Preemptive analgesia by peritonsillar ketamine versus ropivacaine for post-tonsillectomy pain in children

BackgroundPostoperative pain relief is a desired goal after tonsillectomy. Respiratory depression from opioid, bleeding from nonsteroidal antiinflammatory drugs, and airway edema all these factors make pain control is judges. Peritonsillar infiltration of a local anesthetic has been used for reduction of post-tonsillectomy pain.ObjectiveThis study aims to compare the postoperative analgesic efficacy and side-effects of preincisional peritonsillar infiltration of either ketamine or ropivacaine in children undergoing tonsillectomy.MethodsIn this prospective randomized double blind study, 60 children 7–12 years scheduled to tonsillectomy were divided into three groups: the tonsils were infiltrated by 0.2 ml kg⁻¹ ropivacaine, 0.75% in ropivacaine group R (=21), group 0.5 mg kg⁻¹ ketamine in the ketamine group K (n = 20), and 0.2 ml kg⁻¹ normal saline in the control group S (n = 19). All drugs were prepared in normal saline (3 ml per tonsil) infiltrated 3 min after induction of anesthesia and before surgical incision. Surgery was performed by a single otolaryngology fellow using the same dissection and snare technique. Postoperative pain was compared during 8-h period using a visual analog scale (VAS). The fast-tracking score was used to determine the post-anesthesia care unit discharge criteria. Patients were evaluated for: time of first request and the total analgesic requirement, time of first oral intake, nausea, vomiting, bleeding, and hallucination.ResultsIn the post-anesthesia care unit, groups K and R had comparable pain scores that were significantly lower than S group (P < 0.04). Pain scores in the postoperative ward at 2, 6, and 8 h were significantly higher in group S than in K and R groups (P < 0.05). The time of first analgesic demand was significantly longer in R group (5.52 ± 1.7) h than in K group (3.83 ± 0.16) h p = 0.003. It was the shortest in S group (2.57 ± 0.84) h p = 0.001. The time of first oral intake was significantly longer in S than in R and K groups (5 ± 1.72 versus 3.2 ± 1.97 and 3.65 ± 1.72 h) respectively = 0.006. Total analgesic consumption (mg) was significantly higher in S group than in R and K (12. ± 5.3 versus 8, 2 ± 2.3 and 8.6 ± 3.1) p = 0.004. There were no significant differences between groups regarding nausea, vomiting, or bleeding, and there was no other side-effect recorded.ConclusionPerincisional peritonsillar infiltration of both ropivacaine and ketamine was effective in reduction of post-tonsillectomy pain. Ropivacaine was superior to ketamine in reduction of time to first analgesic demand.     

Efficacy of ultrasound-guided transversus abdominis plane blocks for post-cesarean delivery analgesia: a double-blind,dose-comparison,placebo-controlled randomized trial

BackgroundThe analgesic benefit of TAP (transversus abdominis plane) blocks for cesarean delivery pain remains controversial. We compared the analgesic efficacy of two doses of local anesthetic for TAP blocks after cesarean delivery.MethodsSixty women having cesarean delivery under spinal anesthesia were randomized to receive ultrasound-guided TAP blocks using either high-dose ropivacaine (3 mg/kg), low-dose ropivacaine (1.5 mg/kg) or placebo. Patients received intrathecal 0.75% bupivacaine 10–12 mg, fentanyl 10 μg and morphine 150 μg and standard multimodal analgesia. The primary outcome was the difference in pain with movement using a numeric rating scale at 24 h. Other outcomes included time to first request for analgesia, pain scores at 6, 12, 36, 48 h and at 6 and 12 weeks, opioid consumption, adverse effects, quality of recovery, and satisfaction.ResultsThere were no differences between groups in the primary outcome. Mean ± SD pain scores (0–10) with movement at 24 h were: high-dose ropivacaine 3.6 ± 1.5, low-dose ropivacaine 4.6 ± 2.1 and placebo 4.1 ± 1.7. With respect to secondary outcomes, the mean ± SD pain scores at 6 h were lower in the high-dose group 2.0 ± 1.8 compared to the low-dose 3.4 ± 2.7 and placebo groups 4.2 ± 2.0 (P = 0.009). Pain scores at 12 h were also lower in the high-dose group 2.2 ± 2.0 compared to the low-dose group 4.1 ± 2.7 and placebo group 4.0 ± 1.3 (P = 0.011). There was no difference in other outcomes between groups.ConclusionsNeither high- or low-dose TAP blocks as part of a multimodal analgesia regimen including intrathecal morphine improved pain scores with movement at 24 h after cesarean delivery when compared to placebo TAP blocks. High-dose TAP blocks may improve pain scores up to 12 h after cesarean delivery.     

