Age predicts effective epidural morphine dose after abdominal hysterectomy

To determine whether there is a relation between patient age and the effective dose of epidural morphine for relief of incisional pain after abdominal hysterectomy, experience treating 66 patients between the ages of 22 and 84 years was retrospectively examined. Linear regressions were plotted for age vs effective 24-hr morphine dose, age vs pain at rest, and age vs pain during coughing. To evaluate the frequency of side effects, the population was classified into three age groups (less than 40, 40-60, greater than 60 yr) and examined by Fisher's exact test for possible differences. Although there was wide interpatient variability, there was a correlation between patient age and effective 24-hr morphine dose (r = -0.40, P less than 0.01). The relation is described by the following equation: 24-hr morphine dose (mg) = 18-age(0.15). The quality of analgesia did not diminish with the smaller doses administered to the older patients. The frequency of side effects did not differ significantly in the three age groups. These observations may be related to higher CSF morphine concentrations or to a greater analgesic effect from morphine absorbed systemically from the epidural space in older patients.     

The influence of timing of systemic ketamine administration on postoperative morphine consumption

STUDY OBJECTIVE: To determine the influence of timing of systemic ketamine administration on postoperative morphine consumption. DESIGN: Prospective randomized study. SETTING: Operating rooms, postanesthesia care unit, and gynecology service of a university hospital. PATIENTS: Forty-five patients undergoing laparotomy for benign gynecologic pathologies were randomized into 3 groups. INTERVENTIONS: In Group 1, before surgical incision, patients received 0.5 mg/kg ketamine IV, followed by normal saline infusion and normal saline IV at wound closure in group 1 (n = 15). In group 2 (n = 15), patients received 0.5 mg/kg ketamine IV before surgery, followed by ketamine infusion 600 mug . kg(-1) . h(-1), until wound closure and normal saline IV at that time. In the other group (group 3, n = 15), patients received normal saline IV before surgery, followed by saline infusion and then 0.5 mg/kg ketamine IV at wound closure. In the postoperative period, patient-controlled analgesia IV morphine was used for postoperative pain relief. First requested analgesic medication time was recorded. Postoperative pain was assessed by measuring morphine consumption at 0 to 2, 0 to 4, and 0 to 24 hours and visual analog scale (VAS) pain scores in response to cough at 2nd, 4th, and 24th hours and during rest at 0 to 2, 0 to 4, and 0 to 24 hours after surgery. MEASUREMENT AND MAIN RESULTS: First requested analgesia was shorter in group 1 than the others (P < .01). Mean VAS pain scores in response to cough at 24th hour in groups 2 and 3 were significantly lower than in group 1 (P < .001 and P < .01, respectively). Mean VAS pain scores during rest at 0 to 24 hours in groups 2 and 3 were significantly lower than in group 1 (P < .01 and P < .05, respectively). Morphine consumption was lower in groups 2 and 3 at 0 to 2 hours (P < .001 and P < .01). Moreover, morphine consumption at 0 to 4 hours in group 2 was significantly lower (P < .01). CONCLUSIONS: Lower pain scores and morphine consumption in groups 2 and 3 may be related to higher plasma ketamine concentrations caused by the higher doses and later administration. Our findings suggest that a single preoperative dose of ketamine provided less analgesia compared with other dosing regimens that included intraoperative infusions or postoperative administration.     

Laparoscopic surgery may be associated with severe pain and high analgesia requirements in the immediate postoperative period

