Ultrasound-guided bilateral transversus abdominis plane blocks in conjunction with intrathecal morphine for postcesarean analgesia

Study ObjectiveTo determine whether transversus abdominis plane (TAP) blocks administered in conjunction with intrathecal morphine provided superior analgesia to intrathecal morphine alone.DesignRandomized, double-blind, placebo-controlled study.SettingOperating room of a university hospital.Patients51 women undergoing elective Cesarean delivery with a combined spinal-epidural technique that included intrathecal morphine.InterventionsSubjects were randomized to receive a bilateral TAP block with 0.5% ropivacaine or 0.9% saline. Postoperative analgesics were administered on request and selected based on pain severity.MeasurementsPatients were evaluated at 2, 24, and 48 hours after the TAP blocks were performed. Verbal rating scale (VRS) pain scores at rest, with movement, and for colicky pain were recorded, as was analgesic consumption. Patients rated the severity of opioid side effects and their satisfaction with the procedure and analgesia.Main Results51 subjects received TAP blocks with ropivacaine (n = 26) or saline (n = 25). At two hours, the ropivacaine group reported less pain at rest and with movement (0.5 and 1.9 vs 2.8 and 4.9 in the saline group [VRS scale 0 – 10]; P < 0.001) and had no requests for analgesics; there were several requests for analgesia in the saline group. At 24 hours, there was no difference in pain scores or analgesic consumption. At 48 hours, the ropivacaine group received more analgesics for moderate pain (P = 0.04) and the saline group received more analgesics for severe pain (P = 0.01).ConclusionsTransversus abdominis plane blocks in conjunction with intrathecal morphine provided superior early postcesarean analgesia to intrathecal morphine alone. By 24 hours there was no difference in pain scores or analgesic consumption.     

Quadratus lumborum block for postoperative analgesia after cesarean delivery: A systematic review with meta-analysis and trial-sequential analysis

Study objectiveThe aim of this study was to investigate the analgesic efficacy of Quadratus lumborum block (QLB) versus controls, transversus abdominis plane (TAP) block and neuraxial morphine, or when added to neuraxial morphine in women undergoing cesarean delivery.DesignSystematic review and meta-analysis with trial sequential analysis.PatientsParturients undergoing cesarean delivery.InterventionQuadratus lumborum block for postoperative analgesia.MeasurementsThe primary outcomes were dynamic and static pain scores and cumulative opioid consumption at 24 h. Secondary outcomes were dynamic and static pain scores and opioid consumption at 6 and 12 h. Certainty of evidence was assessed using the GRADE system. Trial sequential analyses (TSA) were performed to determine if the results are supported by sufficient data.Main resultsTen studies involving 761 parturients were included. Compared to controls, no difference in dynamic (MD -6; 95%CI -17 to 5) or static (MD -5; 95%CI -14 to 3) pain scores were noted with QLB at 24 h (moderate certainty), although opioid consumption (MD −10.64 mg morphine equivalents; −16.01 to −5.27) was reduced (high certainty), supported by sufficient data. QLB reduced dynamic pain at 6 h, and static pain and opioid consumption at 6 and 12 h compared to controls. Compared to neuraxial morphine, QLB did not alter opioid consumption or pain scores at 24 h (low certainty), although TSA suggests insufficient data. Due to limited data, meta-analysis and TSA were not performed to compare QLB and TAP blocks. Addition of QLB to neuraxial morphine did not alter dynamic and static pain scores at 24 h (moderate certainty, supported by sufficient data).ConclusionsQLB improves post-cesarean delivery analgesia in parturients not receiving neuraxial morphine. Addition of QLB to parturients receiving neuraxial morphine has no significant analgesic benefit. Insufficient data are available to draw firm conclusions of QLB compared to TAP blocks or neuraxial morphine.     

