Ketamine does not decrease postoperative pain after remifentanil-based anaesthesia for tonsillectomy in adults

BACKGROUND: There are conflicting results concerning the pre-emptive effect of ketamine on central sensitization following surgery. The aim of this prospective, randomized, double-blind, placebo-controlled study was to assess the effect of the N-methyl-D-aspartate receptor antagonist ketamine on postoperative morphine consumption and pain score after remifentanil-based anaesthesia in adult patients scheduled for tonsillectomy. METHODS: We studied 40 adult patients undergoing elective tonsillectomy. Total intravenous anaesthesia was induced and maintained with remifentanil (0.125-1.0 microg kg(-1) min(-1)) and propofol target-controlled infusion. Patients in group K received a bolus dose of ketamine 0.5 mg kg(-1) immediately after anaesthetic induction, followed by a continuous infusion of 2 microg kg(-1) min(-1). Saline was administered in the same sequence in group S. Propofol, remifentanil, and the study drug infusions were discontinued at the end of surgery. RESULTS: Intraoperative remifentanil consumption (0.57 +/- 0.18 in group K vs. 0.55 +/- 0.14 microg kg(-1) min(-1) in group S), morphine requirement in the PACU (11 +/- 3 in group K vs. 9 +/- 4 mg in group S) and in the ward (22 +/- 11 in group K vs. 25 +/- 14 mg in group S), median time to first analgesia in the ward (338 +/- 126 in group K vs. 328 +/- 144 min in group S), and VAS pain scores were comparable in both groups. CONCLUSION: Small-dose of ketamine does not seem to be a useful adjunct to remifentanil-based anaesthesia during short, painful surgical procedures.     

Effect of intrathecal tramadol administration on postoperative pain after transurethral resection of prostate

Background. Tramadol administered epidurally has been demonstratedto decrease postoperative analgesic requirements. However, itseffect on postoperative analgesia after intrathecal administrationhas not yet been studied. In this double-blind, placebo-controlledstudy, the effect of intrathecal tramadol administration onpain control after transurethral resection of the prostate (TURP)was studied. Methods. Sixty-four patients undergoing TURP were randomizedto receive bupivacaine 0.5% 3 ml intrathecally premixed witheither tramadol 25 mg or saline 0.5 ml. After operation, morphine5 mg i.m. every 3 h was administered as needed for analgesia.Postoperative morphine requirements, visual analogue scale forpain at rest (VAS) and sedation scores, times to first analgesicand hospital lengths of stay were recorded by a blinded observer. Results. There were no differences between the groups with regardto postoperative morphine requirements (mean (SD): 10.6 (7.9)vs 9.1 (5.5) mg, P=0.38), VAS (1.6 (1.2) vs 1.2 (0.8), P=0.18)and sedation scores (1.2 (0.3) vs 1.2 (0.2), P=0.89). Timesto first analgesic (6.3 (6.3) vs 7.6 (6.2) h, P=0.42) and lengthof hospital stay (4.7 (2.8) vs 4.4 (2.2) days, P=0.66) weresimilar in the two groups. Conclusion. Intrathecal tramadol was not different from salinein its effect on postoperative morphine requirements after TURP. Br J Anaesth 2003; 91: 536–40     

Pain management after adenoidectomy with ketoprofen: comparison of rectal and intravenous routes

