A randomized controlled trial comparing acetaminophen plus ibuprofen versus acetaminophen plus codeine plus caffeine after outpatient general surgery

BACKGROUND: Narcotics are used extensively in outpatient general surgery but are often poorly tolerated with variable efficacy. Acetaminophen combined with NSAIDs is a possible alternative. The objective of this study was to compare the efficacy of acetaminophen, codeine, and caffeine (Tylenol No. 3) with acetaminophen and ibuprofen for management of pain after outpatient general surgery procedures. STUDY DESIGN: A double-blind randomized controlled trial was performed in patients undergoing outpatient inguinal/umbilical/ventral hernia repair or laparoscopic cholecystectomy. Patients were randomized to receive acetaminophen plus codeine plus caffeine (Tylenol No. 3) or acetaminophen plus ibuprofen (AcIBU) 4 times daily for 7 days or until pain-free. Pain intensity, measured four times daily by visual analogue scale, was the primary outcome. Secondary end points included incidence of side effects, patient satisfaction, number of days until patient was pain-free, and use of alternative analgesia. RESULTS: One hundred forty-six patients were randomized (74 Tylenol No. 3 and 72 AcIBU), and 139 (95%) patients completed the study. No significant differences in mean or maximum daily visual analogue scale scores were identified between the 2 groups, except on postoperative day 2, when pain was improved in AcIBU patients (p = 0.025). During the entire week, mean visual analogue scale score was modestly lower in AcIBU patients (p = 0.018). More patients in the AcIBU group, compared with Tylenol No. 3, were satisfied with their analgesia (83% versus 64%, respectively; p = 0.02). There were more side effects with Tylenol No. 3 (57% versus 41%, p = 0.045), and the discontinuation rate was also higher in Tylenol No. 3-treated patients (11% versus 3%, p = 0.044). CONCLUSIONS: When compared with Tylenol No. 3, AcIBU was not an inferior analgesic and was associated with fewer side effects and higher patient satisfaction. AcIBU is an effective, low-cost, and safe alternative to codeine-based narcotic analgesia for outpatient general surgery procedures.     

Scheduled acetaminophen with as-needed opioids compared to as-needed acetaminophen plus opioids for post-cesarean pain management

BackgroundCombination opioid-acetaminophen drugs are commonly used for pain management after cesarean delivery. The aim of this study was to determine if scheduled acetaminophen decreases opioid use compared to as-needed combination acetaminophen-opioid administration.MethodsWe performed a retrospective chart review of women who underwent cesarean delivery before and after a clinical practice change. All patients received spinal anesthesia containing intrathecal morphine 200 μg and scheduled non-steroidal anti-inflammatory drugs for 48 h postoperatively. The first group (As-Needed Group, n=120) received combination oral opioid-acetaminophen analgesics as needed for breakthrough pain. The second group (Scheduled Group, n=120) received oral acetaminophen 650 mg every 6 h for 48 h postoperatively with oral oxycodone administered as needed for breakthrough pain. The primary outcome was opioid use, measured in intravenous morphine mg equivalents, in the first 48 h postoperatively.ResultsThe Scheduled Group used 9.1 ± 2.1 mg (95% CI 5.0–13.2) fewer intravenous morphine equivalents than the As-Needed Group (P <0.0001) over the study period. Fewer patients in the Scheduled Group exceeded acetaminophen 3 g daily compared to the As-Needed Group (P=0.008). Pain scores were similar between study groups.ConclusionsAfter cesarean delivery, scheduled acetaminophen results in decreased opioid use and more consistent acetaminophen intake compared to acetaminophen administered as needed via combination acetaminophen-opioid analgesics, without compromising analgesia.     

