Periarticular infiltration for pain relief after total hip arthroplasty: a comparison with epidural and PCA analgesia

Purpose

Epidural and intravenous patient-controlled analgesia (PCA) are established methods for pain relief after total hip arthroplasty (THA). Periarticular infiltration is an alternative method that is gaining ground due to its simplicity and safety. Our study aims to assess the efficacy of periarticular infiltration in pain relief after THA.

Methods

Sixty-three patients undergoing THA under spinal anaesthesia were randomly assigned to receive postoperative analgesia with continuous epidural infusion with ropivacaine (epidural group), intraoperative periarticular infiltration with ropivacaine, clonidine, morphine, epinephrine and corticosteroids (infiltration group) or PCA with morphine (PCA group). PCA morphine provided rescue analgesia in all groups. We recorded morphine consumption, visual analog scale (VAS) scores at rest and movement, blood loss from wound drainage, mean arterial pressure (MAP) and adverse effects at 1, 6, 12, 24 h postoperatively.

Results

Morphine consumption at all time points, VAS scores at rest, 6, 12 and 24 h and at movement, 6 and 12 h postoperatively were lower in infiltration group compared to PCA group (p < 0.05), but did not differ between infiltration and epidural group. There was no difference in adverse events in all groups. At 24 h, MAP was higher in the PCA group (p < 0.05) and blood loss was lower in the infiltration group (p < 0.05).

Conclusions

In our study periarticular infiltration was clearly superior to PCA with morphine after THA, providing better pain relief and lower opioid consumption postoperatively. Infiltration seems to be equally effective to epidural analgesia without having the potential side effects of the latter.     

Pre-emptive analgesia with ketamine, morphine and epidural lidocaine prior to total knee replacement

Purpose

Pre-emptive analgesia can improve postoperative pain management. The purpose of this study was to examine the effectiveness of ketamine as a pre-emptive analgesic as previous studies have shown the involvement of N-methyl-D-Aspartate (NMDA) receptor in neuroplasticity.

Methods

Forty-five ASA 1–2 patients, undergoing unilateral total knee replacement were studied. In the study groups, epidural lidocaine was used as the primary anaesthestic. Patients received ketamine + morphine epidurally 30 min either before (group EB) or after skin incision (group EA). Group G patients received general anaesthesia and ketamine + morphine were given 30 min after skin incision via an epidural catheter used for postoperative pain control. Epidural morphine and ketamine in lidocaine was given to all patients at the end of surgery and every 12 hr for three days for analgesia supplemented with PCA morphine. The time until first PCA trigger, morphine consumption, pain scores, satisfaction scores, and morphine related side effects were recorded at 6, 12, 24, 48 and 72 hr after surgery.

Results

Epidural ketamine plus morphine with lidocaine before surgical incision produced better pain relief and patient satisfaction than when given after incision. A longer time to PCA and decreased morphine consumption were observed in group EB than in group G. In group EA, epidural anaesthesia also produced some pre-emptive analgesic effect compared with general anaesthesia shown by decreased morphine consumption.

Conclusions

Administration of ketamine plus morphine with epidural lidocaine anaesthesia before surgery provided improved postoperative analgesia compared with general anaesthesia alone or when analgesics were given after skin incision.     

Multimodal analgesia for arthroscopic rotator cuff repair: a randomized,placebo-controlled,double-blind trial

Background

The aim of the study was to investigate whether a multimodal analgesia (MMA) protocol reduces postoperative pain and opioids consumption in patients undergoing arthroscopic rotator cuff repair.

Methods

Fifty-four patients scheduled for arthroscopic rotator cuff repair were randomly assigned to either the MMA group or the control group. The primary outcome was visual analog scale (VAS) for pain. Secondary outcome measures included the time required for the VAS pain to reduce to that of a blood draw, (PCA) consumption, rescue morphine consumption, night awakening, and opioid-related side effects.

Results

The MMA group showed significantly less postoperative pain at postoperative 5 h, and 9 a.m. and 5 p.m. at 4th postoperative day (P < 0.001, = 0.040, and 0.013, respectively). MMA also shortened the time for postoperative pain to reduce down to the blood draw pain level from 5 days in the control group to 2 days in the MMA group. MMA also significantly reduced PCA consumption for up to 24 h postoperatively (P = 0.038) and rescue morphine consumption during the first 6 h and between 48 and 60 h postoperatively (P = 0.036 and 0.044, respectively). No significant differences were observed between the MMA and control groups with respect to side effects.