Respiratory depression after administration of single-dose neuraxial morphine for post-cesarean delivery analgesia: a retrospective cohort study

BackgroundNeuraxial administration of long-acting opioid is the “gold standard” for the management of postoperative pain following cesarean delivery. Respiratory depression, however, remains a concerning complication.MethodsThis retrospective single-center study of 4963 patients evaluated the frequency of respiratory depression after neuraxial morphine administration in a post-cesarean delivery population. The spinal dose of morphine varied from 100 to 450 µg intrathecally, and from 3 to 5 mg epidurally. The primary outcome was the initiation of a Rapid Response Team (RRT) event for respiratory failure due to neuraxial opioid in the 24 h following morphine administration. Secondary outcomes studied included oxygen desaturation events (SpO₂ <90%), initiation of oxygen therapy and naloxone administration.ResultsThere were no respiratory RRT events within the study period (95% confidence interval [CI] 0 to 7 per 10 000). There were no desaturation events recorded and no patients received supplemental oxygen therapy or naloxone (95% CI 0 to 7 per 10 000).ConclusionClinically significant respiratory depression is rare among patients receiving neuraxial morphine for post-cesarean delivery analgesia.     

Intrathecal fentanyl added to bupivacaine and morphine for cesarean delivery may induce a subtle acute opioid tolerance

BackgroundPrevious studies have demonstrated that the addition of intrathecal fentanyl to a spinal anesthetic for cesarean delivery improves intraoperative analgesia. However, intrathecal fentanyl may induce acute tolerance to opioids. The objective of this study was to investigate whether the addition of intrathecal fentanyl to spinal anesthesia with intrathecal morphine increases postoperative analgesic requirements and pain scores.MethodsIn this randomized, double-blinded study, 40 women having elective cesarean delivery were enrolled. Patients received spinal anesthesia with hyperbaric bupivacaine 12 mg, morphine 200 μg, and fentanyl 0, 5, 10 or 25 μg. Each patient received intravenous patient-controlled analgesia morphine for 24 h postoperatively. Outcome measures included postoperative morphine usage and pain scores, as well as intraoperative pain, nausea, hypotension and vasopressor use.ResultsTotal morphine use over the 24-h post-spinal study period was similar among the study groups (P = 0.129). Postoperative pain scores were higher in patients receiving fentanyl 5, 10 and 25 μg compared to fentanyl 0 μg control group (P = 0.003).ConclusionsThe study results suggest that intrathecal fentanyl may induce acute tolerance to intrathecal morphine. However, because there was no difference in postoperative analgesia requirement and the difference in pain scores was small, the clinical significance of this finding is uncertain.     

Neuraxial morphine after unintentional dural puncture is not associated with reduced postdural puncture headache in obstetric patients

Study objectiveTo examine the relationship between neuraxial morphine exposure after unintentional dural puncture and the risk for postdural puncture headache in obstetric patients.DesignRetrospective cohort study.SettingObstetrical unit at a tertiary care referral center.PatientsParturients receiving labor epidural analgesia with recognized unintentional dural puncture.InterventionsCases in which neuraxial morphine was given for any reason were compared to cases in which it was not for the outcome of postdural puncture headache.MeasurementsDevelopment of postdural puncture headache, headache severity, number of epidural blood patches, hospital length of stay.Main resultsOf the 80 cases that were included, 38 women received neuraxial morphine and 42 did not. There was no significant difference in the incidence of headache between the two morphine groups (Headache present: Morphine: 27/56 [48.2%], No morphine: 29/56 [51.8%]; Headache free: Morphine: 11/24 [45.8%], No morphine: 13/24 [54.2%], P = 0.84). There was no difference in the need for epidural blood patch (Morphine: 24/42 [57.1%], No morphine: 18/38 [47.4%], P = 0.50) and headache severity (mean headache pain score: Morphine: 7.9 ± 1.8 vs. No morphine: 7.3 ± 2.4, P = 0.58). Hospital length of stay was higher in the morphine group (4.4 ± 2.9 days vs. 3.0 ± 1.5 days respectively, P = 0.008). Using logistic regression, morphine did not affect headache risk after controlling for covariates (morphine vs. no morphine: adjusted OR 1.24 [0.75]; P = 0.72; pre-eclampsia vs. no pre-eclampsia: adjusted OR 0.56 [0.41], P = 0.42; cesarean vs. normal spontaneous vaginal delivery: adjusted OR 0.97 [0.67]; P = 0.96).ConclusionIn cases of unintentional dural puncture, exposure to neuraxial morphine for any reason may not be protective against the risk of postdural puncture headache. Although an overall protective effect of neuraxial morphine was not observed in this study, its role in specific subsets of patients remains to be investigated.     