Comparação do bloqueio do canal adutor para analgesia em cirurgia artroscópica com ropivacaína isolada e ropivacaína + clonidina

Background and objectivesInadequate pain relief after anterior cruciate ligament reconstruction affects mobility leading to development of adhesions, weakened ligament insertion and muscle atrophy. Adductor canal block for postoperative analgesia preserves quadriceps strength. The present study was conducted to compare pain free period in patients undergoing arthroscopic anterior cruciate ligament reconstruction, receiving ultrasound‐guided adductor canal block with ropivacaine alone and ropivacaine with clonidine.MethodsA prospective randomized double blinded study was conducted including sixty‐three adult, ASA class I, II patients undergoing anterior cruciate ligament reconstruction. They were randomized into three groups: Group S – control group received adductor canal block with 30 mL saline, Group R – ropivacaine group received adductor canal block with 30 mL of 0.375% ropivacaine and Group RC – clonidine group received adductor canal block with 30 mL of 0.375% ropivacaine with clonidine 1 μg.kg⁻¹. The primary aim was to compare the pain free period in patients receiving adductor canal block with ropivacaine alone or ropivacine with clonidine. The secondary outcomes were pain score at rest and movement, total analgesic requirement, sedation score and postoperative nausea and vomiting.ResultsThe mean pain free periods were 20 min, 384.76 min and 558.09 min for Group S, Group R and Group RC, respectively and this difference was statistically significant (p < 0.001). There was no significant difference between Group R and Group RC in terms of pain scores at rest and movement and total analgesic requirement.ConclusionAddition of clonidine to ropivacaine in USG guided adductor canal block led to significant prolongation of pain free period though pain score at rest and movement, and rescue analgesic requirement, did not differ.     

Continuous wound infusion with ropivacaine fails to provide adequate analgesia after caesarean section

BackgroundContinuous wound infusion with local anaesthetic has been used in post-caesarean pain management with conflicting results. We carried out a study comparing three groups: continuous ropivacaine wound infusion, intrathecal morphine with saline wound infusion and saline wound infusion only.MethodsSixty-six women undergoing elective caesarean section under combined spinal-epidural anaesthesia were randomly allocated to receive intrathecal morphine with saline wound infusion or 48 h continuous wound infusion with either ropivacaine or saline. All parturients received oral ketoprofen and intravenous oxycodone patient-controlled analgesia. Consumption of oxycodone, visual analogue scale pain scores (0–10 cm), patient satisfaction, side effects and recovery parameters were recorded for 48 h in a double-blind manner.ResultsContinuous wound infusion with ropivacaine failed to reduce oxycodone consumption or pain scores compared with saline control. In the first 24 h intrathecal morphine reduced mean oxycodone consumption compared to the ropivacaine wound infusion group (26 mg vs. 48 mg, P = 0.007) and saline wound infusion group (26 mg vs. 45 mg, P = 0.021). The first 24-h mean pain score was also lower in the intrathecal morphine group vs. the saline wound infusion group (1.3 vs. 2.2, P = 0.021). Pain scores were not significantly different between intrathecal morphine and ropivacaine wound infusion groups. Pruritus was more common with intrathecal morphine.ConclusionCompared to saline control, continuous wound infusion with ropivacaine failed to reduce the use of intravenous oxycodone patient-controlled analgesia or pain scores. Intrathecal morphine decreased oxycodone consumption by 46% in the first 24 h after surgery when compared to continuous ropivacaine wound infusion.     

Ultrasound guided transversus abdominis plane block versus local wound infiltration in children undergoing appendectomy: A randomized controlled trial

BackgroundThe transversus abdominis plane block (TAP) has been described for pain management following abdominal surgery in adults, but there are only few reports on its use in pediatrics. The aim of this study was to evaluate the analgesic effect of ultrasound guided TAP block in patients scheduled for open appendectomy versus an active comparator (wound infiltration).MethodsForty-four children aged 4–16 years (ASA 1–2) were enrolled. Patients were randomized into two groups (22 in each). Patients in group (T) were assigned to receive ultrasound guided TAP block using 0.4 ml/kg of bupivacaine 0.25%, and those in group (L) were assigned to receive local infiltration by the surgeon. Maximum pain scores, the time to the first analgesic requirement and the number of analgesic requirements were recorded over 48 h.ResultsThe ultrasound guided TAP block increased the mean time to the first analgesic requirement (10.4 ± 1.5 h) in comparison with the local infiltration group (5.4 ± 1.5). The cumulative number of doses of analgesic was significantly lower in TAP group than in local infiltration group (3.7 ± 1.1 versus 5.3 ± 2.1) and the Pain Scale score was significantly lower in the TAP group over the study period. Besides, there were no complications attributable to the ultrasound guided TAP block.ConclusionUltrasound-guided TAP block with (0.4 ml/kg) 0.25% bupivacaine provides prolonged postoperative analgesia and reduced analgesic use without any clinical side-effects after appendectomy in children.     

