The efficacy of intramuscular ketorolac in combination with intravenous PCA morphine for postoperative pain relief.

STUDY OBJECTIVE: To examine the efficacy of intramuscular (IM) ketorolac used in combination with intravenous (IV) patient-controlled analgesia (PCA) morphine for postoperative pain relief following intra-abdominal gynecologic surgery. DESIGN: Randomized, double-blind, placebo-controlled study. SETTING: Patient care unit at a university medical center. PATIENTS: Thirty-five healthy women undergoing intra-abdominal gynecologic surgery who requested postoperative PCA. INTERVENTIONS: Postoperatively, all patients received IV PCA morphine, with the PCA device programmed to deliver a maximum of 1 mg every 6 minutes (maximum of 30 mg over 4 hours). In addition, patients received one of three regimens: (1) IM saline every 6 hours; (2) IM ketorolac 30 mg while in the postanesthesia care unit (PACU), followed by 15 mg every 6 hours; or (3) IM ketorolac 60 mg while in the PACU, followed by 30 mg every 6 hours. MEASUREMENTS AND MAIN RESULTS: Patients were assessed at regular intervals. Visual analog scale (VAS) scores were used to assess analgesia and patient satisfaction with therapy. Data on morphine usage were obtained from the PCA device, and the frequency and severity of adverse effects were assessed for the presence or absence of side effects. Cumulative morphine dosages were lower (p less than 0.05) in both ketorolac groups at 12, 18, and 24 hours. VAS scores and the frequency of side effects did not differ significantly among groups. CONCLUSIONS: IM ketorolac significantly decreased PCA morphine requirements. The analgesic effects of the two drugs appear to be additive.     

Local infiltration analgesia is not improved by postoperative intra-articular bolus injections for pain after total hip arthroplasty

Background and purpose — The effect of postoperative intra-articular bolus injections after total hip arthroplasty (THA) remains unclear. We tested the hypothesis that intra-articular bolus injections administered every 6 hours after surgery during the first 24 hours would significantly improve analgesia after THA.

Patients and methods — 80 patients undergoing THA received high-volume local infiltration analgesia (LIA; 200 mg ropivacaine and 30 mg ketorolac) followed by 4 intra-articular injections with either ropivacaine (100 mg) and ketorolac (15 mg) (the treatment group) or saline (the control group). The intra-articular injections were combined with 4 intravenous injections of either saline (treatment group) or 15 mg ketorolac (control group). All patients received morphine as patient-controlled analgesia (PCA). The primary outcome was consumption of intravenous morphine PCA and secondary outcomes were consumption of oral morphine, pain intensity, side effects, readiness for hospital discharge, length of hospital stay, and postoperative consumption of analgesics at 3, 6, and 12 weeks after surgery.

Results — There were no statistically significant differences between the 2 groups regarding postoperative consumption of intravenous morphine PCA. Postoperative pain scores during walking were higher in the treatment group from 24–72 hours after surgery, but other pain scores were similar between groups. Time to readiness for hospital discharge was longer in the treatment group. Other secondary outcomes were similar between groups.

Interpretation — Postoperative intra-articular bolus injections of ropivacaine and ketorolac cannot be recommended as analgesic method after THA.     

Reconstruction of the medial patellofemoral ligament for treatment of patellar instability

Background and purpose Postoperative pain is often severe after total knee arthroplasty (TKA). We investigated the efficacy of the local infiltration analgesia (LIA) technique, both intraoperatively and postoperatively.

Methods 48 patients undergoing TKA were randomized into 2 groups in a double-blind study. In group A, 400 mg ropivacaine, 30 mg ketorolac, and 0.5 mg epinephrine were infiltrated periarticularly during operation. In group P, no injections were given. 21 h postoperatively, 200 mg ropivacaine, 30 mg ketorolac, and 0.1 mg epinephrine were injected intraarticularly in group A, and the same volume of saline was injected in group P. All patients were followed up for 3 months.