Effect of the addition of clonidine to locally administered bupivacaine on acute and chronic postmastectomy pain

Study ObjectivesTo investigate the analgesic effect of adding clonidine to topical bupivacaine for acute and chronic postmastectomy pain.DesignRandomized, prospective, double-blinded study.SettingCancer institute and university hospital.Patients140 ASA physical status 1 and II women, aged 30 to 50 years, scheduled for modified radical mastectomy with axillary dissection for breast carcinoma.InterventionsPatients were divided into 4 groups of 35 patients each, to receive either saline 0. 9% (control group), plain bupivacaine 0.5% (Bupivacaine group), plain bupivacaine 0.5% and 150 μg of clonidine (Clonidine150 group), or plain bupivacaine 0.5% and 250 μg of clonidine (Clonidine250 group). Study drugs were irrigated into the surgical field before skin closure.Measurements and Main ResultsPain severity, time to first request of rescue analgesia, analgesic consumption, hemodynamics, and side effects were recorded in the first 48 hours postoperatively. The frequency of neuropathic pain was assessed using the Douleur Neuropathique 4-question survey (DN4) in the first and second postoperative months. Mean time to first postoperative analgesic request was significantly prolonged in the Bupivacaine (5.76 ± 0.85 hrs), Clonidine150 (11.6 ± 2.38 hrs), and Clonidine250 (17.4 ± 3.27 hrs) groups compared with the control group (1.86 ± 0.65 hrs). Postoperative tramadol consumption and visual analog scores (VAS) were significantly reduced in the Bupivacaine, Clonidine150, and Clonidine250 groups. Clonidine250 group patients had the lowest VAS scores from 2 to 48 hours postoperatively. Lower mean DN4 scores (P = 0.000) and a significantly reduced frequency of neuropathic pain (P < 0.04) were recorded in the Bupivacaine, Clonidine150, and Clonidine250 groups, with a nonsignificant difference noted among the treatment groups.ConclusionsThe addition of clonidine to topical bupivacaine accentuated its early postoperative analgesic efficacy.     

The effect of posterior tibial and sural nerve blocks on postoperative pain of patients following open reduction and internal fixation of calcaneal fractures

IntroductionPostoperative pain control and achieving opioid-free anesthesia are major issues for surgically treated patients with calcaneal fractures. We evaluated the potential role of posterior tibial and sural nerve blocks as a part of multimodal pain control techniques in patients underwent open reduction and internal fixation (ORIF) of calcaneal fractures via extensile lateral approach.MethodsForty-eight patients randomly allocated to receive either posterior tibial and sural nerve blocks with bupivacaine (peripheral nerve block (PNB) group) or normal saline, after induction of general anesthesia. Patients were assessed for pain intensity, Interval from entrance to the recovery room to the first request for analgesic, recovery room and ward morphine consumption, global satisfaction and morphine side effects.ResultsPNB group had less pain score compared to sham block (SB) group at each time point measurement during recovery room stay. There was also significant difference between the 2 groups regarding the pain scores after 2, 4 and 6 h of the operation in the ward. Time to the first request for analgesic was significantly prolonged in the PNB group (P < 0.001). The recovery room and ward morphine consumption was significantly lower in the PNB group (P < 0.001). Global satisfaction in PNB group was significantly more than that of SB group. No complication related to the nerve block was detected at the first postoperative visit in the outpatient clinic.ConclusionPeripheral nerve block could result in less postoperative pain especially in the early hours after ORIF of calcaneal fractures and reduce opioid administration within the first 24 h following the surgery.     