Conclusion

The MMA protocol used in this study was found to reduce postoperative pain and opioid consumption during the acute postoperative period after arthroscopic rotator cuff repair without increasing side effects after arthroscopic rotator cuff repair.     

Multimodal analgesic approach incorporating paravertebral blocks for open radical retropubic prostatectomy: a randomized double-blind placebo-controlled study

Introduction

Perioperative pain management influences both the quality as well as the speed of recovery following surgery.

Methods

This was a randomized double-blind placebo-controlled study designed to assess the effectiveness of a multimodal analgesic approach (MMA) vs patient-controlled analgesia (PCA) alone in patients undergoing open prostatectomy. Prior to surgery, paravertebral blocks (PVBs) were performed with either 0.5% ropivacaine in the MMA group or saline in the PCA group. Patients in the MMA group also received celecoxib (400 mg po prior to surgery and 200 mg po bid for seven days following surgery) and ketamine 10 mg iv. Following surgery, every patient had free access to morphine PCA. A pain numerical rating scale (NRS) at 24 hr was chosen as the primary endpoint. Secondary endpoints included morphine consumption at 24 hr and SF-36 (36-Item Short-Form Health Survey) scores from two weeks to 24 weeks following surgery.

Results

The primary endpoint, average pain NRS at 24 hr, was 2.6 in the MMA group compared with 3.9 in the PCA group (difference = ?1.6, 95% confidence interval [CI]: ?2.3 to ?0.4; P = 0.01). The average morphine consumption at 24 hr was 4.8 mg in the MMA group compared with 10.5 mg in the PCA group (difference = ?5.7, 95% CI: ?13.0 to 0.5; P = 0.01). Higher SF-36 scores at two, four, eight, and 12 weeks were observed in the MMA group compared with the PCA group, but no statistically significant (P < 0.05) between-group difference was found after Bonferroni correction of comparisons conducted repeatedly over time. Postoperative adverse effects included low episodes of postoperative nausea and vomiting, bladder spasms, constipation, and pruritus.

Conclusion

This study demonstrates that PVBs combined with celecoxib and ketamine provide better immediate postoperative pain control and facilitate earlier functional recovery in patients undergoing an open radical prostatectomy when compared with PCA alone.     

Postoperative analgesia after modified radical mastectomy: the efficacy of interscalene brachial plexus block

Purpose

In the present study, we evaluated the effects of interscalene brachial plexus block on postoperative pain relief and morphine consumption after modified radical mastectomy (MRM).

Methods

Sixty ASA I–III patients scheduled for elective unilateral MRM under general anesthesia were included. They were randomly allocated into two groups: group 1 (n = 30), single-injection ipsilateral interscalene brachial plexus block; group 2 (n = 30), control group. Postoperative analgesia was provided with IV PCA morphine during 24 h postoperatively. Pain intensity was assessed with the visual analogue scale (VAS). Morphine consumption, side effects of opioid, antiemetic requirement, and complications associated with interscalene block were recorded.

Results

VAS scores were significantly lower in group 1, except in the first postoperative 24 h (p < 0.007). The patients without block consumed more morphine [group 1, 5 (0–40) mg; group 2, 22 (6–48) mg; p = 0.001]. Rescue morphine requirements were also higher in the postoperative first hour in group 2 (p = 0.001). Nausea and antiemetic requirements were significantly higher in group 2 (p = 0.03 and 0.018). Urinary retention was observed in 1 patient in group 2 and signs of Horner’s syndrome in 2 patients in group 1.

Conclusions

The optimal method has not been defined yet for acute pain palliation after MRM. Our study demonstrated that the use of interscalene block in patients undergoing MRM improved pain scores and reduced morphine consumption during the first 24 h postoperatively. The block can be a good alternative to other invasive regional block techniques used for postoperative pain management after MRM.     

Schmerzmanagement nach Hämorrhoidektomie

Purpose

The aim of this randomized non-blinded study was to assess the pain management after hemorrhoidectomy using patient-controlled analgesia (PCA).

