusions with ropivacaine 2 mg/mL alone (Group R; n = 60) and in combination with fentanyl 1 microg/mL (R1F; n = 59), 2 microg/mL (R2F; n = 62), and 4 microg/mL (R4F; n = 63) for up to 72 h after major abdominal surgery. Effective epidural neural blockade was established before surgery; postoperatively, the infusion rate was titrated to a maximum of 14 mL/h for analgesia. No additional analgesics other than acetaminophen were permitted during the infusion. The median of individual visual analog scale score with coughing were <20 mm for all groups (0 = no pain, 100 = worst pain) and was significantly lower (P < 0.01) for Group R4F at rest and with coughing (compared with Group R). Infusions were discontinued due to inability to control pain in significantly fewer patients in Group R4F (16%) than the other groups (34% to 39%; P < 0.01). For all groups, >90% of patients had no detectable motor block after 24 h. Hypotension, nausea, and pruritus were more common with the larger dose of fentanyl. We conclude that, after major abdominal surgery, an epidural infusion of ropivacaine 2 mg/mL with fentanyl 4 microg/mL provided significantly more effective pain relief over a 3-day period than ropivacaine alone or ropivacaine with lower concentrations of fentanyl. Implications: Postoperative epidural analgesic infusions are widely used, but there is little information regarding optimal strengths of opioid with local anesthetic. In this blinded, prospective study, we compared four different epidural infusion solutions for efficacy and side effects over a clinically useful postoperative period and conclude that an epidural infusion of ropivacaine 2 mg/mL with fentanyl 4 microg/mL was most effective.     

Comparison of continuous epidural infusion of morphine/bupivacaine with fentanyl/ bupivacaine for postoperative pain relief

The efficacy and safety of postoperative analgesia with continuous epidural infusion of either morphine or fentanyl in combination with bupivacaine were evaluated in 85 patients, ASA physical status I or II, undergoing thoracic and/or upper abdominal surgery. Patients were treated with one of the combinations for 48 h after surgery. The morphine/bupivacaine group (MB; n = 45) received morphine at the rate of 0.2 mg h^-1, and bupivacaine at the rate of 10 mg h^-1 for the first 24 h or 5 mg h^-1 for the second 24 h; the fentanyl/bupivacaine group (FB; n = 40) received fentanyl at the rate of 20 μg–h^-1, and bupivacaine at the rate of 10 mg h^-1 for the first 24 h or 5 mg h^-1 for the second 24 h. The degree of pain relief assessed by the visual pain scale and the modified Prince Henry pain scale was satisfactory in most patients in both groups. In group MB 74% and in group FB 76% of patients did not need any supplementary analgesics. No significant differences were observed between the groups in assessment of pain. The incidence of hypotension ( P < 0.05) and pruritus ( P < 0.05) was higher in group MB than in group FB. None of the patients developed respiratory depression in either group.     

Intra-articular tenoxicam improves postoperative analgesia in knee arthroscopy

PURPOSE: Non Steroidal Anti-inflammatory drugs have a well documented benefit in the relief of postoperative pain. This study was designed to compare the analgesic effect of intra-articular tenoxicam 20 mg with intravenous tenoxicam on postoperative pain in 88 patients undergoing day case knee arthroscopy. METHODS: A prospective, double blind, randomized trial was performed. All patients received a standard general anesthetic. Patients in group A received 20 mg tenoxicam made up to 40 ml with normal saline intra-articularly (ia) and 2 ml normal saline i.v. Patients in group B received 40 ml normal saline intra-articularly and 2 ml, 20 mg of tenoxicam, i.v. RESULTS: Both groups of patients were similar with respect to age, weight, sex and tourniquet inflation time. Patients receiving ia tenoxicam had lower pain scores (at rest and upon movement) at 30, 60, 120 and 180 min postoperatively (0.8+/-0.2 vs. 2.5+/-0.2 at rest and 1.24+/-0.2 vs. 3.4+/-0.2 at movement at 60 min; P< 0.0001). Fewer patients required additional analgesia in the first four hours postoperatively (33% vs. 84%; P<0.00001) and the time to first analgesia (23.7+/-11.2 vs. 9.4+/-0.6; P<0.02) was longer in those receiving ia tenoxicam. CONCLUSION: Intra-articular tenoxicam provides superior postoperative analgesia and reduces postoperative analgesic requirements compared with i.v. tenoxicam in patients undergoing day case knee arthroscopy.     

Epidural magnesium reduces postoperative analgesic requirement

Background: Magnesium has antinociceptive effects in animal and human modelsof pain. Our hypothesis was that the addition of magnesium topostoperative epidural infusion of fentanyl may decrease theneed for fentanyl. Methods: Fifty patients undergoing hip surgery were enrolled to receiveeither fentanyl (Group F) or fentanyl plus magnesium sulphate(Group FM) for 24 h for epidural analgesia. All patients wereequipped with a patient-controlled epidural analgesia deviceand the initial settings of a demand bolus dose of fentanyl25 µg. In Group FM, patients received 50 mg magnesiumsulphate epidurally as an initial bolus dose followed by a continuousinfusion of 100 mg day^–1. Ventilatory frequency, heartrate, blood pressure, pain assessment using a visual analoguescale (VAS), sedation scores and fentanyl consumption were recordedin the postoperative period. Results: There was no significant difference between groups in the timeto first analgesic requirement. Compared with Group F, patientsin Group FM received smaller doses of epidural fentanyl (P <0.05). The cumulative fentanyl consumption in 24 h was 437 (SD110)µg in Group F and 328 (121) µg in Group FM (P <0.05). Patients in Group F showed a higher VAS score in thefirst hour of the postoperative period (P < 0.05). The groupswere similar with respect to haemodynamic and respiratory variables,sedation, pruritis, and nausea. Conclusion: Co-administration of magnesium for postoperative epidural analgesiaresults in a reduction in fentanyl consumption without any side-effects.