Optimal epidural analgesia for patients diagnosed as having gynecologic cancer undergoing interstitial brachytherapy

Study objectiveTo determine the optimal epidural analgesia for patients receiving interstitial brachytherapy (ISBT) for gynecologic cancers.DesignRetrospective analysis.SettingOperating room and hospital ward.PatientsSeventy-three patients diagnosed as having gynecologic cancer and undergoing ISBT.InterventionsTwelve patients received ropivacaine alone, 14 patients received ropivacaine with fentanyl, and 45 patients received ropivacaine with hydromorphone by epidural infusion.MeasurementsNumeric Rating Scale pain scores, amounts of nonnarcotic and narcotic pain medications used in intravenous morphine equivalents (IVMEs), and amount of antiemetic or antipruritic medications used.Main resultsPatients receiving ropivacaine alone had higher pain scores the morning of day 2 (4.2 vs 1.71 vs 0.6, P = .001), the afternoon of day 2 (4.9 vs 2.5 vs 1.7, P = .005), and the night of day 2 (2.4 vs 2.0 vs 0.6, P < .001). Patients receiving opioids in their epidural had lower pain scores on the night of placement (P = .050), the morning of day 2 (P < .001), the afternoon of day 2 (P = .002), and the night of day 2 (P < .001). Patients receiving ropivacaine alone used more oral narcotics than did those receiving ropivacaine with fentanyl or ropivacaine with hydromorphone on day 3 (5.9 vs 3.8 vs 2.8 mg IVME) and received more intravenous opioids day 1 (5.8 vs 0.0 vs 0.7 mg IVME, P = .004) and day 2 (20.6 vs 4.8 vs 1.0 mg IVME, P = .042). There were no differences in antiemetic or diphenhydramine usage at any time point. No epidural complications occurred.ConclusionsFor patients receiving ISBT for gynecologic cancer, epidural analgesia provides safe and effective pain control. Combined modality epidural analgesia improves pain control and lessens oral and intravenous opioid requirements without increased risk of adverse effects compared with epidural analgesia with local anesthetic alone.     

Chronobiology of parturients receiving neuraxial labour analgesia with ropivacaine and fentanyl: a prospective cohort study

BackgroundThe circadian variation in biologic rhythm has been known to affect labour pain. The duration of action of ropivacaine or fentanyl used in treatment of labour pain has been demonstrated to vary with different times of the day. The aim of this study is to find whether the need for epidural supplementation for breakthrough pain is significantly affected by the time of day, in patients who are on a continuous epidural infusion of these drugs.MethodsIn this prospective cohort study, parturients with spontaneous onset of labour were given a combined spinal-epidural technique with spinal ropivacaine 2 mg + fentanyl 15 μg followed by an epidural infusion of ropivacaine 0.1–0.125% with fentanyl 2 μg/mL at 10 mL/hour. A total of 1657 patients were divided into four groups: (1) morning: analgesia request: 7:01 to 13:00, delivery before 19:00; (2) afternoon: analgesia request: 13:01 to 19:00, delivery before 1:00; (3) evening: analgesia request: 19:01 to 1:00, delivery before 7:00 and (4) night: analgesia request: 1:00 to 7:00, delivery before 13:00. Pain scores before epidural analgesia, need for additional epidural supplementation, side effects and patient satisfaction scores were compared between the groups.ResultsThe pain scores before epidural analgesia were significantly higher in evening and night groups than in morning and afternoon groups (6.95 ± 2.4, 7.38 ± 2.2 compared to 6.67 ± 2.5, 6.49 ± 2.7 respectively, P < 0.001). Incidence of breakthrough pain, side effects and parturient satisfaction scores were not significantly different between groups.ConclusionParturients with labour onset and neuraxial analgesia request in the evening and night experienced higher pain scores. However, no significant differences in the incidence of breakthrough pain or the quality of analgesia were observed with the provision of commonly used concentrations of ropivacaine with fentanyl via continuous epidural infusion.     