Patients and methods

In this study following Ferguson hemorrhoidectomy 38 patients were administered either standard pain management with oral non-steroidal analgesics (control n?=?18) or additional PCA with piritramid intravenously by infusion pump within the first 24 h (PCA n?=?19).

Results

The pain score within the first 24 h after surgery was significantly lower in patients with PCA compared to control patients (maximum pain within 12 h postoperatively: mean PCA 2.6 versus control 5.7). During the first 24 h postoperatively, patients with PCA were significantly more satisfied with the pain management than the control patients.

Conclusions

Pain after hemorrhoidectomy can be reduced within the first 24 h using PCA. Patients are significantly more satisfied with PCA than with standard medication.     

Reduction of post-operative nausea and vomiting with the combination of morphine and dropéridol in patient-controlled analgesia

Purpose

To determine whether low doses of droperidol mixed with morphine in patient-controlled analgesia (PCA) would extend the duration of prophylaxis against postoperative nausea and vomiting.

Methods

Healthy women having elective open-abdominal gynaecological surgery consented to this double-blind, place-bo-controlled study. Subjects were randomized to receive placebo, or 1 mg droperidol before induction followed by droperidol 0.0 (bolus group), 0.02 (0.02 group), or 0.04 (0.04 group) mg · mg^?1 of PCA morphine. Study endpoints included severity of nausea, episodes of vomiting and rescue antiemetic doses, pain, and sedation and were assessed at 1, 2, 4, 8, 12, 16, 20 and 24 hr postoperatively.

Results

Seventy-one subjects completed the study. The groups were similar in age, weight, surgical time, pain scores, and morphine used. The 0.04 group had lower mean visual analogue scale scores for nausea (P < 0.05 vs all other groups). The incidence of vomiting was lower in all treatment groups (P < 0.05 for all groups vs placebo). The 0.04 group had lower rescue antiemetic requirements than the bolus group (P < 0.03). Mean sedation scores were tow in all groups but were increased with PCA droperidol (P < 0.02).

Conclusions

Droperidol 1 mg before induction of anaesthesia reduces postoperative vomiting. The addition of droperidol 0.04 mg · mg^?1 of PCA morphine further reduces (i) severity of nausea and (ii) rescue antiemetic requirements postoperatively. No clinically significant side-effects were attributed to this regimen.     

A randomised controlled trial of the efficacy of ultrasound-guided transversus abdominis plane (TAP) block in laparoscopic colorectal surgery

Background

Optimal analgesia following laparoscopic colorectal resection is yet to be determined; however, recent studies have questioned the role of postoperative epidural anaesthesia, suggesting other analgesic modalities may be preferable. The aim of this randomised controlled trial was to assess the effect of transversus abdominis plane (TAP) blocks on opioid requirements in patients undergoing laparoscopic colorectal resection.

Methods

After appropriate trial registration (www.clinicaltrials.gov NCT 00830089) and local medical ethics review board approval (REC 09/H0407/10), all adult patients who were to undergo laparoscopic colorectal surgery at a single centre were randomised into the intervention group receiving bilateral TAP blocks or the control group (no TAP block). The blocks were administered prior to surgery after the induction of a standardised anaesthetic by an anaesthetist otherwise uninvolved with the case. The patient, theatre anaesthetist, surgeon, and ward staff were blinded to treatment allocation. All patients received postoperative analgesia of paracetamol and morphine as a patient-controlled analgesia (PCA). Cumulative opioid consumption and pain scores were recorded at 2, 4, 6, and 24 h postoperatively and compared between the groups as were clinical outcomes and length of stay.

Results

The intervention (TAP block) group (n = 33) and the control group (n = 35) were comparable with respect to characteristics, specimen pathology, and type of procedure. The TAP block group’s median cumulative morphine usage (40 mg [IQR = 25–63]) was significantly less than that of the control group (60 mg [IQR = 39–81]). Pain scores and median length of stay (LOS) were similar between the two groups.

Conclusion

Preoperative TAP blocks in patients undergoing laparoscopic colorectal resection reduced opioid use in the first postoperative day in this study.     