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.     

Single-injection femoral nerve block lacks preemptive effect on postoperative pain and morphine consumption in total knee arthroplasty

ObjectivePostoperative pain is severe after total knee arthroplasty (TKA). Therefore, femoral nerve block (FNB) is commonly used as an adjuvant to spinal anesthesia for TKA. Some anesthesia providers perform this preoperatively, while others perform it postoperatively. To our knowledge, no study has compared the relative benefits of the timing of performing the procedure. In this study, we investigated whether preoperative FNB would provide better analgesic effects than postoperative FNB in patients undergoing unilateral TKA.MethodsIn this double-blind, randomized, controlled trial, we divided 82 patients (ASA physical status I–III) undergoing unilateral TKA into four groups: (1) a pre-treatment group, in which FNB was performed with 0.4 mL/kg 0.375% bupivacaine plus 1:200,000 epinephrine after spinal anesthesia but before the operation; (2) a post-treatment group, in which FNB was performed with the same drugs at similar dosages immediately after the operation; (3) a pre-control group, in which FNB was performed with normal saline in the same volume as the tested drugs before the operation; and (4) a post-control group, in which FNB was performed with normal saline in the same volume as the tested drug after the operation. At 2, 4, 6, 24, 48 and 72 postoperative hours, we recorded cumulative morphine consumption, visual analog pain scales (VAS), the time of first request for morphine and its side effects. We also measured knee maximum flexion range of motion once a day for 3 days. Our primary aim was to obtain cumulative morphine consumption in 24 hours.ResultsWithin the postoperative 24 hours, we found significant differences in cumulative morphine consumption between patients who received true FNB and those who did not (at 24 hours, treatment groups = 45.6 ± 31.7 and 33.5 ± 20.6 mg vs. controls = 70.8 ± 31.2 and 78.8 ± 37.7 mg, p < 0.001). We also found significant differences in VAS (at 24 hours, p < 0.001) and time to first request of morphine (p = 0.005) between the treatment group and the sham group. However, there were no significant differences in these values between the pre-surgical treatment group and the post-surgical treatment group. Beyond 24 hours, there were no significant differences in morphine consumption or maximum flexion range on day 2 and day 3 among the four groups.ConclusionPatients who received FNB used for total knee arthroplasty consumed significantly less postoperative morphine and had significant relief of post-TKA pain on postoperative day 1 than those who did not have FNB. However, at follow-up we found no significant differences in these values between those receiving FNB before surgery and those receiving it after surgery.     

A comparison of epidural magnesium and/or morphine with bupivacaine for postoperative analgesia after cesarean section

BackgroundMagnesium can potentiate the antinociceptive effect of morphine. This prospective randomized double-blinded study was undertaken to establish the analgesic effect of adding magnesium to epidural morphine during cesarean section.MethodsTwo hundred patients undergoing cesarean section under combined spinal–epidural anesthesia were recruited. After administration of intrathecal bupivacaine 10 mg, patients were randomly assigned to receive one of four epidural study solutions: 0.1% bupivacaine 10 mL (Group B); 0.1% bupivacaine 10 mL and morphine 1.5 mg (Group B+Mor); 0.1% bupivacaine 10 mL and magnesium 500 mg (Group B+Mg); or 0.1% bupivacaine 10 mL morphine 1.5 mg and magnesium 500 mg (Group B+Mor+Mg). The primary outcome was the area under the curve for visual analog scale pain scores during 36 h postoperatively. Secondary outcomes included time to the use of rescue analgesics, patient satisfaction and side effects.ResultsPatients in Group B+Mor+Mg had lower for pain scores and area under the curve pain scores both at rest and on movement, increased time for first analgesic request, and increased satisfaction score at 24 h after surgery.ConclusionAddition of magnesium 500 mg and morphine 1.5 mg to epidural 0.1% bupivacaine 10 mL reduced postoperative pain compared with addition of morphine or magnesium alone or no additive.     