Effect of thoracic epidural analgesia on recovery of bowel function after major upper abdominal surgery

Study ObjectiveWe investigated whether thoracic epidural analgesia (TEA) shortens the first gas-out time compared to intravenous patient-controlled analgesia (iv-PCA) and promotes earlier discharge after major upper abdominal surgery.DesignProspective observational study.SettingA tertiary care university hospital.PatientsFifty-six patients undergoing major upper abdominal surgery.InterventionsTEA (n = 28) was performed using a paramedian approach at T6-7 or T7-8. Hydromorphone (8 μg/mL) was added to 0.15% ropivacaine (bolus/lockout time/basal: 3 mL/15 minutes/5 mL). The iv-PCA regimen (n = 28) included 20 μg/mL fentanyl (bolus/lockout time/basal: 0.5 mL/15 minutes/0.5 mL). The 2 analgesic methods were maintained for 3 days.MeasurementThe primary end point was first gas-out time, and the secondary end points were hospital discharge, pain scores, and first voiding time.Main ResultsNo differences in first gas-out time (TEA, 4.1 ± 1.2 days; iv-PCA, 3.4 ± 1.9 days; P = .15) or hospital stay (TEA, 9.8 ± 2.2 days; iv-PCA, 11.4 ± 5.2 days; P = .19) were observed between the 2 groups. A visual analog pain scale scores during rest and coughing were lower in the TEA than those for iv-PCA even with 40% to 46% less rescue analgesic. However, TEA delayed first voiding time (3.6 ± 0.9 vs 2.8 ± 1.6 days; P = .02) and required more frequent bladder catheterization (46% vs 11%; P = .008) than those of iv-PCA.ConclusionTEA with a regimen of hydromorphone (8 μg/mL) added to 0.15% ropivacaine did not provide earlier gas-out compared to that of iv-PCA in patients who underwent major upper abdominal surgery.     

Preincisional peritonsillar vs. intravenous lornoxicam for posttonsillectomy analgesia: A clinical and platelet aggregometry comparative study

BackgroundLornoxicam is a fairly new short-half oxicam with an improved tolerability profile. Our objective was to investigate the safety and efficacy of intravenous and peritonsillar infiltration of 8 mg lornoxicam on pain relief in children undergoing tonsillectomy.MethodsIn a double-blinded, placebo-controlled trial, 60 children were randomized into three groups; intravenous group (n = 20), received lornoxicam 8 mg iv., infiltration group (n = 20) received lornoxicam 8 mg peritonsillar infiltration, and placebo controls (n = 20). The verbal rating pain scale, time to first postoperative analgesic request, total analgesic consumption during 1st 24 h postoperative, platelet aggregometry before, 15 min, 2 and 24 h after study drug administration, intraoperative blood loss, postoperative bleeding, and adverse effects were evaluated.ResultsThe time to first postoperative analgesic request was significantly prolonged in intravenous (318.75 ± 67.37 min) and infiltration (214.50 ± 43.06 min) groups compared with placebo group (66.75 ± 26.95 min). A significantly lower mean postoperative VRS scores and significantly reduced 1st day postoperative diclofenac consumption were recorded in iv. group (44.73 ± 9.31 mg), compared with infiltration (69.80 ± 38.71 mg) and placebo (87.8 ± 24.40 mg) groups. An increased intraoperative blood volume losses and intraoperative bleeding complains were observed in infiltration group (34.25 ± 11.93 ml), rather than in iv. (28.85 ± 10.01 ml) and placebo (24.75 ± 8.70 ml) groups. The (%) of platelet aggregation with ADP, collagen, and arachidonic acid was significantly reduced 15 min and 2 h after study drug administration with highest decreases in iv. group compared with infiltration and placebo groups. No patients reported postoperative bleeding or GIT adverse effects in the study.ConclusionIntraoperative preincisional intravenous lornoxicam enhanced postoperative analgesia after tonsillectomy in children. In comparison, the analgesic efficacy of locally applied lornoxicam was inferior to intravenous administration and was associated with increased incidence of intraoperative bleeding.     

A randomised comparison of regular oral oxycodone and intrathecal morphine for post-caesarean analgesia

BackgroundPrimary post-caesarean analgesia based on oral opioid has not been adequately studied. This approach may show a good side-effect profile and high satisfaction and avoid neuraxial complications.MethodsIn a double-blind, double-dummy, placebo-controlled clinical trial 120 women were randomised to receive either sustained-release oral oxycodone 20 mg in the recovery room followed by immediate-release oxycodone 10 mg 6-hourly for the first 24 h (group O) or intrathecal morphine 100 μg at the time of spinal anaesthesia (group I). All women received regular postoperative diclofenac, paracetamol and standardised supplemental analgesia.ResultsOne hundred and eleven women completed the study. The area under the curve for pain scores to 24 h did not differ significantly between groups for pain at rest (P=0.465) or on movement (P=0.533). Numerical pain scores were low and similar, except at rest at 12 h (group I 1 [0-2] vs. group O 2 [1-3]; P=0.030). The time to first analgesic request was similar but additional postoperative analgesics were required more often in group O (82% vs. 63%, P=0.034). Group O more frequently reported high worst pain scores (score 4-10 in 87% vs. 64%, P=0.007). Pruritus was more common and more severe in group I (87% vs. 56%, P=0.001). At 24 h maternal satisfaction with the analgesic regimen was lower in group O (P=0.010).ConclusionOral oxycodone produced comparable postoperative pain relief to intrathecal morphine with a lower incidence of pruritus, but was associated with a lower satisfaction score.     