Intravenous Lornoxicam Is More Effective than Paracetamol as a Supplemental Analgesic After Lower Abdominal Surgery: A Randomized Controlled Trial

Background

The aim of this prospective, randomized, double-blind study was to determine the more effective supplemental analgesic, paracetamol or lornoxicam, for postoperative pain relief after lower abdominal surgery.

Methods

Sixty patients scheduled for lower abdominal surgery under general anesthesia were randomly allocated to receive either isotonic saline (control group), intravenous paracetamol 1?g every 6?h (paracetamol group), or lornoxicam 16?mg then 8?mg after 12?h (lornoxicam group). Additionally pain was treated postoperatively with morphine patient-controlled analgesia. Postoperative pain scores measured by the verbal pain score (VPS), morphine consumption, and the incidence of side effects were measured at 1, 2, 4, 8, 12, and 24?h postoperatively.

Results

Morphine consumption at 12 and 24?h was significantly lower in the lornoxicam group (19.25?±?5.7?mg and 23.1?±?6.5?mg) than in the paracetamol group (23.4?±?6.6?mg and 28.6?±?7.6?mg). Both treatment groups had less morphine consumption than the control group (28.5?±?5?mg and 38.1?±?6.6?mg) at 12 and 24?h, respectively. Additionally, VPS was reduced in the paracetamol and the lornoxicam groups compared with the control group both at rest and on coughing. Further analysis revealed that VPS in the lornoxicam group was significantly lower than that in the paracetamol group only during coughing. Drug-related side effects were comparable in all groups.

Conclusions

Lornoxicam is superior to paracetamol for postoperative analgesia after lower abdominal surgery. However, paracetamol could be an alternative supplemental analgesic whenever an NSAID is unsuitable. Trial Registration: clinicaltrials.gov.identifier:NCT01564680.     

Is single-shot epidural analgesia more effective than morphine patient-controlled analgesia for donor nephrectomy?

Objective

We compared single-shot epidural analgesia (20 mL 0.125% levobupivacaine and 3 mg diamorphine) followed by regular tramadol versus morphine patient-controlled analgesia (PCA) for postoperative pain following donor nephrectomy.

Methods

We retrospectively evaluated 12 patients who received single-shot epidural analgesia (SSE group) before anesthesia induction, followed by regular tramadol, and 14 patients who received morphine PCA (PCA group) for postoperative pain after donor nephrectomy. Postoperative pain scores were recorded at 0, 1, 12, 24, and 48 hours after nephrectomy. We also collected data regarding morphine consumption, additional analgesia, nausea, antiemetic use, time to oral intake, mobilization, and discharge.

Results

The 2 groups were similar for age, gender, body mass index, American Society of Anesthesiologists status, duration of surgery, laparoscopic/open nephrectomy ratio, and intra- and postoperative additional analgesia. There were no significant between-group differences in pain and nausea scores. The SSE group showed lower intra- and postoperative antiemetic use than the PCA group (25% vs 78.5% and 1 dose vs 2.5 doses, respectively; P < .05). The average time to oral fluid and solid food intake and for assisted mobilization were similar in the 2 groups. However, independent mobilization and hospital discharge were significantly sooner in the SSE group (34 hours vs. 47.4 hours; [P < .05] and 3.7 days vs 4.7 days [P < .05], respectively).

Conclusions

In this small pilot study, SSE with 20 mL 0.125% levobupivacaine and 3 mg diamorphine, followed by regular tramadol, provided postoperative analgesia similar to morphine PCA. However, patients in the SSE group used less antiemetic medication, were independently mobile earlier, and were discharged from the hospital earlier than patients in the PCA group.     

A randomised trial of oral versus intravenous opioids for treatment of pain after cardiac surgery

Background

Cardiac surgery and sternotomy are procedures accompanied by substantial postoperative pain which is challenging to treat. In general, intravenous (IV) opioids are used in the immediate postoperative phase, followed by oral opioids. Oral opioids are easier to use and generally less expensive. Our goal was thus to determine whether a new opioid preparation provides adequate analgesia after sternotomy. In particular, we tested the primary hypothesis that total opioid use (in morphine equivalents) is not greater with oral opioid compared with patient-controlled IV morphine. Our secondary hypothesis was that analgesic efficacy is similar with oral and IV opioids.

