A prospective, open, single blind, randomized study comparing four analgesics in the treatment of peripheral injury in the emergency department.

The efficacy of four analgesics, distinct concerning analgesic power and mechanism of action, was evaluated for pain relief in patients suffering from single peripheral injury. Patients were randomly allocated to receive either propacetamol (the pro-drug of paracetamol) 20 mg/kg i.v., piritramide 0.25 mg/kg i.m., tramadol 1 mg/kg i.v. or diclofenac 1 mg/kg i.v. Pain scores were measured by the patient using the visual analogue scale (VAS) and by an observer using a 4-point verbal rating scale (VRS). Cardiorespiratory variables and side effects were recorded. One hundred and sixty patients were included, 131 completed the study. Groups matched for demography and baseline pain levels. In general pain scores decreased with time. No significant differences were found between groups at any particular time point. VAS scores were significantly (p < 0.02) lower than baseline scores 30 minutes after injection in all treatment groups except for the piritramide group where significance (p < 0.01) was reached after 60 minutes. VRS score analysis showed a similar trend although significances differed. In the piritramide group significantly more side effects were noted than in the other groups (p < 0.05). We conclude that intravenous propacetamol, tramadol and diclofenac are equally efficacious for emergency analgesic treatment of single peripheral trauma.     

Pain during insertion of peripheral intravenous catheters with and without intradermal lidocaine

Phase 1 of this study evaluated the perception of pain in 50 patients undergoing peripheral venous catheter insertion without the use of a local anesthetic. Phase 2 evaluated perceived pain in 50 patients who received intradermal lidocaine before the i.v. catheter was inserted. The researchers found that lidocaine injected intradermally before placement of an i.v. catheter resulted in significantly lower self-reported pain perceptions (p < 0.01). No additional time (determined in intervals of 15 minutes) was required for the study group. Based on these findings, the hospital policy was modified so that intradermal lidocaine would be offered to all patients requiring peripherally inserted i.v. catheters.     

No more tears: a randomized controlled double-blind trial of Amethocaine gel vs. placebo in the management of procedural pain in neonates

AIM: During a comparative double-blind study, the efficacy of Amethocaine local anaesthetic gel was compared with that of a placebo gel to establish their effect on the reduction of behavioural and physiological responses to pain in neonates. METHOD: Forty infants were included in the trial, 20 being randomly assigned to each group. After topical application of either Amethocaine or the placebo for 30 minutes, cannulation was performed using a 24 gauge cannula. Assessment of pain was made with the aid of four point assessment tool incorporating facial expression, cry and heart rate changes and ease of cannulation. Additional baseline data were obtained including sex, gestation, weight and previous experience of cannulation, and analysed using Statistical Package for Social Sciences (SPSS). RESULTS: Good analgesic effects were demonstrated in the Amethocaine group, as there was a high level of significance (P < 0.01) in the difference in pain scores between the two groups using a Mann-Whitney U-test. There was no correlation between gestation or weight and the degree of pain experienced during painful procedures. No significant relationship was found between cannulation and the degree of pain experienced. CONCLUSION: It can, therefore, be concluded that Amethocaine gel is an effective local anaesthetic in the management of skin puncturing procedural pain in neonates, and that all infants regardless of maturity, weight or previous experiences probably experience a similar degree of pain and therefore warrant effective and appropriate analgesic intervention.     

Peripheral analgesic effect of intra-articularly applied clonidine

BACKGROUND AND AIM: Clonidine applied intra-articularly into the knee joint has a peripheral analgesic effect. We examined intra-articularly injected clonidine to determine whether resorption with a measurable systemic concentration could be detected. METHODS: A randomised, placebo-controlled double-blind study was carried out on patients undergoing knee arthroscopies. The 69 patients were randomised into three groups: group 1 received 150 ug clonidine intra-articularly, group two 150 ug clonidine intravenously and group three a placebo. Postoperative pain therapy was carried out with i.v. morphine hydrochloride. Pain scores and side-effects were documented for 24 h. RESULTS: There were no significant differences between the three groups in demographics, duration of operation, duration of anaesthesia, diagnoses or type of operation. The pain score at rest was significantly lower in group 1. In the first 20 min, the systemic concentration of clonidine was significantly higher in the intravenous group than in the intra-articular group. CONCLUSION: Intra-articular clonidine has a postoperative analgesic effect after knee arthroscopies due to a peripheral action.     