Results Median morphine consumption was lower in group A during the first 48 h: 18 (1–74) mg vs. 87 (36–160) mg in group P. Postoperative pain was lower at rest in group A during the first 27 h, and on movement during the first 48 h, except at 21 h. Time to fulfillment of discharge criteria was shorter in group A than in group P: 3 (1–7) vs. 5 (2–8) days. Patient satisfaction was higher in group A than in group P on days 1 and 7. The unbound venous blood concentration of ropivacaine was below systemic toxic blood concentrations.

Interpretation The local infiltration analgesia (LIA) technique provides excellent pain relief and lower morphine consumption following TKA, resulting in shorter time to home readiness and higher patient satisfaction. There were few side effects and systemic LA concentrations were low.     

Efficacy of intra-articular bupivacaine, ropivacaine, or a combination of ropivacaine, morphine, and ketorolac on postoperative pain relief after ambulatory arthroscopic knee surgery: a randomized double-blind study

BACKGROUND: Effective pain relief is important after diagnostic and therapeutic arthroscopic knee surgery to permit early discharge and improve comfort and mobility at home. The aim of this study was to assess the efficacy of bupivacaine, ropivacaine, or a combination of ropivacaine, morphine, and ketorolac injected intra-articularly for postoperative pain relief after arthroscopic knee surgery. METHODS: Sixty-three healthy patients undergoing knee arthroscopy under local anesthesia (LA) were randomized to receive 1 of the following substances intra-articularly postoperatively: group B: 30 mL of bupivacaine (150 mg); group R: 30 mL of ropivacaine (150 mg); and group RMK: ropivacaine 150 mg, morphine 4 mg, and ketorolac 30 mg in normal saline (total volume 30 mL). Oral paracetamol 1g and tramadol 50 mg were used as rescue drugs. Postoperatively, pain was assessed at rest and movement, and side effects were recorded. The patients were asked to self-assess pain for 7 days and record analgesic consumption as well as activities of daily living (ADLs). Plasma concentration of LA was measured in another 8 patients. RESULTS: All groups had excellent analgesia at 0 and 4 hours postoperatively. Group RMK had significantly lower visual analog pain score at rest at 8 hours and during movement at 8 and 24 hours compared with the other groups (P<.05). Group RMK required less paracetamol and tramadol on day 1 (P<.05), had less sleep disturbances because of pain, more patients were ready to work on days 1 and 2 (P<.05), and were more satisfied on days 1 and 4 to 7. Postoperatively, plasma concentrations of ropivacaine and lidocaine were far below known systemic toxic concentrations in all patients. CONCLUSION: Addition of morphine and ketolorac to ropivacaine intra-articularly enhances analgesic efficacy of LA, reduces postdischarge analgesic consumption, and improves ADLs without increasing side effects after ambulatory arthroscopic knee surgery.     

Comparison of Morphine, Ketorolac, and Their Combination for Postoperative Pain: Results from a Large, Randomized, Double-blind Trial

Background: Meta-analyses report similar numbers needed to treat for nonsteroidal antiinflammatory drugs (NSAIDs) and opioids. Differences in baseline pain intensity among the studies from which these numbers needed to treat were derived may have confounded the results. NSAIDs have an opioid-sparing effect, but the importance of this effect is unclear. Therefore, the authors sought to compare the proportions of subjects who obtain pain relief with ketorolac versus morphine after surgery and to determine whether the opioid-sparing effect of an NSAID reduces the magnitude of opioid side effects.

Methods: The study was a double-blind, randomized controlled trial. The authors randomly assigned 1,003 adult patients to receive 30 mg ketorolac or 0.1 mg/kg morphine intravenously. They calculated the proportion of subjects who achieved at least 50% reduction in pain intensity 30 min after analgesic administration. Further, so long as pain intensity 30 min after analgesic administration was 5 or more out of 10, patients received 2.5 mg morphine every 10 min until pain intensity was 4 or less out of 10. The authors assessed the presence of opioid-related side effects.