Combination tramadol plus acetaminophen for postsurgical pain

BACKGROUND: This multicenter, randomized, double-blind, active- and placebo-controlled trial evaluated tramadol plus acetaminophen (APAP) for orthopedic (n = 153) and abdominal (n = 152) postsurgical pain. METHODS: Patients with moderate pain or greater were randomized to an initial two tablets of 37.5 mg tramadol plus 325 mg APAP (n = 98), codeine 30 mg plus APAP 300 mg (n = 109), or placebo (n = 98); thereafter, they received 1 to 2 tablets every 4 to 6 hours as needed for pain for 6 days. Outcome measures were pain relief and pain intensity, total pain relief, sum of pain intensity differences, and sum of pain relief and pain intensity differences during 4 hours and the daily averages. RESULTS: Tramadol plus APAP was superior to placebo for total pain relief, sum of pain intensity differences, and sum of pain relief and pain intensity differences (P < or =0.015); tramadol plus APAP and codeine plus APAP did not separate (P > or=0.281). For average daily pain relief, average daily pain intensity, and overall medication assessment, tramadol plus APAP was superior to placebo (P < or =0.038); codeine plus APAP did not separate from placebo (P > or =0.125). Discontinuation because of adverse events occurred in 8.2% of tramadol plus APAP, 10.1% of codeine plus APAP, and 3.0% of placebo patients. Except for constipation (4.1% tramadol plus APAP vs 10.1% codeine plus APAP) and vomiting (9.2% vs 14.7%, respectively), adverse events were similar for active treatments. CONCLUSIONS: Tramadol plus APAP (mean dose 4.4 tablets) was effective and well tolerated for postsurgical pain and showed better tolerability than did codeine plus APAP.     

Diclofenac or acetaminophen for analgesia in paediatric tonsillectomy outpatients

BACKGROUND: In order to establish an effective drug regimen, we compared the analgesic efficacy of oral diclofenac and high-dose acetaminophen on pain after tonsillectomy. METHODS: In this randomised, double-blind study 48 children, 5 to 15 years of age, following tonsillectomy were assigned to receive either diclofenac 2-3 mg kg(-1) 24 h(-1) (n=24) or acetaminophen 90 mg kg(-1) 24 h(-1) (n=24) for the first three days after surgery. Postoperative pain was assessed by self-report each day before scheduled medication at 7 h, 12 h, 18 h and 23 h. RESULTS: The number of children rating severe pain was high in both the diclofenac group, 5-50%, and in the acetaminophen group, 12-58% during the three day study period. Pain scores in the diclofenac group were only significantly lower at 12 h on day 1-3 compared to pain scores in the acetaminophen group (P<0.05). None of the children in the diclofenac group experienced any episodes of nausea/vomiting compared to 9 children in the acetaminophen group on day 1. The incidences of nausea/vomiting increased with pain (P<0.05). None of the 48 children experienced any episodes of bleeding. CONCLUSIONS: This study indicates that diclofenac was no more effective than high-dose acetaminophen (90 mg vs. 60 mg kg(-1) 24 h(-1)) for analgesia, but resulted in a lower incidence of nausea and vomiting in patients following tonsillectomy.     

Tramadol suppositories are less suitable for post-operative pain relief than rectal acetaminophen/codeine.

The suitability of tramadol suppositories for inclusion in our hospital formulary for the treatment of mild to moderate post-operative pain was evaluated. In an open randomized trial, rectal tramadol was compared with our standard treatment acetaminophen/codeine suppositories. We expected tramadol to be equally effective as our current standard but with fewer side effects. Forty patients were treated with either tramadol suppositories 100 mg 6 hourly (qds) or acetaminophen/codeine suppositories 1000/20 mg qds. Patients were comparable with regard to demographic data and type of surgery and anaesthesia. Post-operative pain was scored with the aid of a Visual Analogue Scale before each drug administration, at rest and during movement. Side effects, notably nausea and vomiting, were recorded by interviewing the patients and by inspecting the nursing report. There was no difference in pain scores between the two groups. The incidence of nausea and vomiting was significantly higher in the tramadol-treated (84%) than in the acetaminophen/codeine treated group (31%). The relative risk of experiencing an episode of nausea under treatment with tramadol was 2.7 (95% confidence interval: 1.3-5.3; P = 0.0001) as compared with acetaminophen/codeine. We conclude that for acute treatment of mild to moderate post-operative pain frequent nausea and vomiting makes tramadol suppositories less suitable than acetaminophen/codeine.     