OBJECTIVE: To assess the immediate (0-4 hours) postoperative pain level in patients after laparoscopy and laparotomy whose analgesic requirement in the Post-Anesthesia Care Unit (PACU) exceeds standard morphine therapy. BACKGROUND DATA: Clinical observation has raised the suspicion that laparoscopic surgery may be associated with more intense immediate postoperative pain than expected. METHODS: This prospective study assessed the 24-hour pain intensity and analgesia requirements in patients who underwent similar abdominal surgery via laparoscopy or laparotomy under standardized general anesthesia and whose pain in the PACU was resistant to 120 microg/kg intravenous morphine. RESULTS: Of 145 sampled PACU patients, 67 were in pain (> or =6 of 10 VAS) within a 30-minute postoperative period. They were then given up to 4 intravenous boluses of 15 microg/kg morphine + 250 microg/kg ketamine. The pain VAS of 36 laparotomy patients was 4.14 +/- 2.14 (SD) and 1.39 +/- 0.55 at 10 and 120 minutes, respectively, after 1.33 +/- 0.59 doses of morphine + ketamine; the pain VAS of 31 laparoscopy patient was 6.06 +/- 1.75 and 2.81 +/- 1.14, respectively (P < 0.0005) following 2.0 +/- 0.53 doses (P = 0.0005). Diclofenac 75 mg intramuscular usage was similar (P = 0.43) between the groups up to 9 hours after surgery but was higher in the laparotomy group by 24 hours (P = 0.01). Pain scores at 24 hours after surgery were lower for the laparoscopy patients (3.01 +/- 0.87) compared with their laparotomy counterparts (4.45 +/- 0.98, P < 0.001). CONCLUSIONS: Among patients after abdominal surgery with severe immediate (0-4 hours) postoperative pain, laparoscopic patients are a significant (46%) proportion, and their pain is more intense, requiring more analgesics than painful patients (54%) do after laparotomy. By 24 hours, the former are in less pain than the latter.     

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.     

A prospective randomized trial of nebulized morphine compared with patient-controlled analgesia morphine in the management of acute thoracic pain

BACKGROUND: Successfully managing pain for the trauma patient decreases morbidity, improves patient satisfaction, and is an essential component of critical care. Using patient-controlled analgesia (PCA) morphine to control pain may be complicated by concerns of respiratory depression, hemodynamic instability, addiction, urinary retention, and drug-induced ileus. Morphine is rapidly absorbed by mucosal surfaces in the respiratory tract, achieving systemic concentrations equal to 20% of equivalent intravenous doses. The purpose of this study was to evaluate the safety, efficacy, and utility of nebulized morphine in patients with posttraumatic thoracic pain. METHODS: This double-blinded, prospective study randomized patients with severe posttraumatic thoracic pain into two groups. The experimental group (NMS) received nebulized morphine every 4 hours and normal saline by PCA. The control group (PCA) received nebulized saline every 4 hours and morphine by PCA. Dose adjustments were made based on patient response to treatments using a 10-point visual analog scale (VAS) for pain. Pulmonary function, pain relief (VAS), level of sedation (0-3), total drug administration, and systematic side effects were recorded. RESULTS: Forty-four patients were randomized (22 per group). Seven hundred seventy observations were made. The mean 4-hour dose of morphine was 11.96 +/- 3.4 mg for NMS and 6.22 +/- 4.7 mg for PCA (p < 0.001). Patients with NMS had lower heart rates compared with PCA (79 +/- 11 bpm versus 92 +/- 12 bpm; p < 0.001) and were less sedated (0.33 +/- 0.7 versus 0.56 +/- 0.9; p = 0.03). The mean pain level (VAS) was 3.38 +/- 1.8 for NMS and 3.84 +/- 2.7 for PCA (p = 0.2). There was no difference between pain levels before and after dosing. There were no differences between groups with respect to arterial blood pressure, respiratory rate, vital capacity, mean forced expiratory volume in 1 second, spirometric volumes, or Sao2. CONCLUSION: Nebulized morphine can be safely and effectively used to control posttraumatic thoracic pain. Pain can be successfully managed while vital capacity, mean forced expiratory volume in one second, and spirometric volumes are maintained. Compared with PCA morphine, nebulized morphine provides equivalent pain relief with less sedative effects.     

Intravenous paracetamol improves the quality of postoperative analgesia but does not decrease narcotic requirements