Results: Five hundred patients received morphine and 503 received ketorolac. Fifty percent of patients in the morphine group achieved pain relief, compared with 31% in the ketorolac group (difference, 19%; 95% confidence interval, 13-25%). The ketorolac-morphine group required less morphine (difference, 6.5 mg; 95% confidence interval, -5.8 to -7.2) and had a lower incidence of side effects (difference, 11%; 95% confidence interval, 5-16%) than the morphine group.     

Comparison of the morphine-sparing effects of diclofenac sodium and ketorolac tromethamine after major orthopedic surgery

STUDY OBJECTIVES: To compare the efficacy of diclofenac sodium with ketorolac tromethamine in reducing postoperative morphine use after major orthopedic surgery. DESIGN: Double-blind, randomized, placebo-controlled study. SETTING: Major teaching institution. PATIENTS: 102 ASA physical status II patients undergoing hip and knee replacement with general anesthesia. INTERVENTIONS: Before induction of anesthesia, patients were randomly allocated to receive intravenously either diclofenac sodium 75 mg (Group D), ketorolac tromethamine 60 mg (Group K), or placebo (Group P). Patient-controlled analgesia was supplied postoperatively using morphine. MEASUREMENTS: Visual analog scale (VAS), verbal pain score (VPS), sedation score, frequency of opioid side effects, and morphine consumption were recorded every 4 hours. MAIN RESULTS: There was a highly significant downward trend for VAS, VPS, and sedation scores over time, p = 0.001. The mean VAS and VPS scores were significantly lower in Groups D and K compared with Group P at time 0, p = 0.009 and 8 hours, p = 0.026. The mean (SD) 24-hour morphine requirements were 36.3 mg (16.9), 47.2 mg (34.9), and 51.6 mg (22.2) for Groups D, K, and P, respectively, p = 0.032. Fewer patients suffered from postoperative nausea and vomiting in the treatment groups (Groups D and K) compared with Group P (9, 8, and 19, respectively), p < 0.05. Fewer patients also suffered from pruritus in Groups D and K compared with Group P (3, 4, and 11, respectively), p < 0.01. CONCLUSIONS: Preoperative administration of intravenous diclofenac 75 mg or ketorolac 60 mg significantly reduces morphine requirements and associated side effects after major orthopedic surgery.     

Reduced morphine consumption and pain intensity with local infiltration analgesia (LIA) following total knee arthroplasty: A randomized double-blind study involving 48 patients

Background and purpose

Postoperative pain is often severe after total knee arthroplasty (TKA). We investigated the efficacy of the local infiltration analgesia (LIA) technique, both intraoperatively and postoperatively.

Methods

48 patients undergoing TKA were randomized into 2 groups in a double-blind study. In group A, 400 mg ropivacaine, 30 mg ketorolac, and 0.5 mg epinephrine were infiltrated periarticularly during operation. In group P, no injections were given. 21 h postoperatively, 200 mg ropivacaine, 30 mg ketorolac, and 0.1 mg epinephrine were injected intraarticularly in group A, and the same volume of saline was injected in group P. All patients were followed up for 3 months.

Results

Median morphine consumption was lower in group A during the first 48 h: 18 (1–74) mg vs. 87 (36–160) mg in group P. Postoperative pain was lower at rest in group A during the first 27 h, and on movement during the first 48 h, except at 21 h. Time to fulfillment of discharge criteria was shorter in group A than in group P: 3 (1–7) vs. 5 (2–8) days. Patient satisfaction was higher in group A than in group P on days 1 and 7. The unbound venous blood concentration of ropivacaine was below systemic toxic blood concentrations.

Interpretation

The local infiltration analgesia (LIA) technique provides excellent pain relief and lower morphine consumption following TKA, resulting in shorter time to home readiness and higher patient satisfaction. There were few side effects and systemic LA concentrations were low.     