Pre-emptive analgesia using intravenous fentanyl plus low-dose ketamine for radical prostatectomy under general anesthesia does not produce short-term or long-term reductions in pain or analgesic use

The aim of the study was to evaluate post-operative pain and analgesic use after pre-operative or post-incisional i.v. fentanyl plus low dose i.v. ketamine vs. a standard treatment receiving i.v. fentanyl but not ketamine. Men undergoing radical prostatectomy under general anesthesia were randomly assigned in a double-blinded manner to one of three groups. Patients received i.v. fentanyl before incision followed by an i.v. bolus dose (0.2 ml kg⁻¹) and an i.v. infusion (0.0025 ml kg⁻¹ min⁻¹) of 1 mg ml⁻¹ ketamine (group 1) or normal saline (groups 2 and 3). Seventy minutes after incision, patients received i.v. fentanyl followed by an i.v. bolus dose (0.2 ml kg⁻¹) and an i.v. infusion (0.0025 ml kg⁻¹ min⁻¹) of saline (groups 1 and 3) or ketamine (group 2). Pain, von Frey pain thresholds, and cumulative morphine consumption using patient-controlled analgesia (PCA) were assessed up to 72 h after surgery. 143 patients completed the study (group 1, n=47; group 2, n=50; group 3, n=46). Cumulative PCA morphine (mean±SD) did not differ significantly among groups (group 1, 92.3±45.9 mg; group 2, 107.2±58.4 mg; group 3, 103.6±50.4 mg; P=0.08 for groups 1 vs. 2, and groups 1 vs. 3). On day 3, the hourly rate (mean±SEM) of morphine consumption was significantly lower (P<0.0009) in group 1 (0.61±0.013 mg h⁻¹) than group 2 (0.86±0.011 mg h⁻¹) and group 3 (0.89±0.008 mg h⁻¹). Pain scores and von Frey pain thresholds did not differ significantly among groups. Two-week and 6-month follow-ups did not reveal significant group differences in pain incidence, intensity, disability or mental health. Pre-operative, low-dose administration of i.v. ketamine did not result in a clinically meaningful reduction in pain or morphine consumption when compared with post-incisional administration of ketamine or a saline control condition.     

Lignocaine is a better analgesic than either ethyl chloride or nitrous oxide for peripheral intravenous cannulation

Background: Peripheral intravenous (i.v.) cannulation is a painful, frequently performed ED procedure. It is common practice in other medical settings to offer analgesia prior to cannulation. Objective: The present trial aims to reproduce in the ED studies that found a reduction in the pain of i.v. cannulation after intradermal lignocaine, ethyl chloride topical spray and entonox (50:50 oxygen : nitrous oxide). It also intends to determine which is analgesic most effective and explore the role of entonox for cannulation analgesia. Methods: Three hundred subjects were randomized into four groups: i.v. cannula inserted with (i) no anaesthesia; (ii) entonox; (iii) ethyl chloride; and (iv) 0.1 mL intradermal 1% lignocaine. Pain was recorded on 100 mm visual analogue scales (VAS) after lignocaine injection or ethyl chloride spray and following i.v. cannulation. A clinically significant reduction in VAS pain score was determined to be 13 mm. Results: Patients cannulated without analgesia reported the most pain. Those cannulated after lignocaine had the least pain (median VAS 20 mm, 95% CI 15–25, vs 1 mm 95% CI 0–6, P ≤ 0.001). Ethyl chloride (VAS 11 mm, 95% CI 7–15, P = 0.003) and entonox (VAS 13 mm, 95% CI 8–18, P = 0.047) reduced i.v. cannulation pain but did not reach clinical significance. Neither pain from presenting symptoms (P = 0.3), nor size of cannula (P = 0.8) affected pain scores. VAS scores were independent of sex and age (P = 0.1). Cannulation success was not affected by either the choice of analgesia or cannulation site. Conclusions: The present trial confirms the findings of Harris and colleagues that lignocaine reduces the pain of cannulation in the ED. Lignocaine reduced the pain of i.v. cannulation more effectively than entonox or ethyl chloride.     

The effect of the use of ultrasound in the success of peripheral venous catheterisation

The aim of this study was to investigate the effect of ultrasound-guided peripheral venous catheterisation in patients where difficulty was experienced in peripheral venous catheterisation. The study was conducted in the emergency department at a university hospital in İzmir Turkey. After obtaining institutional review board approval and written informed consent, 60 patients with a history or suspicion of difficult cannulation were enrolled with 30 patients in traditional and 30 in ultrasound group. In the ultrasound group, peripheral intravenous catheterisation was performed using a portable ultrasound device with 13.5 MHz ultrasound probe and 20 gauge intravenous catheter. The success rate of peripheral venous catheterisation was 30% in the control group and 70% in the treatment group. The success rate was significantly higher among the treatment group. The mean intensity of felt pain was 6.00 ± 1.98 in the control group and 4.77 ± 1.74 in the treatment group. The mean intensity of felt pain was significantly lower in the treatment group. The state of chronic disease affected the success rate in patients in the treatment group.     