Paracetamol, a centrally acting inhibitor of cyclooxygenase, has less gastrointestinal and platelet-inhibiting side effects and is clinically better tolerated than nonsteroidal anti-inflammatory drugs. Therefore, it will be ideally suited for postoperative pain relief. In this prospective, double-blind, randomized, placebo-controlled study, we evaluated the analgesic efficacy, opioid-sparing effect and effects on opioid-related adverse effects of intravenous (IV) paracetamol in combination with IV morphine after lumbar laminectomy and discectomy. Forty patients were divided into 2 groups (n=20 each) to receive either paracetamol 1 g (group 1) or 0.9% NaCl 100 ml (group 2) at the end of the operation and at 6-hour intervals over 24 hours. IV patient-controlled analgesia with morphine was used as a rescue analgesic in both groups. Pain was evaluated at rest and on movement at the 1st, 2nd, 4th, 6th, 12th, 18th, and 24th hours using a visual analog scale. Hemodynamic parameters, morphine usage, patient satisfaction, and probable side effects were also evaluated. Pain scores at rest and on movement at the 12th, 18th, and 24th hours were significantly lower in group 1 (P<0.001). Morphine consumption was not statistically significantly different between the groups (P>0.05). Vomiting in group 2 was significantly higher (P=0.027). Significantly more patients in the paracetamol group rated their pain management as excellent (45% vs. 5%). Although repeated IV paracetamol usage after lumbar laminectomy and discectomy did not demonstrate a significant opioid-sparing effect, it did decrease visual analog scale scores at certain evaluation times and incidence of vomiting and increase patient satisfaction.     

Intra-articular morphine and/or bupivacaine in the management of pain after total knee arthroplasty

The purpose of this study was to determine if intra-articular injection of morphine or bupivacaine significantly decreased postoperative pain as well as the use of intravenous narcotics for pain relief in patients undergoing total knee arthroplasty (TKA). In a prospective, double-blind, randomized fashion, 105 patients undergoing TKA were divided into the following 4 groups defined by the intra-articular injection they received: group 1 (n = 27) received saline solution, group 2 (n = 26) received morphine sulfate (5 mg), group 3 (n = 24) received bupivacaine (50 mg), and group 4 (n = 28) received a combination of morphine sulfate and bupivacaine. The injections were administered immediately after wound closure by the Hemovac drainage tubing that remained clamped for 45 minutes after surgery to allow for absorption. Before surgery and at 2, 4, 6, 24, and 48 hours after surgery, pain intensity was recorded using a visual analog scale. Postoperative supplemental intravenous morphine and/or meperidine was administered via a patient-controlled analgesia device, and 24-hour drug usage was tabulated. Results were suggestive of a modest short-term reduction in pain scores in the morphine and bupivacaine treatment groups compared with placebo (saline); however, results were statistically significant only at 4 hours because of the great variability in the pain score data. The total amount of postoperative pain medication used in the first 24 hours after surgery was not statistically significant between the 4 treatment groups. Thus, the results put into question the benefit of postoperative intraarticular administration of morphine or bupivacaine in patients undergoing TKA.     

KETOROLAC TROMETAMOL FOR POSTOPERATIVE ANALGESIA AFTER ORTHOPAEDIC SURGERY

We have compared the postoperative morphine requirements andanalgesic efficacy of four doses of i.m. ketorolac 30 mg administered6-hourly with placebo in a double-blind study of patients undergoingmajor or minor orthopaedic surgery. During the 24-h postoperativestudy period which began at the end of surgery, patients wereprescribed i.m. morphine 10 mg as required 2-hourly and assessmentswere made of pain at 4 and 24 h. After major surgery, the medianmorphine consumption over 24 h was 10 mg in patients who receivedketorolac, compared with 30 mg in those who received placebo(P = 0.008). Visual analogue pain scores and verbal pain assessmentswere better than placebo at 4 h (P = 0.028 and P = 0.008, respectively),but were not statistically different between the groups at 24h. Overall assessment of pain was similar in both groups whohad undergone major surgery. In the minor surgery groups, medianmorphine consumption was 0 mg in patients who received ketorolac,compared with 10 mg in those given placebo (ns). Visual analoguepain scores at 24 h after surgery were significantly less inpatients who had received ketorolac compared with placebo (P= 0.046) and the overall assessment of pain relief was betterin the ketorolac group (P = 0.0007). Mandatory administrationof ketorolac appeared to be of benefit in both major and minororthopaedic surgery, although the principal effects were reductionin requirement for supplementary morphine for major surgeryand better overall analgesia for minor surgery.     