We compared the efficacy of rectally and intravenously administeredketoprofen for pain management after day-case adenoidectomy.Patients (123 children aged 1–9 yr) were allocatedrandomly to receive on induction of anaesthesia ketoprofen 25 mgrectally with an i.v. placebo, ketoprofen 25 mg i.v. witha rectal placebo, or placebo both i.v. and rectally. The methodof anaesthesia and the operative technique were standardized.Postoperative pain was assessed at rest and during swallowingusing the Maunuksela pain scale (0=no pain, 10=worst possiblepain). Fentanyl 0.5 µg kg^–1 was givenas rescue analgesia. There was no significant difference betweenthe two ketoprofen groups in their requirement for rescue analgesics.However, both the proportion of children needing rescue analgesics[55 of 84 children (65%) vs. 33 of 39 children (84%); difference19%, 95% confidence interval 4–34%, P=0.029] and the numberof rescue analgesic doses [mean 1.2 (SD 1.2) vs. 2.2 (1.4);mean difference 0.9, 95% confidence interval 0.4–1.4,P=0.001] were significantly lower among children receiving ketoprofenthan in children receiving placebo. Adverse events, durationof operation, perioperative bleeding, pain scores and time ofdischarge were similar in the three groups. Br J Anaesth 2000; 85: 836–40     

Effects of intraoperative i.v. acetaminophen vs i.m. meperidine on post-tonsillectomy pain in children

Background. Enteral acetaminophen, when used alone, is not veryeffective for postoperative analgesia because of delayed absorptionand sub-therapeutic plasma concentrations. In contrast, i.v.acetaminophen is devoid of these shortcomings and could potentiallyprovide adequate postoperative analgesia as a single agent.This randomized double-blind study compared the analgesic effectsof i.v. acetaminophen and i.m. meperidine in paediatric patientsundergoing tonsillectomy. Methods. Eighty children undergoing tonsillectomy were randomizedto receive either acetaminophen 15 mg kg^–1 i.v. (acetaminophengroup) or meperidine 1 mg kg^–1 i.m. (meperidine group),intraoperatively. Anaesthesia was induced with either sevofluraneinhalation or propofol, and was maintained with sevoflurane.After operation, the objective pain scale (OPS), Ramsay sedationscore and Aldrete score were recorded every 5 min, and nurses'satisfaction was determined on a 7-point scale (1–7). Results. On admission to the recovery room, OPS scores were3.1 (SEM 0.3) for the acetaminophen group and 2.1 (SEM 0.3)for the meperidine group (P=0.147); however, Ramsay sedationscores were 3 (SEM 0.2) and 4 (SEM 0.3) for the acetaminophenand meperidine groups, respectively (P<0.05). Patients inthe meperidine group continued to be more sedated 5 min afterarrival in recovery (P<0.05). Acetaminophen group patientsachieved an Aldrete score of 10 min sooner than those in themeperidine group [median (IQR) time: 15 (0–20) min vs25 (15–30) min, respectively, P=0.005]. Adjusted nursesatisfaction scores were similar in both groups [6.1 (SEM 0.2)vs 5.7 (SEM 0.2) min, P=0.311]. Conclusion. Compared with i.m. meperidine, i.v. acetaminophenprovided adequate analgesia, less sedation and earlier readinessfor recovery room discharge among paediatric patients undergoingtonsillectomy.     

Preventive effects of perioperative parecoxib on post-discectomy pain

BACKGROUND: Cyclooxygenase inhibitor treatment is viewed increasingly critical because of safety considerations, and there are several open questions on their optimal use. METHODS: In a randomized placebo-controlled study in 320 patients undergoing discectomy, we administered parecoxib 40 mg either perioperatively (before operation and after operation), after operation (first dose given in the evening after surgery), or before operation (single parecoxib dose given 45 min before surgery). We measured the main outcome variables: average pain score, morphine consumption, and opioid-related symptom distress at 25, 49, and 73 h after surgery. RESULTS: Perioperative parecoxib significantly (i) improved the pain score compared with both placebo and postoperative parecoxib, (ii) decreased morphine consumption, and (iii) reduced the opioid-related symptom distress score. Neither a single preoperative dose nor postoperative parecoxib (first dose given in the evening after surgery) significantly improved morphine's analgesic effectiveness. CONCLUSIONS: Perioperative parecoxib compared with postoperative parecoxib improves post-discectomy pain and results in a reduction in adverse effects associated with opioid therapy. Postoperative parecoxib, or a single pre-incisional parecoxib dose, does not significantly improve post-discectomy pain or opioid side-effects up to 3 days after surgery.     