Bilateral multi-injection iliohypogastric-ilioinguinal nerve block in conjunction with neuraxial morphine is superior to neuraxial morphine alone for postcesarean analgesia

Study ObjectiveTo determine whether bilateral iliohypogastric and ilioinguinal (IHII) peripheral nerve blocks, given in conjunction with neuraxial morphine, reduce postcesarean analgesic requirements and side effects, resulting in improved maternal satisfaction.DesignRandomized, prospective, double-blinded, placebo-controlled study.SettingLabor and delivery suite at Johns Hopkins Hospital.Patients34 women scheduled for elective cesarean delivery.InterventionsPatients were randomized to receive IHII nerve blocks bilaterally, with either total 24 mL of 0.5% bupivacaine or normal saline, following cesarean delivery via Pfannensteil incision with a standard intrathecal dose of 12 mg of 0.75% bupivacaine with 10 µg of fentanyl and 200 µg of preservative-free morphine.MeasurementsPatients were assessed at 0, 6, 12, 18, and 24 hours postoperatively. Visual analog scale (VAS) pain scores at rest were recorded at each time period. Analgesic use, patients’ perception of nausea, vomiting, pruritus, and their overall satisfaction with their analgesia were recorded for the first 24 hours.Main ResultsLower VAS pain scores were seen in the bupivacaine group at 6, 12, 18, and 24 hours postoperatively (P = 0.01, P < 0.01, 0.02, and 0.04, respectively). A longer mean time to first rescue dose of ketorolac was noted in the bupivacaine group (14.3 ± 1.8 hrs) than the saline group (mean 5.6 ±1.1 hrs), (P < 0.01). Fewer patients in the bupivacaine group made requests for acetaminophen 500 mg/oxycodone 5 mg in the first 24 hours. Satisfaction was greater in the bupivacaine group. No difference in side effects was noted between groups.ConclusionsBilateral multilevel injection IHII nerve blocks result in lower resting VAS pain scores, lower analgesic requirements, and greater satisfaction following cesarean delivery in patients who received neuraxial morphine.     

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

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

Preemptive analgesic effects of ketorolac in ankle fracture surgery

BACKGROUND: Preemptive analgesia has been difficult to show in human experiments. If ketorolac has preemptive effects, then there may be an advantage to administering it at the beginning of surgery despite the potential for increased blood loss. METHODS: The authors performed a randomized, double-blind, controlled trial of 48 patients scheduled for ankle fracture surgery in a county trauma hospital. Anesthesia management was standardized and included adequate opioid analgesia (5 microg/kg fentanyl and 0.1 mg/kg morphine). Intravenous 30 mg ketorolac was administered to 23 patients before tourniquet inflation and to 25 patients after tourniquet inflation. Visual analog scale pain scores, morphine patient-controlled analgesia consumption, nausea-vomiting, and postoperative bleeding were measured. RESULTS: The 23 patients given ketorolac before tourniquet inflation had no increase in pain postoperatively compared with their preoperative baseline (P = 0.280). The 25 patients who received ketorolac minutes later after tourniquet inflation had significant increases in their postoperative pain compared with their preoperative baseline (P = 0.00116). This effect was short-lived, and by 6 h the pain score in this group was not significantly more than it was preoperatively. Intergroup comparison showed a lower visual analog scale score at 2 (P = 0.0203) and 4 h (P = 0.00549) in the preemptive group and lower nausea scores at hour 6 (P = 0.00704). There was no difference in patient-controlled analgesia consumption between groups. CONCLUSIONS: Intravenous 30 mg ketorolac appears to have preemptive analgesic effects in patients undergoing ankle fracture repair. Ketorolac administered before tourniquet inflation prevents postoperative pain being perceived as more intense than preoperative pain.     