Methods

A total of 51 patients having elective cardiac surgery were enrolled in this study. After rapid postoperative respiratory weaning, the patients were randomised into one of two groups receiving different types of analgesia: oral Targin (a combination of oxycodone–hydrochloride and the opioid antagonist naloxone hydrochloride-dihydrate) or patient-controlled IV morphine. Pain score (visual analogue scale), sedation (Ramsey score), respiratory rate and side effects were assessed at 3, 5, 7, 9 and 11 h after surgery, and every 6 h throughout the third postoperative evening.

Results

The total opioid dose in morphine equivalent doses was significantly lower with oral opioid than with IV morphine (adjusted geometric means [95 % confidence interval]: 34 [29; 38] vs. 69 [61; 78] mg, respectively). Pain scores were similar in each group.

Conclusions

Analgesic quality was comparable with oral and IV opioids, suggesting that postoperative pain even after very painful procedures can be sufficiently managed with oral opioids.     

Comparison of tramadol and morphine via subcutaneous PCA following major orthopaedic surgery

Purpose

To compare subcutaneous PCA tramadol with subcutaneous PCA morphine for postoperative pain relief after major orthopaedic surgery and for the incidence of side-effects.

Methods

In a double-blind randomised controlled study 40 patients (20 in each group) self-administered either tramadol or morphine for 72 hr after surgery viasc PCA The following variables were recorded at various time intervals: (i) pain score by means of a visual analogue scale, (ii) drug consumption and total PCA demands, (iii) vital signs (blood pressure and heart rate), (iv) oxygen saturation and respiratory rate, and (v) side-effects (sedation, nausea/vomiting, pruritus, urinary retention and constipation).

Results

Both drugs provided effective analgesia. The mean consumption in the first 24 hr was 792 ± 90 mg tramadol and 42 ± 4 mg morphine. Thereafter, consumption of both drugs declined markedly. Moderate haemodynamic changes were observed in both the tramadol and morphine groups (with a maximum 20% decrease in mean blood pressure and a maximum 17% increase in heart rate) during the 72 hr period. Both tramadol and morphine were associated with a clinically and statistically significant (P < 0.001) decrease in oxygen saturation, but without changes in respiratory rates. Desaturation was less marked with tramadol. Tramadol appeared to cause more nausea and vomiting than morphine. Sedation was mild and only seen during the first few hours after surgery in both groups.

Conclusion

Tramadol is an effective analgesic agent for the relief of acute postoperative pain when administered by PCA via the subcutaneous route. Under these conditions tramadol behaves much like morphine with a similar side-effect profile.     

Ultrasound-guided adductor canal block for arthroscopic medial meniscectomy: a randomized, double-blind trial

Purpose

The saphenous nerve block using a landmark-based approach has shown promise in reducing postoperative pain in patients undergoing arthroscopic medial meniscectomy. We hypothesized that performing an ultrasound-guided adductor canal saphenous block as part of a multimodal analgesic regimen would result in improved analgesia after arthroscopic medial meniscectomy.

Methods

Fifty patients presenting for ambulatory arthroscopic medial meniscectomy under general anesthesia were prospectively randomized to receive an ultrasound-guided adductor canal block with 0.5% ropivacaine or a sham subcutaneous injection of sterile saline. Our primary outcome was resting pain scores (numerical rating scale; NRS) upon arrival to the postanesthesia care unit (PACU). Secondary outcomes included NRS at six hours, 12 hr, 18 hr, and 24 hr; postoperative nausea; and postoperative opioid consumption.

Results

There was a statistically significant difference in mean NRS pain scores upon arrival to the PACU (P = 0.03): block group NRS = 1.71 (95% confidence interval [CI] 0.73 to 2.68) vs sham group NRS = 3.25 (95% CI 2.27 to 4.23). Cumulative opioid consumption (represented in oral morphine equivalents) over 24 hr was 71.8 mg (95% CI 56.5 to 87.2) in the sham group vs 44.9 mg (95% CI 29.5 to 60.2) in the block group (P = 0.016).

Conclusions

An ultrasound-guided block at the adductor canal as part of a combined multimodal analgesic regimen significantly reduces resting pain scores in the PACU following arthroscopic medial meniscectomy. Furthermore, 24-hr postoperative opioid consumption and pain scores were also reduced.     