Rectus sheath catheters provide equivalent analgesia to epidurals following laparotomy for colorectal surgery

Introduction

Rectus sheath catheters (RSCs) are increasingly being used to provide postoperative analgesia following laparotomy for colorectal surgery. Little is known about their efficacy in comparison with epidural infusion analgesia (EIA). They are potentially better as they avoid the recognised complications associated with EIA. This study compares these two methods of analgesia. Outcomes include average pain scores, time to mobilisation and length of stay.

Methods

This was a 33-month single centre observational study including all patients undergoing elective open or laparoscopic-converted-to-open colorectal resection for both benign and malignant disease. Patients received either EIA or RSCs. Data were collected prospectively and analysed retrospectively.

Results

A total of 95 patients were identified. Indications for surgery, operation and complications were recorded. The mean time to mobilisation was significantly shorter in patients who had RSCs compared with EIA patients (2.4 vs 3.5 days, p<0.05). There was no difference in postoperative pain scores or length of stay.

Conclusions

RSCs provide equivalent analgesia to EIA and avoid the recognised potential complications of EIA. They are associated with a shorter time to mobilisation. Their use should be adopted more widely.     

A double-blind comparison of codeine and morphine for postoperative analgesia following intracranial surgery

Codeine and morphine were compared in a double-blind study of postoperative analgesia in 40 patients after intracranial neurosurgery. Eighteen patients received codeine phosphate 60 mg and 18 morphine sulphate 10 mg, both by intramuscular injection; 4 patients (10%) required no analgesia. Both drugs provided analgesia within 20 min of injection but morphine was more effective than codeine beyond 60 min (p = 0.01). Fewer doses of morphine than codeine were required (p = 0.003). Nine patients requested one dose of morphine and 9 two doses. Seven patients required three doses of codeine and 1 patient required four doses. Neither drug caused respiratory depression, sedation, pupillary constriction or unwanted cardiovascular effects. We conclude that, in the doses used, morphine is a safe alternative to codeine for analgesia after neurosurgery and has a more persistent action.     

Ropivacaine 0.15% plus sufentanil 0.5 microg/mL and ropivacaine 0.10% plus sufentanil 0.5 microg/mL are equivalent for patient-controlled epidural analgesia during labor

We compared the administration of 0.15% ropivacaine plus 0.5 microg/mL of sufentanil with that of 0.10% ropivacaine plus 0.5 microg/mL of sufentanil for labor analgesia with patient-controlled epidural analgesia (PCEA) to determine whether a decreased concentration of ropivacaine could produce equally effective analgesia. One-hundred-thirty healthy pregnant women at term were randomized in a double-blinded fashion. The PCEA settings were as follows: 12-mL initial bolus, 5-mL bolus dose, 5-min lockout interval, and 10 mL/h basal infusion. Patient demographics and labor characteristics were comparable in both groups. No differences were observed for pain scores, maternal satisfaction, volume of anesthetic solution administered, number of boluses requested and delivered, need for supplemental boluses, mode of delivery, motor block, side effects, or Apgar scores. Patients in the 0.10% ropivacaine group used significantly less drug than those in the 0.15% group (mean, 57 mg; 95% confidence interval, 50.5-63.5 mg; versus mean, 88.0 mg; 95% confidence interval, 74.4-93.3 mg, respectively; P < 0.0001). Ropivacaine 0.10% plus 0.5 microg/mL of sufentanil administered via PCEA for labor analgesia is equally effective as ropivacaine 0.15% plus 0.5 microg/mL of sufentanil, with a 30% local anesthetic-sparing effect and a 40% reduction in cost. However, this reduction in local anesthetic is not associated with a decrease in the incidence of motor block, side effects, or instrumental deliveries. IMPLICATIONS: Ropivacaine 0.10% plus 0.5 microg/mL of sufentanil given via patient-controlled epidural anesthesia for labor analgesia is equally as effective as ropivacaine 0.15% plus 0.5 microg/mL of sufentanil, with a 30% local anesthetic-sparing effect and a 40% reduction in cost. This reduction in ropivacaine concentration is not associated with a decrease in the incidence of motor block, side effects, or instrumental deliveries.     