Post-cesarean gabapentin is not associated with lower opioid consumption or pain scores in women on chronic buprenorphine therapy: A 10-year retrospective cohort study

Study objectiveTo determine if postoperative gabapentin administration is associated with decreased opioid consumption or pain scores following cesarean delivery in women on chronic buprenorphine.DesignRetrospective cohort study.SettingPostoperative recovery area and postpartum inpatient unit.Patients214 women undergoing cesarean delivery while on chronic buprenorphine at a single institution between 2007 and 2017.InterventionsGabapentin treatment for post-cesarean analgesia.MeasurementsThe primary outcome was opioid consumption in morphine milligram equivalents, comparing patients who received ≥1 dose of gabapentin within 24 h of cesarean delivery to those who did not. Secondary outcomes included opioid consumption 24–48 and 48–72 h post-cesarean and postoperative numerical rating scale pain scores.Main resultsOf 214 included patients, 64 (30%) received gabapentin while 150 (70%) did not. Gabapentin patients were more likely than controls to have received neuraxial fentanyl (30% vs. 14%, p = 0.01) and transversus abdominis plane block (6% vs. 1%, p = 0.05) and overall received higher doses of ketorolac and acetaminophen. Control patients were more likely to have received neuraxial morphine (78% vs. 90%, p = 0.04) and received higher doses of ibuprofen. In unadjusted analysis, there was no significant difference in morphine milligram equivalent consumption 0–24 h postoperatively between gabapentin (55 mg [IQR 26,84]) and control (53 mg [IQR 28,75]) groups (p = 0.38). After controlling for potential confounders, there remained no significant effect of gabapentin administration (overall effect p = 0.99). Opioid consumption and pain scores were also not significantly different at any other time points.ConclusionsIn parturients receiving chronic buprenorphine, inclusion of gabapentin in a multimodal analgesic regimen was not associated with lower opioid consumption or pain scores during the first 72 h after cesarean delivery. Prospective randomized studies are needed to confirm these findings.     

Patient and procedural risk factors for increased postoperative pain after cesarean delivery under neuraxial anesthesia: a retrospective study

BackgroundThere is significant interindividual variability in pain experienced after cesarean delivery. The goal of this study was to identify risk factors for increased postoperative pain in women undergoing cesarean delivery under neuraxial anesthesia with neuraxial morphine.MethodsA retrospective chart review was conducted (June 1, 2013 to August 25, 2015). Patients were categorized into three groups, according to the weighted area-under-the-curve (AUC) of pain scores within 48 h of surgery, as mild (weighted AUC 0–3), moderate (4–6) or severe (7–10) pain. We evaluated potential factors that could influence variability in pain, including patient demographics, comorbidities, obstetric history, and surgical details.ResultsA total of 1899 patients were included in the analysis. Pain was mild in 896 patients, moderate in 895, and severe in 108 patients. In the multivariable analysis, the following factors were associated with increased pain severity: history of chronic pain (OR 4.12, 95% CI 1.15 to 14.75]), current tobacco use (2.52, 1.17 to 5.44), pre-existing anxiety (1.93, 1.21 to 3.07), receipt of intra-operative intravenous ketamine or fentanyl (1.56, 1.21 to 2.01), and repeat cesarean delivery (1.54, 1.18 to 2.02). Being of non-Black race and having private health insurance were associated with lower pain severity (OR 0.44, 95% CI 0.31 to 0.62 and 0.51, 0.39 to 0.68, respectively). The overall accuracy of the model was 56%.ConclusionsCertain patient and procedural factors were associated with higher levels of reported postoperative pain. Patients with those factors may require a more targeted analgesic strategy for post-cesarean delivery pain control.     