Low-dose ketorolac improves analgesia and reduces morphine requirements following posterior spinal fusion in adolescents

PURPOSE: To determine if low-dose ketorolac would improve analgesia while minimizing unwanted side effects in adolescents following posterior spinal fusion (PSF). METHODS: A prospective randomized double-blind placebo-controlled trial assessed the analgesic effects of low-dose ketorolac following PSF. Thirty-five adolescents aged 11-17 yr were randomly assigned to receive placebo or 0.5 mg x kg(-1) ketorolac (maximum of 15 mg) six hourly postoperatively for 36 hr in conjunction with standard morphine patient controlled analgesia (PCA). Pain and sedation were assessed twice daily for the first three postoperative days (POD). The incidence of side effects related to both non-steroidal anti-inflammatory agents and opioids were recorded. RESULTS: Adolescents in the ketorolac group received an average dose of 0.2 mg x kg(-1) (average exposure 1.2 mg x kg(-1)), had lower pain scores on POD one and two (P < 0.05) and consumed less morphine in the postanesthesia care unit and on POD two. There was no difference in the incidence of pruritus, nausea, vomiting or constipation, but patients in the ketorolac group tolerated activity better on POD one (P < 0.05). There were no differences between groups with regard to postoperative blood loss or transfusion requirements. Fourteen patients were followed for two years and the incidence of curve progression, hardware failure or back pain at final follow-up was not different. CONCLUSION: Low-dose ketorolac in conjunction with morphine PCA improved the quality of analgesia and reduced morphine requirements following PSF compared to placebo without increasing the incidence of non-steroidal anti-inflammatory side effects.     

Comparison of morphine, ketorolac, and their combination for postoperative pain: results from a large, randomized, double-blind trial

BACKGROUND: Meta-analyses report similar numbers needed to treat for nonsteroidal antiinflammatory drugs (NSAIDs) and opioids. Differences in baseline pain intensity among the studies from which these numbers needed to treat were derived may have confounded the results. NSAIDs have an opioid-sparing effect, but the importance of this effect is unclear. Therefore, the authors sought to compare the proportions of subjects who obtain pain relief with ketorolac versus morphine after surgery and to determine whether the opioid-sparing effect of an NSAID reduces the magnitude of opioid side effects. METHODS: The study was a double-blind, randomized controlled trial. The authors randomly assigned 1,003 adult patients to receive 30 mg ketorolac or 0.1 mg/kg morphine intravenously. They calculated the proportion of subjects who achieved at least 50% reduction in pain intensity 30 min after analgesic administration. Further, so long as pain intensity 30 min after analgesic administration was 5 or more out of 10, patients received 2.5 mg morphine every 10 min until pain intensity was 4 or less out of 10. The authors assessed the presence of opioid-related side effects. RESULTS: Five hundred patients received morphine and 503 received ketorolac. Fifty percent of patients in the morphine group achieved pain relief, compared with 31% in the ketorolac group (difference, 19%; 95% confidence interval, 13-25%). The ketorolac-morphine group required less morphine (difference, 6.5 mg; 95% confidence interval, -5.8 to -7.2) and had a lower incidence of side effects (difference, 11%; 95% confidence interval, 5-16%) than the morphine group. CONCLUSIONS: Opioids are more efficacious analgesics than NSAIDs, although historic data for these two drugs yield similar numbers needed to treat. Adding NSAIDs to the opioid treatment reduces morphine requirements and opioid-related side effects in the early postoperative period.     