Low-dose sufentanil dœs not potentiate intra-thecal morphine for perioperative analgesia after major colorectal surgery

PURPOSE: Both intrathecal sufentanil (ITS) and intrathecal morphine (ITM) improve analgesia in obstetrical or cardiac procedures. From a pharmacokinetic standpoint, combining these two opioids may improve perioperative analgesia. We performed a prospective randomized double-blind study to compare the analgesic efficacy of ITM alone vs a mixture of a low dose of ITS plus ITM for perioperative pain relief in colorectal surgery. METHODS: Eighty adult patients undergoing colorectal surgery were randomly allocated to receive either 0.4 mg ITM alone or 10 microg ITS plus 0.4 mg ITM before general anesthesia. Intraoperative intravenous sufentanil consumption, postoperative morphine consumption delivered with a patient controlled analgesia device, pain scores, patient satisfaction and adverse effects were recorded for the first 48 hr postoperatively. RESULTS: No differences were observed between groups with respect to intraoperative sufentanil consumption (39 +/- 23 microg in group ITM and 40 +/- 25 microg in group ITS plus ITM, P = 0.85) and in postoperative morphine consumption in postanesthesia care unit (6 +/- 5 mg vs 6 +/- 5 mg, P = 0.59), at 24 hr (26 +/- 17 vs 24 +/- 15 mg, P = 0.59) and at 48 hr (47 +/- 31 vs 44 +/- 22 mg, P = 0.58). Similarly, no differences were observed in regards to pain relief, patient satisfaction and incidence of adverse effects. CONCLUSIONS: These results do not support the addition of 10 microg ITS to 0.4 mg ITM for colorectal surgery, as low dose sufentanil does not improve intraoperative and postoperative analgesia in this setting.     

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.     

Does prophylactic intravenous infusion of indomethacin improve the management of postoperative pain in children?

The efficacy of prophylactic intravenous infusion of indomethacin as a postoperative analgesic was studied in 100 children aged one to 16 years. At the end of surgery a bolus dose of indomethacin 0.35 mg.kg-1 followed by an infusion 0.07 mg.kg-1.hr-1 for 24 hr or placebo was given in double-blind manner. The efficacy of the treatment was measured by the need of additional morphine given 0.1 mg.kg-1 intravenously in the Recovery Room and 0.15 mg.kg-1 intramuscularly on the ward according to clinical needs. The other measure of the efficacy was assessment of pain intensity in the Recovery Room and pain relief on the ward. In the Recovery Room the pain scores differed between the groups in advantage of indomethacin only at 30 minutes (p less than 0.05) but the need of morphine was significantly less (p less than 0.01) in the indomethacin group. On the ward the mean doses of morphine given and the nurses' pain relief scores were not different between the study groups. However, in the indomethacin group the total dose of morphine given during 24 hr was lower (p = 0.02) and the children assessed the pain relief to be significantly better (p less than 0.02). Twenty per cent of the children in both groups had transient nausea and vomiting. No skin reactions or other allergic manifestations were observed. Prophylactic indomethacin infusion diminished the need of morphine and resulted in better postoperative analgesia than morphine p.r.n. alone.     

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.     

氯胺酮与吗啡超前镇痛对内脏牵拉痛及术后镇痛的影响

目的探讨氯胺酮与吗啡复合液硬膜外超前镇痛对抑制手术内脏牵拉痛的影响及术后镇痛情况的影响。方法60例ASAⅠ~Ⅱ级择期全子宫切除术患者,均于硬膜外麻醉下行全子宫切除术。随机分为两组,每组30例,即Ⅰ组(对照组):术前不施行超前镇痛;Ⅱ组(实验组):切皮前10 min将氯胺酮30 mg与吗啡2 mg用生理盐水稀释成5 ml注入硬膜外腔。所有患者术后均行自控硬膜外镇痛(PCEA)。镇痛药物为0.15%罗哌卡因+5 mg吗啡,共100 ml。观察两组患者术中牵拉反应、术后镇痛情况及并发症。结果Ⅱ组用药对抑制术中牵拉痛的效果明显优于Ⅰ组(P<0.01);Ⅱ组PCEA泵首次触发时间较Ⅰ组显著延长(P<0.01),48 h内有效触发次数显著减少(P<0.01),24 h PCEA泵总用量明显减少(P<0.05),术后并发症无明显差异。结论氯胺酮与吗啡硬膜外超前镇痛能明显抑制术中牵拉痛,提供良好的术后镇痛效果,减少阿片类药物的用量。     