Ultrasound guided transversus abdominis plane block in pediatric patients undergoing laparoscopic surgery

ObjectiveTo assess safety and effectiveness of ultrasound-guided TAP block in children undergoing laparoscopic surgery for undescended testis.Subjects and methodsThis randomized controlled trial involved 108 children, 3–7 years old, randomly allocated into one of two equal groups; TAP Group and Control Group. All children received general anesthesia using propofol 1.5–2.5 mg/kg, atracurium 0.5 mg/kg and fentanyl 2 μg/kg. TAP Group received 0.5 ml/kg of ropivacaine 0.375% bilaterally under ultrasound guidance and control group received regular analgesics. Quality of analgesia was assessed using Children’s Hospital Eastern Ontario Pain Scale (CHEOPS) and Objective behavioral pain score (OPS). The primary outcome measures were hemodynamic parameters and degree of pain. Secondary outcome measures were intraoperative fentanyl requirement, postoperative rescue analgesia (time and dose), complications, hospital stay and degree of satisfaction of patients and their parents.ResultsTAP block group had significantly lower intraoperative fentanyl dose (p < 0.001), significantly longer time to first postoperative request of analgesic (p < 0.001), lower analgesic dose during the first postoperative 24 h (p < 0.001) and lower pain scores along the whole 24 postoperative hours. Mean arterial pressure and heart rate were within the clinically accepted range in the two groups. Parents’ satisfaction was significantly higher (p < 0.001) in the TAP block group.ConclusionTAP block under ultrasound guidance was easy, safe, reliable and effective analgesic in children undergoing laparoscopic surgery for undescended testis.     

Efficacy of preoperative melatonin versus pregabalin on perioperative anxiety and postoperative pain in gynecological surgeries

BackgroundWe compared the efficacy of melatonin and pregabalin on perioperative anxiety and postoperative pain in patients undergoing laparoscopic gynecological surgeries.MethodsIn this randomized double-blind study, 40 patients, 25–35 yr undergoing gynecological surgeries were divided into 2 equal groups to receive either melatonin capsule 6 mg (Group M), or pregabalin capsule 150 mg (Group P) 1 h before induction of general anesthesia. Our primary outcome was preoperative acute anxiety level 1 h after drug administration, 1, 6, and 12 h after operation. The secondary outcomes were postoperative visual analog scale (VAS) for pain, analgesic consumption, sedation level using the inverted observer’s assessment of alertness/sedation scale (OAA/S) scale, and incidence of adverse effects.ResultsThe anxiety scores decreased significantly >50% after premedication in both groups compared to baseline values (p < 0.01) with no statistically significant difference between the two groups (30.4 ± 4.5 in group M versus 31.7 ± 4.2 in group P, p > 0.05). Postoperative VAS for pain, time for first analgesic demand and number of patients requiring postoperative analgesia did not differ between groups, and the sedation score was higher in melatonin group compared to pregabalin group 1 h after drug (3.45 ± 0.7 versus 1.95 ± 0.6, p < 0.001, respectively) and at all the subsequent readings postoperatively with equal incidence of adverse effects in both groups.ConclusionOral melatonin 6 mg or pregabalin 150 mg administered 1 h before operation had reduced perioperative anxiety and postoperative pain in patients undergoing gynecological surgeries, without untoward sedative effects in the pregabalin group compared to melatonin group.     

Pulmonary effects of bupivacaine,ropivacaine, and levobupivacaine in parturients undergoing spinal anaesthesia for elective caesarean delivery: A randomised controlled study