Intrathecal bupivacaine with morphine or neostigmine for postoperative analgesia after total knee replacement surgery

PURPOSE: To compare the postoperative analgesic efficacy and safety of intrathecal (IT) neostigmine and IT morphine in patients undergoing total knee replacement under spinal anesthesia. METHODS: Sixty patients scheduled for elective total knee replacement under spinal anesthesia were randomly divided into three equal groups which received IT 0.5% hyperbaric bupivacaine 15 mg with either normal saline 0.5 mL, neostigmine 50 microg, or morphine 300 microg. The maximal level of sensory block, duration of analgesia, time to use of rescue analgesics, the overall 24-hr and four-hour interval visual analogue scale (VAS) pain score, and the incidence of adverse effects were recorded for 24 hr after administration. RESULTS: There was no significant difference in maximal level of sensory block among the three groups. The morphine group had a later onset of postsurgical pain and longer time to first rescue analgesics than the neostigmine group (P <0.05). Overall 24-hr VAS pain scores were significantly higher in the saline group vs the morphine and neostigmine groups (P <0.05). Motor block lasted significantly longer in the neostigmine group than in the morphine and saline groups (P <0.05). The incidence of adverse effects was similar in the neostigmine and morphine groups except for pruritus (70%) occurring more frequently in the morphine group than in the neostigmine and saline groups (0%; P <0.05). Overall satisfaction rates were better in the neostigmine group than in the morphine and saline groups (P <0.05). CONCLUSIONS: IT neostigmine 50 microg produced postoperative analgesia lasting about seven hours with fewer side effects and better satisfaction ratings than IT morphine 300 microg.     

Comparative study of continuous extrapleural intercostal nerve block and lumbar epidural morphine in post-thoracotomy pain

Objectives

To compare the efficacy of continuous extrapleural intercostal nerve block with bupivacaine 0.5% in 1:200 000 epinephrine and continuous lumbar epidural block with morphine in controlling post-thoracotomy pain and to measure serum bupivacaine concentrations during extrapleural infusion.

Design

A prospective, randomized, controlled trial.

Setting

St. Joseph’s Hospital, Hamilton, Ont., a tertiary care teaching centre.

Patients

Sixty-one patients booked for elective thoracotomy were randomized by sealed envelope to two groups.

Interventions

Group A received a continuous extrapleural intercostal nerve block with bupivacaine 0.5% in 1:200 000 epinephrine as a bolus of 0.3 mL/kg followed by an infusion of 0.1 mL/kg every hour for 72 hours. Group B received a continuous lumbar epidural block with morphine as a bolus of 70 g/kg followed by an infusion of 7 g/kg every hour for 72 hours.

Main outcome measures

Pain was assessed by a linear visual analogue scale (VAS) pain score. The cumulative amount of “rescue” intravenous morphine used, and serum bupivacaine concentrations were measured as secondary outcomes.

Results

Pain control was the same in both groups as assessed by linear VAS score (p = 0.33). The cumulative dose of intravenous morphine for supplemental analgesia was statistically significant between the groups: group A patients used more morphine than group B (p < 0.05). Accumulation of serum bupivacaine was present with no clinical toxicity.

Conclusions

There is no significant difference in the degree of post-thoracotomy pain control measured by the VAS score when analgesia is provided by continuous extrapleural intercostal nerve block with bupivacaine 0.5% in 1:200 000 epinephrine or lumbar epidural block with morphine. Larger amounts of rescue analgesia were used by patients in the continuous extrapleural group with bupivacaine than those in the continuous lumbar epidural block with morphine. Serum bupivacaine concentrations rise without clinical toxicity.     

Does Nefopam Provide Analgesic Effect and Reduce Morphine Consumption After Primary Total Knee Arthroplasty? A Prospective,Double-Blind,Randomized Controlled Trial