Optimal dose of intrathecal clonidine added to sufentanil plus bupivacaine for labour analgesia

PURPOSE: The combination of intrathecal (IT) 5 microg sufentanil plus 1.25 mg bupivacaine is useful for inducing labour analgesia, albeit of short duration and slow onset. As a supplementation to this regimen, the effect of IT clonidine on the duration of analgesic action was investigated. METHODS: Forty-eight healthy parturients were randomly assigned into three groups to receive 0 microg (group C0), 15 microg (C15) or 30 microg (C30) of clonidine IT in addition to 5 microg sufentanil plus 1.25 mg bupivacaine IT for labour analgesia. The quality of pain relief was assessed on 0-100 visual analogue scale by the author. The occurrence of side effects was also evaluated before the request for additional analgesia. RESULTS: Clonidine (C15 and C30), produced a longer duration of analgesia than C0 (mean 144 +/- sd 27.9, 165 +/- 31.8 vs 111 +/- 21.9 min, P < 0.01). Also, C15 and C30 produced a more rapid onset and a higher quality of analgesia than C0, (P < 0.01). The most cephalad level of sensory block was higher in C30 than C15 (median T3 vs T4, P < 0.05) but lowest in C0 (median T7 vs T3,T4, P < 0.01). Side effects, sedation and hypotension, occurred more frequently in C30 than in either C0 or C 15, (9 vs 2,5 and 9 vs 1,3, respectively, P < 0.05). CONCLUSION: The optimal dose of intrathecal clonidine to enhance labour analgesia with the current sufentanil-bupivacaine regimen is 15 microg. In view of the side effect profile, doses greater than 30 microg clonidine are unlikely to be useful.     

Combined spinal epidural analgesia is the preferred technique for labour analgesia

To justify its place as the preferred method of pain relief in labour, CSE must demonstrated a clear superiority over epidural analgesia. Looking at the relative efficacy of the two techniques failure rates appear to be equal. Speed of onset may be faster with an initial spinal injection although perhaps only clinically relevant in advanced labour where the quality of analgesia may sometimes be better. CSE would not seem to offer significant advantage in terms of mode of delivery or the ability to ambulate. The side effects of the technique are somewhat more concerning as CSE would appear to carry slightly greater risk than epidural analgesia, most notably in neurological sequelae and the effects of intrathecal opioids. Certainly CSE confers no benefit in terms of cost. What then is the place of CSE in labour analgesia? Its potential benefit makes it a reasonable option when there is a clear clinical advantage such as requests for analgesia in late labour or where maternal distress is extreme or where epidural analgesia has been ineffective. However even in such situations the slight increase in risk must be weighed against the possible advantage. Consequently the CSE cannot at the present time be recommended as the preferred option for labour analgesia.     

Sedation and analgesia with propofol plus low-dose ketamine for retrobulbar block