Comparison of low-dose intrathecal and epidural morphine and bupivacaine infiltration for postoperative pain control after surgery for lumbar disc disease

This prospective, blinded, placebo-controlled study was performed to compare the postoperative analgesic efficacy of low-dose intrathecal and epidural morphine with paraspinal muscle infiltration of bupivacaine in lumbar discectomy cases. Eighty ASA I-III adult patients undergoing elective surgery for lumbar disc disease were enrolled in the study. Patients were randomized to four groups by envelopes. Study groups were as follows: group 1 (n = 20), intrathecal morphine 0.1 mg; group 2 (n = 20), epidural morphine 2 mg; group 3 (n = 20), 30 mL of bupivacaine 0.25% paraspinal muscle infiltration; group 4 (n = 20), 30 mL of saline paraspinal muscle infiltration before wound closure. Recorded parameters were time to response to painful and verbal stimuli and postoperative pain assessed at 30 minutes and 2, 4, 6, 8, 12, and 24 hours by Visual Analog Scale (VAS) and Numeric Pain Scale (NPS). Hemodynamic data, sedation scores, and side effects were also recorded. Meperidine and naproxen sodium were used for postoperative analgesia. Follow-up was performed by a blinded investigator. Mean VAS scores were lower in groups 1 and 2 at 30 minutes (P < 0.05). Mean VAS score of group 2 was lower than that of group 4 at 4 hours postoperatively (P < 0.05). Mean NPS scores were lower in groups 1 and 2 at 2, 4, and 6 hours (P < 0.05) and in group 2 at 8 hours compared with the other groups. The number of patients requiring meperidine at early postoperative phase (0-6 hours) was less in groups 1 and 2 compared with groups 3 and 4 (P < 0.05).There were no statistically significant differences in the late postoperative analgesic requirements, after correction for multiple testing. In conclusion, low-dose intrathecal and epidural morphine provide lower postoperative pain scores and a reduction in early postoperative analgesic requirement with insignificant side effects compared with paraspinal bupivacaine or saline infiltration.     

Preemptive Analgesic Effects of Ketorolac in Ankle Fracture Surgery

Background: Preemptive analgesia has been difficult to show in human experiments. If ketorolac has preemptive effects, then there may be an advantage to administering it at the beginning of surgery despite the potential for increased blood loss.

Methods: The authors performed a randomized, double-blind, controlled trial of 48 patients scheduled for ankle fracture surgery in a county trauma hospital. Anesthesia management was standardized and included adequate opioid analgesia (5 [mu]g/kg fentanyl and 0.1 mg/kg morphine). Intravenous 30 mg ketorolac was administered to 23 patients before tourniquet inflation and to 25 patients after tourniquet inflation. Visual analog scale pain scores, morphine patient-controlled analgesia consumption, nausea-vomiting, and postoperative bleeding were measured.

Results: The 23 patients given ketorolac before tourniquet inflation had no increase in pain postoperatively compared with their preoperative baseline (P = 0.280). The 25 patients who received ketorolac minutes later after tourniquet inflation had significant increases in their postoperative pain compared with their preoperative baseline (P = 0.00116). This effect was short-lived, and by 6 h the pain score in this group was not significantly more than it was preoperatively. Intergroup comparison showed a lower visual analog scale score at 2 (P = 0.0203) and 4 h (P = 0.00549) in the preemptive group and lower nausea scores at hour 6 (P = 0.00704). There was no difference in patient-controlled analgesia consumption between groups.     

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

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

Postoperative analgesia with i.v. patient-controlled morphine: effect of adding ketamine

We have studied the effect of adding ketamine to i.v. morphine patient- controlled analgesia (PCA) for the treatment of pain after laparotomy. Thirty patients were allocated randomly to receive PCA with saline or ketamine in a double-blind, randomized study. Analgesia was started in the recovery room when visual analogue scale (VAS) scores were > 4. A bolus dose of morphine 3 mg was given to all the patients followed by i.v. PCA. Simultaneously, an infusion of ketamine 2.5 micrograms kg-1 min-1 or saline was started. Pain scores, morphine consumption and side effects were noted for up to 48 h after the start of PCA. VAS scores decreased significantly with time (P = 0.0001) and were similar (P = 0.3083) in both groups. Cumulative morphine consumption at 48 h was significantly lower in the ketamine group (28 mg) than in the control group (54 mg) (P = 0.0003). Nausea was less frequent in the ketamine group (P = 0.03).      