Intranasal diamorphine for paediatric analgesia: assessment of safety and efficacy.

OBJECTIVE: To evaluate the safety and efficacy of intranasal diamorphine as an analgesic for use in children in accident and emergency (A&E). METHODS: A prospective, randomised clinical trial with consecutive recruitment of patients aged between 3 and 16 years with clinically suspected limb fractures. One group received 0.1 mg/kg intranasal diamorphine, and the other group received 0.2 mg/kg intramuscular morphine. At 0, 5, 10, 20, and 30 minutes pain scores, Glasgow coma score, and peripheral oxygen saturations were recorded; parental acceptability was assessed at 30 minutes. RESULTS: 58 children were recruited, with complete data collection in 51 (88%); the median summed decrease in pain score was better for intranasal diamorphine than intramuscular morphine (9 v 8), though this was not significant (P = 0.4, Mann-Whitney U test). The episode was recorded as "acceptable" in all parents whose child received intranasal diamorphine, compared with only 55% of parents in the intramuscular morphine group (P < 0.0001, Fisher's exact test). There was no incidence of decreased peripheral oxygen saturation or depression in the level of consciousness in any patient. CONCLUSIONS: Intranasal diamorphine is an effective, safe, and acceptable method of analgesia for children requiring opiates in the A & E department.     

Evaluation of a low-dose lidocaine iontophoresis system for topical anesthesia in adults and children: a randomized, controlled trial

BACKGROUND: Commonly used classes of topical anesthetics require 30 to 60 minutes to provide effective anesthesia. A new low-dose lidocaine iontophoresis system (LDLIS) may provide topical anesthesia in 10 minutes at a lower dose than previous systems, thereby limiting adverse events. METHODS: This was a prospective, randomized, multicenter, double-blind, placebo-controlled, clinical trial. Adults and children aged 5 to 17 years (inclusive) received a 10-minute ionntophoretic treatment with either lidocaine or a saline placebo before venipuncture or venous cannulation. Intensity of pain associated with venipuncture or venous cannulation was assessed using either a 10-cm Visual Analog Scale (VAS) for adults and children aged 12 to 17 years or the Facial Affective Scale (FAS) for all children enrolled. RESULTS: Five hundred forty-eight patients (276 adults, 272 children) participated. Mean (SD) VAS pain scores were lower in adults who received iontophoresis with lidocaine rather than with placebo (0.77 [1.49] vs 2.52 [2.30], P < 0.001) and in children aged 12 to 17 years (1.50 [1.87] vs 2.58 [2.26], P = 0.001). FAS pain scores were lower among children who received iontophoresis with lidocaine rather than with placebo (0.36 [0.26] vs 0.51 [0.27], P < 0.001). Similar results were found for children stratified by age group (5-7 years: 0.40 [0.30] vs 0.60 [0.31], P = 0.011; 8-11 years: 0.35 [0.27] vs 0.48 [0.27], P = 0.021; 12-17 years: 0.33 [0.21] vs 0.48 [0.24], P = 0.001). Mean (SD) parental ratings of pain on the FAS for children aged 5 to 11 years were also lower for the lidocaine group (0.45 [0.28] vs 0.55 [0.25], P = 0.018). Adverse events were similar between groups and included skin erythema and edema. One patient in the study experienced a partial-thickness burn. CONCLUSION: In this study of adults and children, the LDLIS provided effective topical anesthesia for venipuncture and venous cannulation within 10 minutes.     

The effect of standard care, ibuprofen, and distraction on pain relief and patient satisfaction in children with musculoskeletal trauma.

INTRODUCTION: The purpose of this study was to determine the effectiveness of nursing interventions in decreasing pain for children with minor musculoskeletal trauma and moderate pain and to examine patient satisfaction. METHODS: Children were assigned to 1 of 3 intervention groups: (1) standard care (ice, elevation, and immobilization) only; (2) standard care and ibuprofen; or (3) standard care and distraction. Children were monitored for pain ratings for 60 minutes. Children who sustained minor musculoskeletal trauma within the past 24 hours and presented with pain ratings of 2 or greater using the 0-5 Wong/Baker faces scale were included. Two patient satisfaction questions were asked of parents upon their child's discharge from the emergency department. RESULTS: A statistically significant decrease in pain for all patients (76) occurred at 30 minutes (F = 4.39, P <.05) and was maintained at 60 minutes. The distraction group demonstrated a statistically significant reduction in pain compared with the other groups at 30 minutes; this reduction was maintained at 60 minutes (F = 47.07, P <.05). Parents of only 6 children expressed dissatisfaction with overall pain management. Twelve percent of children who were not in the group receiving medication received analgesics while in the emergency department. At discharge, only 37% of children with fractures and/or sprains had received medications for pain. DISCUSSION: Children with musculoskeletal trauma may be under-medicated. Distraction techniques can be an effective adjunct to analgesia for children with musculoskeletal pain in the emergency department and should be made available. Ibuprofen may not be an effective analgesic for children with these injuries; stronger analgesics may be required.     