Postoperative pain and pulmonary complications: comparison of three analgesic regimens

In a prospective study, patients undergoing cholecystectomy were randomly allocated to receive (a) intermittent intramuscular morphine (n = 25), (b) continuous intravenous morphine infusion (n = 25) or (c) epidural bupivacaine (n = 25) for postoperative pain relief. Morphine by intravenous infusion provided comparable pain relief to intermittent intramuscular morphine; there was no significant difference in the incidence of postoperative pulmonary complications. Patients receiving epidural bupivacaine for 12 h had better analgesia than patients receiving morphine (P less than 0.001). Arterial oxygen tensions were also significantly higher in the epidural group for the first three postoperative days (P less than 0.05). Epidural analgesia was associated with a significant reduction in the incidence of pulmonary complications (P less than 0.01) and chest infection (P less than 0.05).     

Postoperative analgesia using caudal morphine in pediatric surgery: randomized double-blind study compared with bupivacaine

Morphine and bupivacaine have been administered caudal via to 28 children between 2 and 12 years old for the postoperative pain treatment. All of them were submitted to general anesthesia and randomly divided into 3 groups depending on the drug administered caudal via. a) Morphine group (n = 10): morphine chlorhydrate 50 micrograms/kg (0.5 ml/kg of morphine solution 100 micrograms/ml). b) Bupivacaine group (n = 10): bupivacaine 0.5%, 2.5 mg/kg. c) Control group (n = 8): no drug administered. Pain evaluation was made on the basis of physiological and clinical data. In the morphine group, the postoperative time until analgesia was required 20 +/- 5 hours and analgesia has been significantly better (p less than 0.001) than bupivacaine and control group. The number of analgesic drug needed during the postoperative 24 first hours was also less in morphine group. No differences on postoperative complications were seen among the 3 groups and no case of respiratory depression was observed. It is concluded that epiduro-caudal morphine provides effective and prolonged analgesia and can be safely used for postoperative pain treatment in pediatric urologic surgery. However, we believe, that larger series of patients will provide better information of its efficacy and other side effects.     

Postoperative pain control with methadone following lower abdominal surgery

STUDY OBJECTIVES: To describe a technique for the use of methadone during and following lower abdominal surgery that integrates its pharmacokinetic and pharmacodynamic properties with the objective of postoperative analgesia; to compare methadone with morphine for postoperative pain control. DESIGN: Randomized prospective clinical trial. Patients were not told which agent they received (single-blind). SETTING: Department of anesthesia and gynecology surgical service at a university medical center. PATIENTS: Forty women undergoing abdominal hysterectomy (n = 39) or myomectomy (n = 1). INTERVENTIONS: Patients received either methadone (Group 1) or morphine (Group 2) 20 mg intravenously (IV) following induction of anesthesia, additional IV opioid in the recovery room, and subsequent opioid as needed (PRN) intramuscularly (IM) on the postsurgical wards. MEASUREMENTS AND MAIN RESULTS: Pain was assessed using a visual analog scale (VAS). Respiratory rate, sedation, and hemodynamics were assessed frequently (at least every 4 hours). Patients were studied for 72 hours following recovery room discharge. Patients required less methadone than morphine in the recovery room (2.0 +/- 2.9 mg vs 4.4 +/- 2.9 mg). Patients requested less methadone than morphine for pain relief on the wards (4.5 +/- 4.2 mg vs 42.3 +/- 14.3 mg). Patients in the methadone group reported lower pain intensity by VAS (1.9 +/- 0.3 vs 3.4 +/- 0.6). These differences are statistically significant (p less than 0.01). CONCLUSION: Sustained analgesia with methadone is predicted by its pharmacokinetics. Patients who received 22 +/- 2.9 mg of IV methadone (combined intraoperative and recovery room doses) reported less pain and required minimal additional analgesic over the next 72 hours than did patients who received morphine. This is consistent with sustained therapeutic plasma levels due to methadone's long plasma half-life (54 +/- 20 hours). Use of methadone in this manner is an effective therapy for postoperative pain control and is not associated with toxicity or notable side effects.     