BackgroundSpinal anaesthesia is the method of choice for elective caesarean delivery, but has been reported to worsen dynamic pulmonary function when using bupivacaine. Similar investigations are lacking for ropivacaine and levobupivacaine. We have therefore compared the pulmonary effects of intrathecal bupivacaine, ropivacaine and levobupivacaine used for caesarean delivery.MethodsForced vital capacity, forced expiratory volume in the first second, and peak expiratory flow rate were measured in 48 parturients before and after onset of spinal anaesthesia using either 0.5% bupivacaine 10 mg, 1% ropivacaine 20 mg, or 0.5% levobupivacaine 10 mg. Apgar scores and umbilical arterial pH were recorded.ResultsThe final level of sensory blockade was not different between groups. Forced vital capacity was significantly decreased with bupivacaine (3.6 ± 0.5 L to 3.5 ± 0.4 L, P < 0.05) and ropivacaine (3.2 ± 0.4 L to 3.1 ± 0.5 L, P < 0.05), but not with levobupivacaine (3.6 ± 0.5 L to 3.4 ± 0.6 L). Forced expiratory volume during the first second was not decreased in any group. Peak expiratory flow rate was significantly decreased with ropivacaine (5.5 ± 1.5 L/s to 5.0 ± 1.1 L/s, P < 0.05) and levobupivacaine (from 6.0 ± 1.1 L/s to 5.2 ± 0.9 L/s, P < 0.01). Neonatal vital parameters did not differ between the three groups.ConclusionsDecreases in maternal pulmonary function tests were similar following spinal anaesthesia with bupivacaine, ropivacaine, or levobupivacaine for caesarean delivery. The clinical maternal and neonatal effects of these alterations appeared negligible.     

Effect of intra-articular injection of midazolam and/or bupivacaine on postoperative analgesia after arthroscopic knee surgery

BackgroundA variety of analgesic techniques have been used to manage postoperative pain after arthroscopic knee surgery. We investigated the hypothesis that intra-articular midazolam would result in lower pain score and reduced analgesic requirements.MethodsOne-hundred patients undergoing arthroscopic meniscectomy were allocated randomly to receive intra-articular 20 mL of isotonic saline containing 50 μg/kg midazolam (midazolam group (group M),the bupivacaine group (group B) received 0.25% (20 mL) bupivacaine, and the midazolam with bupivacaine group (group MB) received bupivacaine 0.25% and 50 μg/kg of midazolam in 20 mL. The postoperative analgesia was assessed using visual analog score at rest and during movement at 1/2 h, 1 h, 2 h, 6 h, 12 h, and 24 h.ResultsPatients in group MB showed significantly lower visual analog scores, both at rest and during movement, long time to first postoperative analgesic request, as well as reduced total analgesic consumption than the other two groups.ConclusionIntraarticular administration of midazolam in combination with bupivacaine improves the quality of postoperative analgesia after arthroscopic meniscectomy.     

Can systemic lidocaine be used in controlled hypotension? A double-blinded randomized controlled study in patients undergoing functional endoscopic sinus surgery

IntroductionFunctional endoscopic sinus surgery (FESS) is one of the operations that need controlled hypotension. Many drugs were successfully used in this purpose, e.g., magnesium sulfate, esmolol, and volatile anesthetics. Hypotension was observed to occur after submucosal injection of lidocaine. Based on this observation, it was hypothesized in this double-blinded randomized controlled study that lidocaine may be effective in producing controlled hypotension.MethodsForty-eight ASA I–II adults planned to undergo FESS were given a standard general anesthetic after which they were divided into 2 equal groups to receive either lidocaine infusion in a dose of 1.5 mg/kg/h (group L, n = 24) or equal volumes of normal saline (group C, n = 24). Primary outcome was the surgical field rating score (0–5 points). Secondary outcomes included hemodynamic parameters, extubation time, end-tidal sevoflurane concentrations, fentanyl consumption, and postoperative visual analog pain scores (VASs).ResultsBoth groups were similar regarding hemodynamic parameters. Surgical field scores were significantly lower in group L than in group C at all intraoperative time points (P < 0.05). Extubation time was significantly longer in group C than in group L [group C: 12.4(2.3) min and group L: 9.1(3) min, P = 0.03]. Intraoperative fentanyl dose was significantly higher in group C than in group L [group C: 172(37) mcg and group L: 149(34) mcg, P = 0.03]. End-tidal sevoflurane concentrations were significantly lower in group L than in group C at most intraoperative time points (P < 0.05). Postoperative VAS pain scores in the PACU were higher in group C than in group L (P < 0.05).ConclusionThis study showed the ability of intravenous lidocaine infusion of 1.5 mg/kg/h to produce controlled hypotension in patients undergoing FESS and the superiority of this technique over placebo to achieve favorable surgical field scoring.     

The effects of intravenous lidocaine infusion on hospital stay after major abdominal pediatric surgery. A randomized double-blinded study