No clinical evidence of acute opioid tolerance after remifentanil-based anaesthesia

We have prospectively assessed whether remifentanil-based anaesthesiais associated with clinically relevant acute opioid tolerance,expressed as greater postoperative pain scores or morphine consumption.Sixty patients undergoing elective gynaecological, non-laparoscopic,surgery were randomly assigned to receive remifentanil (groupR, n=30) or sevoflurane (group S, n=30) based anaesthesia. Postoperativeanalgesia was provided with morphine through a patient-controlledinfusion device. Mean (SD) remifentanil infusion rate in groupR was 0.23 (0.10) µg kg^–1 min^–1 and mean inspiredfraction of sevoflurane in group S was 1.75 (0.70)%. Mean (SD)cumulative morphine consumption during the first 24 postoperativehours was similar between groups: 28.0 (14.2) mg (group R) vs28.6 (12.4) mg (group S). Pain scores, were also similar betweengroups during this period. These data do not support the developmentof acute opioid tolerance after remifentanil-based anaesthesiain this type of surgery. Br J Anaesth 2001; 87: 866–9     

Intrathecal morphine reduces breakthrough pain during labour epidural analgesia

BACKGROUND: When using the combined spinal-epidural (CSE) technique forlabour analgesia, parturients often experience breakthroughpain after the spinal medication has receded. We tested thehypothesis that a small dose of intrathecal morphine would reducebreakthrough pain. METHODS: This was a randomized, double-blind, placebo-controlled trial.Subjects were randomized to receive either 100 µgof morphine (MS) or placebo (PLCB) with the spinal injectionof bupivacaine and fentanyl. Assessments included need for supplementationduring labour analgesia, use of pain medications for 24 hafter delivery, and side-effects. The primary end-point wasthe rate of breakthrough pain. RESULTS: Sixty subjects were enrolled, 55 subjects completed the trial.The MS group had a significantly lower rate of breakthroughpain than the PLCB group [0.6 (0.6) vs 1.1 (0.8) episodes perpatient; P < 0.01], and longer time to first episode of breakthroughpain (300 vs 180 min; P = 0.03). The MS group used 75%less opioid medications during the subsequent 24 h, buthad a 17% incidence of nausea. CONCLUSIONS: The addition of small dose of morphine to the spinal componentof the CSE technique improved the effectiveness of epidurallabour analgesia and reduced the need for pain medications over24 h, but resulted in a small increase in nausea.     

Preemptive diclofenac reduces morphine use after remifentanil-based anaesthesia for tonsillectomy

BACKGROUND: We investigated the effect of preincisional rectal diclofenac on pain scores and postoperative morphine requirements of children undergoing tonsillectomy after remifentanil-propofol anaesthesia in a randomized clinical trial. METHODS: Induction and maintenance of anaesthesia were with remifentanil and propofol. Forty children were randomly assigned into two groups before incision. The diclofenac group (n=20) received diclofenac suppositories (approximately 1 mg x kg(-1)) and the control group (n=20) received no treatment. Following discontinuation of remifentanil, patient-controlled analgesia (PCA) with morphine (a loading dose 50 micro g x kg(-1), a background infusion 4 micro g x kg(-1) x h(-1) and a demand dose 20 micro g x kg(-1) with 5-min intervals) was started. We assessed pain score [verbal analogue scales (VAS), 0-10] and sedation level at 5-min intervals and recorded the total morphine consumption of the first hour in the PACU. Patients were discharged to the ward with a new PCA morphine programme (a demand dose 20 micro g.kg-1 with a lockout time of 30 min, for 4 h), and total morphine consumption was recorded. RESULTS: The mean VAS score of the diclofenac group was significantly lower than the control group on arrival in the PACU (2.85 +/- 0.77, 7.60 +/- 0.83, respectively, P < 0.01) and it remained significantly lower in the PACU stay of the children. The mean total morphine consumption of the diclofenac group was less than the control group in the PACU (130.33 +/- 11.26 and 169.92 +/- 9.22, respectively, P=0.012) and the ward (50.80 +/- 11.38 and 87.77 +/- 10.55, respectively, P=0.021). CONCLUSIONS: Preemptive diclofenac given rectally reduced pain intensity and morphine requirements of children anaesthetized with remifentanil for tonsillectomy.     