OBJECTIVES: To determine if adding ketamine to propofol provides better sedation than propofol alone for patients receiving a retrobulbar block for eye surgery. MATERIAL AND METHODS: Randomized double-blind trial enrolling 50 patients receiving a retrobulbar nerve block for eye surgery. Patients were randomly assigned to 2 groups. In the propofol group sedation was induced with 0.45 mg x kg(-1) of propofol. In the ketamine plus propofol group sedation was induced with 0.45 mg x kg(-1) of propofol plus 0.25 mg x kg(-1) of ketamine. We recorded patient characteristics (age, weight, ASA class, height, sex), hemodynamic variables (blood pressure, heart rate), puncture conditions, sedation (score on the Observer's Assessment of Alertness/Sedation [OAA/S] scale), ventilation (end-tidal carbon dioxide pressure, apneas, need for reanimation maneuvers, pulse oximetry), time until onset of effect, duration of effect, and amnesia. RESULTS: No significant differences were observed in time to onset, duration of effect, patient characteristics, hemodynamic or respiratory variables, or amnesia. Sedation assessed on the OAA/S-scale was lower in the propofol group and the puncture conditions were significantly better in the ketamine plus propofol group. The only adverse psychomimetic reaction was transient agitation, observed in 2 propofol group patients. CONCLUSIONS: Low doses of ketamine associated with propofol improve puncture conditions for performing a retrobulbar block without increasing unwanted side effects.     

地佐辛和芬太尼用于甲状腺术后镇痛对患者呼吸的影响

目的比较等效剂量地佐辛与芬太尼用于甲状腺术后镇痛对患者呼吸的影响。方法甲状腺手术患者80例,年龄20~65岁,随机均分为地佐辛组(D组)和芬太尼组(F组)。两组患者术后第1次感到疼痛时分别静注地佐辛0.15 mg/kg或芬太尼1.5μg/kg。记录用药前及用药后10、20、30 min的RR、SpO2;记录用药前及用药后1、2、4、8 h吞咽时VAS评分及咳嗽和深呼吸时的BCS评分。结果两组患者用药后各时点VAS、BCS评分差异无统计学意义。用药后10、20 min两组RR较用药前明显减慢,F组明显慢于D组(P<0.05),且F组有3例患者出现SpO2<90%。结论等效剂量地佐辛用于甲状腺术后镇痛对呼吸的抑制作用较芬太尼弱。     

Topical lidocaine and oral acetaminophen provide similar analgesia for myringotomy and tube placement in children

PURPOSE: Preoperative oral acetaminophen (30 mg x kg(-1)) was compared with topical 2% lidocaine ear drops for postoperative analgesia following bilateral myringotomy and tube placement (BMT) in children. METHODS: In a randomized, prospective, double-blind trial, we studied 124 patients, six months to eight years, ASA physical status I or II, undergoing elective BMT under general anesthesia. The patients in Group I received acetaminophen 30 mg x kg(-1) orally in a grape flavoured syrup 30 to 60 min before surgery and 0.9% saline drops (placebo) in each ear upon insertion of tympanostomy tube. Patients in Group II received a placebo (grape flavoured syrup) before surgery and 2% lidocaine, 0.5 mL in each ear when ear tubes were inserted. Postoperative pain assessments were recorded every five minutes in the postanesthesia care unit, and every 15 min in the day care surgical unit (DCSU) using the modified Children's Hospital of Eastern Ontario pain scale (mCHEOPS), a ten-point scale. Pain at home was documented by parents using a 0 (no pain) to 10 (worst pain imaginable) scale. RESULTS: The median (range) mCHEOPS scores in the DCSU at 15 and 30 min were similar, i.e., 5 (4-9) in the acetaminophen group and 4 (4-8) in the lidocaine group. The proportion of patients receiving supplemental analgesics in the 24 hr following surgery was similar in both groups (45% and 42% respectively). CONCLUSION: Topical lidocaine and oral acetaminophen in a dose of 30 mg x kg(-1) provide similar analgesia following BMT.     

Comparison of morphine alone with morphine plus clonidine for postoperative patient-controlled analgesia

Editor—We were interested to read the article by Jeffsand colleagues¹ on the addition of clonidine to morphine PCAdevices, and would like to make some comments. First, the medianpain score in the morphine group for the first 12 h wasgiven as 3 with a range of 1–4, although it was stated     

Comparison of morphine alone with morphine plus clonidine for postoperative patient-controlled analgesia

Background. Clonidine is an