BackgroundOne of the most undesirable results after total knee arthroplasty (TKA) is severe immediate postoperative pain, resulting in patient dissatisfaction. We aimed to evaluate nefopam’s analgesic efficacy after primary TKA along with related outcomes, including morphine consumption and adverse events.MethodsWe conducted a double-blind, randomized controlled trial of patients undergoing unilateral primary TKA, comparing 24 hours of 80 mg of continuous intravenous nefopam to placebo infusion. A 100-mm Visual Analog Scale (VAS) for pain-at-rest and in-motion ≤48 hours was the primary outcome measure. Secondary outcomes were morphine and antiemetic consumption, adverse events, and functional outcomes: time-to-walk, timed up-and-go test, postoperative knee range of motion at 24 and 48 hours, time-to-discharge, and patient satisfaction scores.ResultsPatients in the nefopam group had significantly lower VAS at rest 6 hours postop (20.3 ± 27.3 vs 35 ± 24.3, P = .01). Other timepoints and in-motion VAS did not significantly differ. Total morphine consumption (0-48 hours) was 37% less, significantly lower, in the nefopam group (5.3 ± 4.5 vs 8.4 ± 7.5 mg, P = .03). Antiemetic consumption was also 61% lower in the nefopam group but not statistically significant (0.8 ± 2.3 vs 2.0 ± 3.8 mg, P = .08). There were no variations in adverse events, functional outcomes, and satisfaction scores between groups.ConclusionContinuous nefopam administration as part of multimodal analgesia for 24 hours post-TKA produced a significant analgesic effect but only within the first 6 hours. However, there was a notable reduction in morphine use 48 hours postop. Nefopam is a useful agent for contemporary pain control after TKA.Level of EvidenceTherapeutic Level I.     

Neuraxial opioids for post-cesarean delivery analgesia: can hydromorphone replace morphine? A retrospective study

BackgroundCesarean delivery is the most common surgical procedure performed in the USA. We evaluated the postoperative analgesic properties of neuraxial hydromorphone compared to neuraxial morphine for post-cesarean delivery analgesia.MethodsA retrospective chart review was performed of women who underwent cesarean delivery and received neuraxial anesthesia from March to November 2011 and from March to November 2012. A total of 450 patients received intrathecal morphine 200 μg and 387 patients received intrathecal hydromorphone 60 μg. Eighty-one patients received epidural morphine 3 mg and 102 patients received epidural hydromorphone 0.6 mg.ResultsMedian time to first opioid after intrathecal morphine was 17.0 h versus 14.6 h after intrathecal hydromorphone (P <0.0001). Patients who received intrathecal hydromorphone consumed more opioids in the first 24 h; 37.0 mg versus 26.4 mg oral morphine equivalents (P <0.001). The side effect profile between the intrathecal groups was similar. Median time to first opioid with epidural morphine was 20.1 h versus 13.0 h with epidural hydromorphone (P=0.0007). Total opioid consumption was not significantly different between the epidural groups. The side effect profiles were similar.ConclusionsHydromorphone is a reasonable alternative to morphine for post-cesarean delivery analgesia. With the dosing used in our study, analgesia from morphine lasted longer than hydromorphone via intrathecal and epidural routes; however, neuraxial hydromorphone remains a reasonable option for long-acting analgesia post cesarean delivery.     

Incidence of respiratory depression after epidural administration of morphine for cesarean delivery: findings using a continuous respiratory rate monitoring system

BackgroundEpidural morphine is widely used for postoperative analgesia after cesarean delivery. However, respiratory depression can occur after neuraxial administration of morphine. Previous reports describing respiratory depression in obstetric patients have relied on intermittent visual counting of the respiratory rate. In this study, we estimated the incidence of respiratory depression in patients who had received epidural morphine after cesarean delivery, using a continuous respiratory rate monitoring system with a finger sensor.MethodsOne hundred patients scheduled to undergo elective cesarean delivery and receive intraoperative neuraxial morphine between April and December 2016 were recruited for this single-center, prospective observational study. Postoperatively, all patients received epidural morphine 3 mg and were equipped with the Nellcor respiratory rate monitoring system. Respiratory depression was defined as both bradypnea (respiratory rate ≤10 breaths/min) and oxygen desaturation (mild ≤95%; moderate ≤90%; severe ≤85%) for longer than one minute. The number of patients with respiratory depression between administration of morphine and first ambulation was recorded hourly.ResultsComplete monitoring was obtained for 89 of 100 women. The median duration of monitoring was 19.0 hours. Forty-six patients (52%) developed mild respiratory depression at least once before ambulation, but only one (1%) developed moderate respiratory depression. None required supplemental oxygen or naloxone.ConclusionsApproximately half the women experienced mild respiratory depression, but only one developed moderate respiratory depression. Continuous respiratory rate monitoring until ambulation may assist in early identification of respiratory depression after neuraxial administration of morphine.     