Fentanyl HCl iontophoretic transdermal system (ITS): clinical application of iontophoretic technology in the management of acute postoperative pain

The fentanyl HCl iontophoretic transdermal system (fentanylITS) is a novel patient-controlled analgesia (PCA) system thathas been approved in the USA and Europe for the management ofacute, moderate-to-severe postoperative pain. This system extendsthe applicability of transdermal drug delivery to acute painmanagement, allowing patients to self-administer pre-programmeddoses of fentanyl non-invasively through the use of iontophoretictechnology. Iontophoresis is the process by which an electriccurrent is used to drive ionized drug molecules across the skinand into the systemic circulation. Results of a recent US clinicaltrial found the fentanyl ITS to provide pain control equivalentto a standard regimen of morphine i.v. PCA, with a similar incidenceof opioid-related adverse events. The fentanyl ITS may offera number of clinical advantages over existing PCA modalities.Its method of drug delivery avoids the risk of complicationsfrom needle-related injuries and infection, and its pre-programmedelectronics eliminate the potential for manual programming errorsand excessive dosing. In addition, the compact size of the systemcould enable greater patient mobility following surgery. Thefentanyl ITS has the potential to become a valuable option inthe management of acute postoperative pain.     

Effect of pre-emptive ketamine on sensory changes and postoperative pain after thoracotomy: comparison of epidural and intramuscular routes

Background. In this study we have evaluated the efficacy ofketamine via i.m. and epidural routes for the control of post-thoracotomypain. Methods. The study was randomized, double blinded and placebocontrolled. With the approval of the Faculty Ethics Committee,60 patients undergoing elective thoracotomy were randomizedinto three equal groups. Group IM had i.m. ketamine 1 mg kg^–1in 2 ml plus epidural normal saline; Group EPI had epiduralketamine 1 mg kg^–1 in 10 ml plus i.m. normal saline; GroupC had epidural normal saline 10 ml plus i.m. normal saline 10ml. Anaesthesia was standardized. Postoperative analgesia wasmaintained with epidural patient-controlled analgesia usingbupivacaine and morphine. Visual analogue scale values and analgesicconsumption were evaluated at 2, 4, 6, 8, 10, 12, 24 and 48h after surgery. The areas of allodynia, pin-prick hyperalgesiaand pressure hyperalgesia were measured at 48 h, and days 15and 30 in all groups. Results. Intraoperative fentanyl requirement was significantlylower in Group EPI than Group C. The morphine and bupivacainerequirements were significantly lower in Group EPI than theother two groups in the postoperative period. There was reducedpin-prick hyperalgesia and touch allodynia in the EPI group.There were no side-effects attributable to ketamine. Conclusion. The results of the present study demonstrate thatpre-emptive epidural ketamine is effective in reducing intra-and postoperative analgesic requirements, hyperalgesia and touchallodynia.     