BackgroundLidocaine attenuates the stress response to surgery when given intravenously. This study investigated the effect of perioperative lidocaine infusion on hormonal responses, bowel function and hospital stay after major abdominal surgeries in pediatrics.MethodsAfter obtaining the Research Ethics Board (REB) approval and written informed parental consent, 80 pediatric patients aged 1–6 years, ASA II, III scheduled for abdominal major surgery were randomly allocated into two groups, each of forty children. Twenty minutes before induction, children in placebo group received saline in a rate of 1.5 ml/kg/h and those in lidocaine group received lidocaine 1.5 mg/kg intravenously then infusion of 1.5 mg/kg/h up to 6 h postoperatively. Length of hospital stay and return of bowel function were reported. Plasma cortisol was recorded at baseline, 10 min after continuous infusion, 5 min after intubation and 10 min after extubation. Serum lidocaine concentrations were recorded 10 min after start of infusion, 10 min and 4 h after extubation.ResultsPatients in placebo group showed significant higher plasma cortisol concentrations (P = 0.001) in response to induction of anesthesia and extended postoperatively when compared to lidocaine group.Hospital stay was significantly less in lidocaine group (5 ± 2 days) compared to placebo group (7 ± 2 days; P = 0.03). Also, fentanyl (μg/kg/d) requirement was significantly less in lidocaine group (5.4 ± 2.9 on 1st postoperative day and 4.1 ± 2.6 on 2nd postoperative day) compared to placebo group (14.4 ± 2.5 on 1st postoperative day and 12.6 ± 3.3 on 2nd postoperative day). Moreover, return of bowel function was earlier in lidocaine group compared to placebo group (19 ± 6.2 h vs. 23 ± 3.65 h respectively).ConclusionIntravenous lidocaine infusion, started preoperatively and continued for 6 h postoperatively, attenuated stress response to major abdominal pediatric surgery. It also decreased hospital stay, opioid requirement and hastened return of bowel function.     

Intrathecal morphine 100 and 200 μg for post-cesarean delivery analgesia: a trade-off between analgesic efficacy and side effects

IntroductionIntrathecal morphine is highly effective for post-cesarean analgesia; however, the optimal dose is yet to be established. The aim of this study was to compare analgesia and side effects after a change in institutional practice to give 200 μg rather than 100 μg.MethodsWe conducted a retrospective chart review of 241 patients who had an elective cesarean delivery and received either 100 or 200 μg of intrathecal morphine. The primary outcome variables were mean and peak verbal pain scores (0–10) and analgesic use (milligram-morphine equivalents). Postoperative administration of antiemetics, antipruritics and episodes of nausea or vomiting were recorded. Data are reported as mean ± SD or percentages with P < 0.05 considered statistically significant.ResultsWomen receiving intrathecal morphine 200 μg had lower pain scores and opioid use compared with morphine 100 μg. Mean verbal pain scores were 1.6 ± 1.1 versus 2.0 ± 1.1 (P = 0.01) and peak verbal pain scores were 4.9 ± 2.0 versus 5.6 ± 1.8, respectively (P = 0.008). The group receiving 200 μg used less opioids in the first 24 h after surgery (44 ± 35 versus 54 ± 35 milligram-morphine equivalents, respectively, P = 0.04) and received less intravenous opioids (18% versus 30%, P = 0.02). However, women receiving intrathecal morphine 200 μg had more nausea (mean number of episodes of nausea 1.9 ± 1.3 versus 1.6 ± 1.3, P = 0.037) and used more antiemetics (52% versus 24%, P < 0.0001).ConclusionsIntrathecal morphine 200 μg provided better analgesia but with more nausea compared with morphine 100 μg. Our results can be used to help guide intrathecal morphine dosing in cesarean delivery based on patient preference for analgesia versus side effects.     

Femoral nerve block in a representative sample of elderly people with hip fracture: A randomised controlled trial

IntroductionThe number of elderly people with hip fracture and dementia is increasing, and many of these patients suffer from pain. Opioids are difficult to adjust and side effects are common, especially with increased age and among patients with dementia. Preoperative femoral nerve block is an alternative pain treatment.AimTo investigate whether preoperative femoral nerve block reduced acute pain and opioid use after hip fracture among elderly patients, including those with dementia.Patients and methodsIn this randomised controlled trial involving patients aged ≥70 years with hip fracture (trochanteric and cervical), including those with dementia, we compared femoral nerve block with conventional pain management, with opioid use if required. The primary outcome was preoperative pain, measured at five timepoints using a visual analogue scale (VAS). Preoperative opioid consumption was also registered.ResultsThe study sample comprised 266 patients admitted consecutively to the Orthopaedic Ward. The mean age was 84.1 (±6.9) years, 64% of participants were women, 44% lived in residential care facilities, and 120 (45.1%) had dementia diagnoses. Patients receiving femoral nerve block had significantly lower self-rated pain scores from baseline to 12 h after admission than did controls. Self-rated and proxy VAS pain scores decreased significantly in these patients from baseline to 12 h compared with controls (p < 0.001 and p = 0.003, respectively). Patients receiving femoral nerve block required less opioids than did controls, overall (2.3 ± 4.0 vs. 5.7 ± 5.2 mg, p < 0.001) and in the subgroup with dementia (2.1 ± 3.3 vs. 5.8 ± 5.0 mg, p < 0.001).ConclusionPatients with hip fracture, including those with dementia, who received femoral nerve block had lower pain scores and required less opioids before surgery compared with those receiving conventional pain management. Femoral nerve block seems to be a feasible pain treatment for elderly people, including those with dementia.     