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.     

Intraarticular patient-controlled regional anesthesia after arthroscopically assisted anterior cruciate ligament reconstruction: ropivacaine/morphine/ketorolac versus ropivacaine/morphine

Anterior cruciate ligament reconstruction (ACLR) is associated with moderate to severe postoperative pain. We compared the intraarticular analgesic effects of ropivacaine and morphine with or without ketorolac and the need for rescue IV morphine at rest and during movement in patients undergoing anterior cruciate ligament reconstruction during spinal anesthesia. Thirty-nine patients receiving intraarticular patient-controlled regional analgesia with a 10-mL bolus and a 60-min lockout interval were randomized into 3 groups: the RM group received 0.25% ropivacaine and morphine 0.2 mg/mL; the RMK group received 0.25% ropivacaine, morphine 0.2 mg/mL and ketorolac 1 mg/mL; the P group received saline. Analgesic mixtures were prepared in 100-mL bags and coded. If needed, rescue morphine 2 mg was self-administered IV with 10-min lockout intervals. Pain scores and patient satisfaction were assessed at rest and during movement. There were no significant differences among the groups in pain scores and patient satisfaction. Daily morphine consumption was significantly smaller in the RMK group (8 +/- 8 mg) compared with the RM group (23 +/- 20 mg; P = 0.002) and in both groups compared with control (46 +/- 21 mg; P < 0.001). We conclude that intraarticular patient-controlled regional analgesia provides effective pain relief after anterior cruciate ligament reconstruction. The combination of intraarticular ropivacaine, morphine, and ketorolac was superior to control or to a combination of ropivacaine and morphine. IMPLICATIONS: This study showed the feasibility and efficacy of intraarticular patient-controlled regional analgesia technique for pain relief after anterior cruciate ligament reconstruction. The combination of intraarticular ropivacaine, morphine, and ketorolac was superior to control or to a combination of ropivacaine and morphine.     

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.     

Postoperative Pain After Lumbar Disc Surgery: A Comparison Between Parenteral Ketorolac and Narcotics

Summary  Objective. Lumbar discectomy is a common elective surgical procedure but many patients still experience postoperative back pain which may delay hospital discharge. We therefore evaluated the efficacy of a parenteral non-steroidal antiinflammatory agent, ketorolac, for the management of post-surgical pain.  Methods. Fifty three patients undergoing lumbar discectomy at a Medical School affiliated Veterans Administration hospital were randomly assigned to receive either: 1) 30 mg intramuscular ketorolac upon surgical closure and every 6 hours for 36 hours and narcotic analgesics as needed (PRN); or 2) only narcotic analgesics as needed. A blinded observer recorded the average, minimum and maximum postoperative pain intensity using a Numeric Pain Intensity Scale; total postoperative narcotic consumption, complications, length of hospitalization (from surgery to discharge) and outcome at 6 weeks.  Results. The patients who received ketorolac reported significantly lower average (p<0.001), minimum (p<0.001), and maximum (p<0.001) pain scores than patients receiving only narcotic analgesics. Cumulative narcotic doses (standardized to parenteral morphine) were significantly lower in the ketorolac group (p< 0.001). There was no significant difference between groups in the frequency of side effects, and no complication specifically associated with ketorolac use was observed. Mean length of hospitalization was significantly shorter (p=0.05) in patients receiving ketorolac than in patients receiving only narcotics. Six weeks after surgery 5 (19.2%) patients who received only narcotics were troubled by persistent back pain. By contrast, all patients who received ketorolac were free of back pain at follow-up (p=0.03).  Conclusions. These results suggest that ketorolac, when used with PRN narcotics, is more effective than PRN narcotics alone for postoperative pain following lumbar disc surgery. In addition, this strategy also may contribute to early discharge from hospital after lumbar disc surgery.