I.v. ketoprofen for analgesia after tonsillectomy: comparison of pre- and post-operative administration

We have evaluated the safety and efficacy of ketoprofen duringtonsillectomy in 106 adults receiving standardized anaesthesia.Forty-one patients received ketoprofen 0.5 mg kg^–1 atinduction (‘pre’ ketoprofen group) and 40 patientsafter surgery (‘post’ ketoprofen group), in bothcases followed by a continuous ketoprofen infusion of 3 mg kg^–1over 24 h; 25 patients received normal saline (placebo group).Oxycodone was used for rescue analgesia. Patients in the ketoprofengroups experienced less pain than those in the placebo group.There was no difference between the study groups in the proportionof patients who were given oxycodone during the first 4 h aftersurgery. However, during the next 20 h, significantly more patientsin the placebo group (96%) received oxycodone compared withpatients in the ‘pre’ ketoprofen group (66%) andthe ‘post’ ketoprofen group (55%) (P=0.002). Patientsin the placebo group received significantly more oxycodone dosesthan patients in the two ketoprofen groups (P=0.001). Two patients(5%) in the ‘pre’ ketoprofen group and one (3%)in the ‘post’ ketoprofen group had post-operativebleeding between 4 and 14 h. All three patients required electrocautery. Br J Anaesth 2001; 86: 377–81     

Preoperative rectal diclofenac versus paracetamol for tonsillectomy: effects on pain and blood loss

BACKGROUND: Diclofenac is widely used for postoperative analgesia but the perioperative safety of this drug is controversial because of its effect on platelet aggregation, which might increase blood loss. In a prospective investigator-blinded study the effects of diclofenac and paracetamol on pain and blood loss were compared in patients undergoing tonsillectomy. METHOD: Ninety patients were randomised to receive rectal diclofenac 0.65-1.0 mg x kg(-1) or paracetamol 13-20 mg x kg(-1) preoperatively. Ten patients were excluded after randomisation. Pain was evaluated postoperatively by means of the visual analogue scale and by recording the use of pethidine for rescue analgesia. Perioperative blood loss was estimated from measured intraoperative blood loss; use of drugs to achieve haemostasis, and the incidence of reoperations. RESULTS: Anaesthetic or surgical managements did not differ between the groups, but a significantly longer period of surgery was found in the diclofenac group, 32+/-16 vs. 25+/-11 min (P = 0.024). Pain scores or pethidine consumption were not significantly different between the groups. Intraoperative blood loss was significantly larger in the diclofenac group, 1.9 (1.1-3.1) vs. 1.1 (0.7-2.0) ml x kg(-1) (P = 0.007). CONCLUSION: Preoperative rectal diclofenac offers no advantage over paracetamol with respect to postoperative analgesia in tonsillectomy patients but increases intraoperative blood loss.     

A comparison of intramuscular tenoxicam with intramuscular morphine for pain relief following tonsillectomy in children

A double blind trial was conducted to evaluate the analgesic efficacy of intramuscular tenoxicam for pain relief following tonsillectomy in children. Fifty children, aged 3–10 years, were randomly allocated to receive intramuscular tenoxicam 0.75 mg·kg^?1 or intramuscular morphine sulphate 0.2 mg·kg^?1 after induction of anaesthesia. Although the tenoxicam group required significantly more postoperative morphine (mean 57.8 μg·kg^?1 compared with 26.9 μg·kg^?1, P=0.025), the total morphine dose was significantly reduced after tenoxicam (57.8 μg·kg^?1 compared with 226.9 ug·kg^?1, P<0.0001). There was no difference between the quality of analgesia after discharge from recovery. The incidence of postoperative vomiting was significantly reduced after tenoxicam (20%) compared with morphine (71%).     

Hormonal and metabolic stress responses after major surgery in children aged 0-3 years: a double-blind, randomized trial comparing the effects of continuous versus intermittent morphine