Analgésie après cholécystectomie par voie cœlioscopique par administration intrapéritonéale de bupivacaïne

ObjectivesThe aims of this study were to assess the analgesic effect of the intraperitoneal topical administration of 0.375% bupivacaine in patients undergoing laparoscopic cholecystectomy and to carry out a pharmacokinetic study of bupivacaine administered topically by intraperitoneal route.Study designRandomized, double-blind controlled trial.Patients and methodsTwenty-four patients of ASA physical status 1 or 2, undergoing elective laparoscopic cholecystectomy, were included. Anaesthesia technique was the same for all patients. At the end of surgery, they were randomly assigned to one of two groups. Patients in group bupivacaine were administered 0.375% bupivacaine, 0.6 mL·kg⁻¹ intraperitoneally in both subdiaphragmatic areas and the cholecystectomy wound, those of the control group were given the same volume of NaCl 0.9%. Analgesia was provided by morphine PCA. Postoperative pain, assessed on a 100 mm visual analogue pain scale (VAS), and administered morphine were recorded 30 min after extubation, and 0.5, 1, 2, 3, 6, 12, 24, 36 and 48 hours later. Blood samples were collected 2, 5, 15, 30, 60, 90, 120, 180, 300 and 480 min after the intraperitoneal administration of bupivacaine to measure bupivacaine plasma concentration. Statistics included Student t test and Chi square test. P < 0.05 was considered significant.ResultsThere was no significant difference between the two groups with regard to VAS scores during the first 48 postoperative hours. Morphine requirements (total and at each point) were also similar. Plasma bupivacaine concentrations reached a plateau at 10–20 min, and then decreased slowly. The median plasma peak concentration was 0.94 ± 0.47 μg·mL⁻¹.ConclusionsIntraperitoneal administration of 0.6 mL.kg- of 0.375% bupivacaine is ineffective in reducing postoperative pain after laparoscopic cholecystectomy. Furthermore these high doses of bupivacaine may result in toxic plasma concentrations. This technique is not safe and cannot be recommended.     

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.     

Efficacy of intrathecal morphine with epidural ropivacaine infusion for postcesarean analgesia

Study ObjectiveTo evaluate the analgesia following cesarean delivery and the frequency of side effects of intrathecal morphine when combined with a continuous epidural infusion.DesignRandomized, double-blinded study.SettingUniversity hospital.Patients76 ASA physical status I and II term parturients undergoing cesarean delivery with combined spinal-epidural anesthesia.InterventionsPatients were randomized to one of three groups to receive 0, 50, or 100 μg (Group 0, Group 50, and Group 100, respectively) intrathecal morphine in addition to 8 mg of hyperbaric bupivacaine. Each patient received a continuous epidural infusion of 0.2% ropivacaine at the rate of 6 mL/hr.Measurements24-hour visual analog pain scores (VAPS), number of patients who requested rescue analgesics, frequency of requests for rescue analgesics per patient, and time interval before the first request for rescue analgesics were recorded. Frequency of pruritus and postoperative nausea and vomiting (PONV) were also recorded.Main ResultsGroup 50 and Group 100 patients exhibited lower VAPS and longer time intervals before the first request for rescue analgesics, and they requested rescue analgesics less frequently than Group 0 patients. The frequency of pruritus was significantly higher in Group 100 than Group 0. The groups did not differ with regard to PONV.Conclusions50 μg and 100 μg of intrathecal morphine improve analgesia when combined with a continuous epidural infusion of 0.2% ropivacaine (6 mL/hr) after cesarean delivery. 50 μg of intrathecal morphine is associated with a low frequency of side effects such as pruritus and PONV.