A randomized placebo-controlled trial of two doses of pregabalin for postoperative analgesia in patients undergoing abdominal hysterectomy

Purpose

Acute pain after open abdominal hysterectomy limits the function of patients in the postoperative period, but data regarding the analgesic efficacy of a low dose of pregabalin (75 or 150 mg) have been conflicting. This study was performed to determine if a low dose of pregabalin could decrease postoperative opioid use following abdominal hysterectomy when compared with placebo.

Methods

American Society of Anesthesiologists I-II patients older than 18 yr and scheduled for open elective abdominal hysterectomy were recruited for participation and randomized to one of three groups: pregabalin 75 mg (P75), pregabalin 150 mg (P150), or placebo. The study drug was administered two hours prior to surgery and 12 hr following the initial dose. Anesthetic technique and postoperative analgesia were standardized. Postoperative pain was managed using patient-controlled analgesia with morphine. Pain at rest and movement as well as nausea were assessed with an 11-point numeric rating scale.

Results

One hundred and one patients were recruited, and 89 patients completed the study. Mean (SD) cumulative morphine consumption at 24 hr postoperatively was 54.0 (26.2) mg for the placebo group, 53.1 (22.7) mg for the P75 group, and 44.3 (20.9) mg for the P150 group. Independent Student’s t tests indicated no difference between the placebo group and either the P75 group (95% confidence interval [CI]: ?11.75 to 13.44; P = 0.8937) or the P150 group (95% CI: ?2.74 to 22.15; P = 0.1238).

Conclusions

At the doses used in this study, pregabalin treatment may not be effective in reducing opioid use up to 24 hr postoperatively following abdominal hysterectomy. This trial was registered at www.ClinicalTrials.gov: NCT00781131.     

Opioid use prior to total hip arthroplasty leads to worse clinical outcomes

Purpose

The purpose of this study was to compare the clinical outcomes of patients undergoing total hip arthroplasty (THA) who had been using narcotic medications prior to surgery to those who had not used them.

Methods

Fifty-four patients (62 hips) who had required opioid analgesia for hip pain in the three months prior to THA were compared to a matched group of opioid-naïve patients. Narcotic consumption was converted to a standardized morphine equivalent dose and compared between both groups of patients during their hospital stay, after six weeks, and at final follow-up. Other outcome measures included clinical outcome scores and the proportion of patients remaining on narcotic pain medication at final follow-up.

Results

The narcotic group required significantly higher total daily opioid doses as inpatients had a longer hospital stay and a higher proportion of patients who remained on opioids at six weeks and at final follow-up. Of the patients who were taking opioids pre-operatively, 81 % were able to wean off opioids at final follow-up. At a mean post-operative follow-up of 58 months (range, 24–258 months), Harris hip scores were lower in the narcotic group, with a mean of 84 compared to 91 points in the matching group. However, in both cohorts, there were significant improvements in Harris hip scores compared to pre-operative outcomes.

Conclusions

Patients who use narcotics prior to total hip arthroplasty may be more likely to suffer from opioid-induced hyperalgesia after surgery and have worse clinical outcomes. When possible, efforts should be made to use other modes of analgesia or wean patients from their use prior to total hip arthroplasty.     

Gabapentin does not improve multimodal analgesia outcomes for total knee arthroplasty: a randomized controlled trial

Purpose

This study assessed whether gabapentin given preoperatively and for two days postoperatively (in addition to patient-controlled analgesia [PCA] morphine, acetaminophen, and ketorolac) is effective in reducing morphine requirements and moderating pain scores when compared with placebo for primary total knee arthroplasty.

Methods

This single-centre double-blind randomized controlled trial was undertaken in patients who underwent primary total knee arthroplasty. All subjects received acetaminophen 1,000 mg and ketorolac 15 mg po preoperatively. Postoperatively, subjects received PCA morphine, acetaminophen 1,000 mg every six hours, and ketorolac 15 mg po every six hours. Subjects received either gabapentin 600 mg po preoperatively followed by 200 mg po every eight hours for two days or matching placebo. The primary outcome was cumulative morphine consumption at 72 hr following surgery. Secondary outcome measures included pain scores and patient satisfaction.