Children aged 0–3 yr were stratified for age and randomizedto receive either continuous morphine (CM, 10 µg kg^–1 h^–1)with three-hourly placebo boluses or intermittent morphine (IM,30 µg kg^–1 every 3 h) with a placeboinfusion for postoperative analgesia. Plasma concentrationsof epinephrine, norepinephrine, insulin, glucose and lactatewere measured before and at the end of surgery and 6, 12 and24 h after surgery. Pain was assessed with validated painscales [the COMFORT scale and a visual analogue scale (VAS)]with the availability of additional morphine doses. Minor differencesoccurred between the randomized treatment groups, the oldestIM group (aged 1–3 yr) having a higher blood glucoseconcentration (P=0.003), mean arterial pressure (P=0.02) andCOMFORT score (P=0.02) than the CM group. In the neonates, preoperativeplasma concentrations of norepinephrine (P=0.01) and lactate(P<0.001) were significantly higher, while the postoperativeplasma concentrations of epinephrine were significantly lower(P<0.001) and plasma concentrations of insulin significantlyhigher (P<0.005) than in the older age groups. Postoperativepain scores (P<0.003) and morphine consumption (P<0.001)were significantly lower in the neonates than in the older agegroups. Our results show that continuous infusion of morphinedoes not provide any major advantages over intermittent morphineboluses for postoperative analgesia in neonates and infants. Br J Anaesth 2001; 87: 390–9     

Lumbar epidural fentanyl: segmental spread and effect on temporal summation and muscle pain

Background. Despite extensive use, different aspects of thepharmacological action of epidural fentanyl have not been clarified.We applied a multi-modal sensory test procedure to investigatethe effect of epidural fentanyl on segmental spread, temporalsummation (as a measure for short-lasting central hyperexcitability)and muscle pain. Methods. Thirty patients received either placebo, 50 or 100µg single dose of fentanyl epidurally (L2–3), ina randomized, double-blind fashion. Heat pain tolerance thresholdsat eight dermatomes from S1 to fifth cranial nerve (assessmentof segmental spread), pain threshold to transcutaneous repeatedelectrical stimulation of the sural nerve (assessment of temporalsummation) and pain intensity after injection of hypertonicsaline into the tibialis anterior muscle (assessment of musclepain) were recorded. Results. Fentanyl 100 µg, but not 50 µg, producedanalgesia to heat stimulation only at L2. Surprisingly, no effectat S1 was detected. Both fentanyl doses significantly increasedtemporal summation threshold and decreased muscle pain intensity. Conclusions. The findings suggest that a single lumbar epiduraldose of fentanyl should be injected at the spinal interspacecorresponding to the dermatomal site of pain. Increased effecton L2 compared with S1 suggests that drug effect on spinal nerveroots and binding to opioid receptors on the dorsal root gangliamay be more important than traditionally believed for the segmentaleffect of epidurally injected fentanyl. Epidural fentanyl increasestemporal summation threshold and could therefore contributeto prevention and treatment of central hypersensitivity states.I.M. injection of hypertonic saline is a sensitive techniquefor detecting the analgesic action of epidural opioids. Br J Anaesth 2003; 90: 467–73     

Peroperative treatment with i.v. ketoprofen reduces pain and vomiting in children after strabismus surgery

Background: Strabismus surgery is associated with both pain and vomiting. Ketoprofen is widely used in adults to treat acute pain, but there are only few reports of its use in children. This randomised, double-blind, placebo-controlled, parallel group study was designed to investigate the analgesic effect of i.v. ketoprofen and its effect on the incidence of vomiting in children after day-case strabismus surgery.
Methods: Fifty-nine ASA 1 children, aged 1–12 years, entered the study. After premedication with diazepam and glycopyrronium, anaesthesia was induced with fentanyl and propofol and maintained with isoflurane. After induction the children in the ketoprofen group received 1 mg kg⁻¹ ketoprofen followed by an infusion of 1 mg kg⁻¹ ketoprofen over 2 h. In the placebo group, children received 0.9% saline. The postoperative pain was assessed by the Maunuksela pain score (0=no pain, 10=worst possible pain). All children received fentanyl as a rescue analgesic if the Maunuksela score was ≥3.
Results: In the ketoprofen group the number of fentanyl doses was smaller compared to the placebo group (median 1, quartiles (0–2) vs. 2 (1–3), P =0.047). The children in the ketoprofen group had less pain at 30 min ( P =0.02) and the worst pain observed in the post anaesthesia care unit was lower (3 (0–6) vs. 5 (3–8), P =0.035). The incidence of vomiting was less in the ketoprofen group compared to the placebo group (17% vs. 41%, P =0.036). No serious adverse reactions occurred.
Conclusion: We concluded that ketoprofen administered i.v. during the operation produced analgesia and reduced opioid consumption and the incidence of vomiting in children after strabismus surgery.     