Structured preoperative patient education for patient-controlled analgesia

STUDY OBJECTIVE: To investigate the effectiveness of a structured preoperative education program in patients receiving patient-controlled analgesia (PCA). DESIGN: Randomized controlled trial. SETTING: University-affiliated hospital. PATIENTS: 60 ASA physical status I and II women undergoing major gynecologic surgery. INTERVENTIONS: Patients were randomly allocated to receive either standard information given during routine preanesthetic assessment (n = 30) or additional structured preoperative education on the use of PCA (n = 30). MEASUREMENTS: All patients received standard anesthesia and PCA was provided for postoperative analgesia. Patients were reviewed bid by an independent team of pain specialists and nurses. Patient satisfaction, severity of postoperative pain, nausea, dizziness, and morphine consumption were measured at discharge from recovery room, 24, and 48 hours after operation. Recovery characteristics of patients were also measured. MAIN RESULTS: Pain scores and morphine consumption decreased over time (p < 0.01), but there was no significant difference between groups. The overall analgesic efficacy, side effects, and recovery times was not affected by the education program. Patient satisfaction in the education group was better than control during early recovery (p= 0.03), but there was no additional benefit in the remaining postoperative period. CONCLUSIONS: Structured preoperative PCA education did not affect patient outcome. The early improvement in patient satisfaction was minimized by continued education and pain team supervision during the rest of the postoperative period.     

Continuous infusion of interpleural bupivacaine maintains effective analgesia after cholecystectomy

Twenty-five patients who had undergone elective cholecystectomy were prospectively randomized to receive via an interpleural catheter either a continuous infusion of 0.25% bupivacaine at 0.125 mL.kg-1.h-1 (n = 13) or repeated bolus injections (n = 12) of 0.5% bupivacaine with epinephrine 1:200,000 at 0.4 mL/kg every sixth hour. Adequacy of pain relief was measured by the amount of patient-controlled analgesia morphine required postoperatively and by patient scores on a visual analog scale obtained every sixth hour. Two venous blood samples for measurements of serum bupivacaine levels were obtained from patients in the continuous group at hours 6 and 24; four blood samples were obtained from patients in the bolus group, both immediately before and 30 min after injections at hours 6 and 24. Among the patients receiving the bolus injections, morphine was required 62 +/- 15 (SEM) times over the 24-h study period with total morphine dosage averaging 30 +/- 15 mg. Corresponding values for patients in the continuous groups were 35 +/- 10 times and 23 +/- 5 mg of morphine. The difference was not, however, statistically significant, but when activity during the 2-h time periods immediately before reinjection were examined, patients in the bolus group required and received significantly more morphine than did those in the continuous group (P less than 0.05). Patients in the continuous group had visual analog scale scores that averaged 2.9 +/- 0.6 over the 24-h study period. Patients within the bolus group had visual analog scale scores before and again 30 min after injection that averaged 5.8 +/- 0.8 and 1.8 +/- 0.5, respectively (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

Effective doses of epidural morphine for relief of postcholecystectomy pain

Having previously established the effective dose of intrathecal morphine for relief of postcholecystectomy pain, we determined in this study the effective dose of epidural morphine for relief of postcholecystectomy pain in 154 patients given epidural injections of a placebo (group 1, n = 49), 2 mg morphine (group 2, n = 54), or 4 mg morphine (group 3, n = 51) intraoperatively mixed in 1.5% lidocaine. The percentage of patients who did not request an analgesic, 30 mg IM pentazocine, for relief of pain during the first 24 postoperative hours was significantly greater in groups 2 and 3 than in group 1. In patients who did need 30 mg IM pentazocine postoperatively, the number of times pentazocine was administered was also significantly greater in group 1 than in groups 2 and 3. The percentage of patients developing respiratory depression or vomiting in the first 48 postoperative hours was similar in the three groups. Based on the present data and those we previously reported for intrathecal morphine, we conclude that an epidural morphine dose of 2-4 mg and an intrathecal morphine dose of 0.06-0.12 mg are equipotent for relief of postcholecystectomy pain.