Results

There were 52 subjects in the gabapentin group and 49 subjects in the placebo group. The average cumulative morphine consumption at 72 hr postoperatively was 66.3 mg in the gabapentin group and 72.5 mg in the placebo group (difference ?6.2 mg; 95% confidence interval ?29.1 to 16.8 mg; P = 0.59). Mean pain scores at rest, with passive movement, or with weight bearing were similar in both groups at corresponding time periods for the first three days following surgery. In addition, mean patient satisfaction scores and hospital length of stay were similar in the two groups.

Conclusion

Gabapentin 600 mg po given preoperatively followed by 200 mg po every eight hours for two days has no effect on postoperative morphine consumption, pain scores, patient satisfaction, or length of hospital stay. This trial is registered at ClinicalTrials.gov NCT01307202.     

Oral clonidine reduces postoperative PCA morphine requirements

Purpose

The purpose of this study was to evaluate the effect of perioperative oral clonidine on postoperative analgesia and PCA morphine requirements in adult patients after major orthopaedic knee surgery.

Methods

In this prospective, double blind, placebo-controlled study 44 patients undergoing either total knee replacement or hemiarthroplasty of the knee were randomly assigned to receive oral placebo or clonidine (5 μg · kg^?1) 1.5 hr before surgery, and at 12 hr, and 24 hr after the initial dose. Five patients were subsequently withdrawn from study. No other preoperative drugs were given. Preoperative sedation score was recorded. A standardized general anaesthetic was administered to all patients. Postoperative blood pressure, heart rate, PCA morphine use, visual analogue score (VAS) for pain, sedation, nausea, and pruritus were recorded for 36 hr postoperatively.

Results

The cumulative PCA morphine used was 37% lower after clonidine 57.3 ± 26.8 mg (mean ± SD) compared with placebo 91 ± 31.6 mg (P = 0.031). There was no difference in pain or sedation scores postoperatively but patients who received clonidine were more sedated preoperatively (P < 0.001) and had a lower mean arterial blood pressure throughout the period of study by 10 to 26 mmHg (P < 0.0001). Clonidine reduced the incidence of postoperative nausea (25% vs 74%) (P < 0.01) and vomiting compared with placebo (10% vs 53%) (P < 0.01) and required less antiemetic (dimenhydrinate 37.5 ± 20.9 mg vs 82.1 ± 49.4 mg) but not statistically significant (P = 0.065).

Conclusions

Oral clonidine is a useful component to postoperative balanced analgesia as it decreases PCA morphine requirements and decreases the incidence of nausea and vomiting.     

Does Epidural Morphine Loading in Addition to Thoracic Epidural Analgesia Benefit the Postoperative Management of Morbidly Obese Patients Undergoing Open Bariatric Surgery? A Pilot Study

Background

Insufficient data exist regarding postoperative thoracic epidural analgesia for morbidly obese patients undergoing open bariatric surgery. This study evaluated the effectiveness of morphine loading in a postoperative thoracic epidural analgesic regimen of patient-controlled epidural analgesia (PCEA) with levobupivacaine combined with continuously administered epidural morphine in this patient group.

Methods

In this prospective randomized controlled trial, 48 superobese patients (body mass index of ≥50 kg/m²) undergoing open bariatric surgery were randomly allocated to three groups of 16 patients each. Postoperatively, all groups received a continuous epidural morphine infusion of 0.2 mg/h with 0.1 % levobupivacaine via PCEA. Group A did not receive intraoperative epidural morphine loading, while groups B and C received an intraoperative 1- and 2-mg morphine bolus, respectively. Levobupivacaine consumption via PCEA (primary outcome), pain scores at rest and on cough, the time to return of bowel function and ambulation, and arterial blood gas levels (secondary outcomes) were recorded.

Results

The increase in perioperative morphine administration (groups B and C) led to a significantly prolonged return to normal bowel function and delayed ambulation (P?Conclusions Thoracic PCEA with 0.1 % levobupivacaine combined with continuous epidural morphine administration of 0.2 mg/h without morphine loading is an effective postoperative analgesic regimen that provides adequate pain control, early ambulation, and early return of bowel function in superobese patients, particularly those with OSA.