Intravenous ketoprofen for pain relief after total hip or knee replacement

Background: There are few studies in which ketoprofen, a propionic acid derivate NSAID, has been tested as an intravenous postoperative analgesic. The aim of this double-blind, randomized, placebo-controlled work was to study the tolerability and efficacy of intravenous ketoprofen in seventy-six patients undergoing hip or knee total endoprothesis surgery using three different doses.
Methods: The patients received either ketoprofen 50 mg, 100 mg or 150 mg, or placebo as an initial intravenous loading, followed by an infusion containing 50 mg, 100 mg or 150 mg or placebo, respectively, over the following eleven and a half hours. The consumption of fentanyl was recorded and the patients assessed their pain intensity on a 10-cm visual analogue scale (VAS) at 0, 2, 4 and 12 hours. Possible side-effects were recorded at the same intervals.
Results: Patients receiving ketoprofen showed significantly lower total fentanyl consumption and significantly better pain relief at 12 hours was achieved by a 300 mg dose of ketoprofen than by placebo. Side-effects were minimal, with no differences between the groups.
Conclusion : A bolus of ketoprofen following continuous infusion of ketoprofen, coupled with a PCA-system, was an effective and safe approach for the relief of postoperative pain.     

Pain relief after tonsillectomy Effect of benzydamine hydrochloride spray on postoperative pain relief after tonsillectomy

The efficacy of benzydamine hydrochloride (Difflam) spray to relieve pain from postoperative tonsillectomy was assessed, but it was found that it did not relieve the symptoms after operation when compared to matching placebo.     

Iontophoretic transdermal system using fentanyl compared with patient-controlled intravenous analgesia using morphine for postoperative pain management

Background: The fentanyl iontophoretic transdermal system (fentanyl ITS)enables needle-free, patient-controlled analgesia for postoperativepain management. This study compared the efficacy, safety, andease of care of fentanyl ITS with patient-controlled, i.v. analgesia(PCIA) with morphine for postoperative pain management. Methods: A prospective, randomized, multicentre trial enrolled patientsin Europe after abdominal or orthopaedic surgery. Patients receivedfentanyl ITS (n = 325; 40.0 µg fentanyl over 10 min) ormorphine PCIA [n = 335; bolus doses (standard at each hospital)]for 72 h. Supplemental i.v. morphine was available during thefirst 3 h. The primary efficacy measure was the patient globalassessment (PGA) of the pain control method during the first24 h. Results: PGA ratings of ‘good’ or ‘excellent’were reported by 86.2 and 87.5% of patients using fentanyl ITSor morphine PCIA, respectively (95% CI, –6.5 to 3.9%).Mean (SD) last pain intensity scores (numerical rating scale,0–10) were 1.8 (1.77) and 1.9 (1.86) in the fentanyl ITSand morphine PCIA groups, respectively (95% CI, –0.38to 0.18). More patients reported a system-related problem forfentanyl ITS than morphine PCIA (51.1 vs 17.9%, respectively).However, fewer of these problems interrupted pain control (4.4vs 41.3%, respectively). Patients, nurses, and physiotherapistsreported more favourable overall ease-of-care ratings for fentanylITS than morphine PCIA. Study termination rates and opioid-relatedside-effects were similar between groups. Conclusion: Fentanyl ITS and morphine PCIA were comparably effective andsafe.