CT-guided infiltration of greater occipital nerve for refractory craniofacial pain syndromes other than occipital neuralgia

PurposeThe purpose of this study was to evaluate the effectiveness of computed tomography (CT)-guided infiltration of greater occipital nerve (GON) for the treatment of refractory craniofacial pain syndromes other than occipital neuralgia.Materials and methodsFifty-six patients suffering from refractory craniofacial pain syndromes were included between 2011 and 2017. There were 33 women and 23 men with a mean age of 50.7 years ± 13.1 (SD) (range: 27–74 years). CT-guided infiltration was performed at the intermediate site of the GON with local anesthetics and cortivazol. Twenty-six (26/56; 46%) patients suffered from chronic migraine, 14 (14/56; 25%) from trigeminal neuralgia and 16 (16/56; 29%) from cluster headaches. Clinical success at 1, 3, and 6 months was defined by a decrease of at least 50% of pain as assessed using visual analog scale (VAS).ResultsMean overall VAS score before infiltration was 8.7 ± 1.3 (SD) (range: 6 - 10). Mean overall VAS scores after infiltration were 2.3 ± 3 (SD) (range: 0 - 10) (P < 0.01) at one month, 3.5 ± 3.3 (SD) (range: 0 - 10) (P < 0.01) at three months and 7.6 ± 1.3 (SD) (range: 1–10) (P < 0.01) at six months. After infiltration, clinical success was achieved in 44 patients (44/56; 78.5%) at 1 month, 37 patients (37/56; 66%) at 3 months and 13 patients (13/56; 23%) at 6 months. Clinical success according to the clinical presentation were as follows: 88% (23/26) at one month, 73% (19/26) at 3 months, and 23% (6/26) at 6 months in patients with chronic migraine, 81% (13/16), 69% (11/16) and 31% (5/16) in those with cluster headaches and 57% (8/14), 50% (7/14) and 14% (2/14) in those with trigeminal neuralgia. No major complications due to CT-guided GON infiltration were reported in any patient.ConclusionCT-guided infiltration at the intermediate site of the GON appears as an effective treatment of craniofacial pain syndromes especially in patients with chronic migraine and those with cluster headaches.     

Intravenous dexamethasone as an adjunct to improve labor analgesia: A randomized,double-blinded,placebo controlled clinical trial

ObjectiveTo study the role of intravenous (i.v.) dexamethasone as an analgesic adjunct in labor analgesia.DesignDouble-blinded randomized controlled trial.SettingLabor analgesia in a tertiary-care teaching hospital.PatientsEighty consenting ASA I-II parturients, age > 18 year, nulliparous, single gestation, cephalic presentation at ≥ 36 wk. of gestation, in early spontaneous labor (cervical dilatation ≤ 5 cm) requesting epidural analgesia.InterventionsThe patients were randomized to two groups. The Dexa group received 8 mg of dexamethasone i.v. in 50 ml normal saline approximately 45 min before the procedure. Placebo group patients received 50 ml normal saline only. All patients underwent epidural labor analgesia per hospital protocol. After an initial bolus, they received continuous background infusion of 5 ml/h of 0.1% of levobupivacaine with 2 μg/ml of fentanyl, with the provision of patient controlled boluses of 5 ml of the same drug combination with a lockout interval of 12 min if needed.MeasurementsPrimary outcome measure: hourly average consumption of neuraxially administered levobupivacaine-fentanyl combination. Secondary outcomes and observations: pain score, maternal satisfaction, sensory and motor block characteristics, hemodynamic parameters of mother, fetal heart rate, duration of second stage of labor, mode of delivery, Apgar scores at 1 and 5 min, and adverse effects.Main resultsAverage hourly drug consumption was significantly lower in Dexa group as compared to Placebo group (10.34 ± 1.79 ml/h vs. 11.34 ± 1.83 ml/h; mean difference 1.007, 95% CI 0.199–1.815; P = 0.015). The median number of bolus doses was 4 (interquartile-range [IQR] 3–5.75) and 5 (IQR 3–6) in the Dexa and Placebo groups, respectively (P = 0.162). There was no significant difference between groups with regard to pain scores, maternal satisfaction and hemodynamics, mode of delivery, and adverse effects.ConclusionsI.v. dexamethasone significantly decreased hourly average drug consumption of levobupivacaine-fentanyl combination through the epidural route, demonstrating the epidural drug dose sparing effect during labor analgesia.