Comparison of the analgesic efficacy of rofecoxib and enteric-coated diclofenac sodium in the treatment of postoperative dental pain: a randomized,placebo-controlled clinical trial

BACKGROUND: Rofecoxib is a selective cyclooxygenase-2 inhibitor indicated for the treatment of acute pain, with similar analgesic efficacy to ibuprofen and naproxen sodium. Diclofenac sodium is the most commonly prescribed nonsteroidal anti-inflammatory drug worldwide; it is effective for the treatment of pain as well as the signs and symptoms associated with the painful conditions of osteoarthritis and rheumatoid arthritis. OBJECTIVE: The aim of this study was to compare the analgesic efficacy and tolerability of a single dose of rofecoxib 50 mg, 3 doses of enteric-coated diclofenac sodium 50 mg, and placebo over 8-hour and 24-hour periods in patients with moderate to severe pain after oral surgery. METHODS: In this double-blind, placebo- and active comparator-controlled, parallel-group study, patients experiencing moderate to severe pain after the surgical extraction of > or = 2 third molars were randomized to receive a single dose of rofecoxib 50 mg, 3 doses of enteric-coated diclofenac sodium 50 mg (50 mg given every 8 hours), or placebo. Patients rated pain intensity, pain relief, and global assessments at prespecified times throughout the 24-hour period after initial dosing. Overall analgesic efficacy was determined by total pain relief over 8 hours (TOPAR8) and 24 hours (TOPAR24) and patient global assessments at 8 and 24 hours. Onset of analgesic effect was determined by using the 2-stopwatch method for confirmed perceptible pain relief. Peak analgesic effect was the maximum pain relief attained during the first 8 hours. The duration of analgesic effect was determined by median time to rescue analgesia use. RESULTS: A total of 305 patients were randomized to treatment: 121 received rofecoxib, 121 received diclofenac sodium, and 63 received placebo. The baseline demographics were similar among the groups. Overall, 61.3% experienced moderate pain and 38.7% experienced severe pain; 53.1% were female; and the mean age was 23.4 years. The overall analgesic efficacy, as assessed by TOPAR8, of a single dose of rofecoxib 50 mg was significantly greater than a single dose of enteric-coated diclofenac sodium 50 mg (20.5 vs 8.2) and placebo (20.5 vs 5.9). Patient global assessment at 8 hours was also significantly better for rofecoxib compared with enteric-coated diclofenac sodium and placebo. TOPAR24 was significantly greater for a single dose of rofecoxib 50 mg compared with 3 doses of enteric-coated diclofenac sodium 50 mg (64.1 vs 25.1) and placebo (64.1 vs 19.2). At 24 hours, the patient global assessment for rofecoxib was significantly better than that achieved with enteric-coated diclofenac sodium and placebo. The onset of analgesic effect was significantly more rapid for rofecoxib than for enteric-coated diclofenac sodium and placebo (median times: 31 minutes, >4 hours, and >4 hours, respectively). The peak analgesic effect was significantly greater for rofecoxib compared with enteric-coated diclofenac sodium (3.2 vs 1.5) and placebo (3.2 vs 1.1). The duration of analgesia was significantly longer for rofecoxib than enteric-coated diclofenac sodium (median times: >24 hours vs 1 hour and 37 minutes) and placebo (>24 hours vs 1 hour and 37 minutes). Enteric-coated diclofenac sodium was numerically greater than placebo for the key end points measuring overall efficacy (total pain relief and patient global assessment), but diclofenac sodium did not provide as much analgesic effect as expected for a drug effective for pain, osteoarthritis, and rheumatoid arthritis and did not differ significantly from placebo. Overall, both rofecoxib and enteric-coated diclofenac sodium were generally well tolerated, although the rofecoxib group had a significantly lower incidence of clinical and drug-related adverse events than the enteric-coated diclofenac sodium group. CONCLUSIONS: A single 50-mg dose of rofecoxib provided greater overall analgesic efficacy over 8 hours, more rapid onset of analgesia, greater maximum analgesic effect, and longer duration of effect than a single 50-mg dose of enteric-coated diclofenac sodium in patients with moderate to severe pain associated with oral surgery. Compared with 3 doses of enteric-coated diclofenac sodium 50 mg (50 mg every 8 hours), a single dose of rofecoxib 50 mg provided greater overall analgesic efficacy over 24 hours.     

Analysis of factors affecting pain in intravenous catheter placement: a survey of 925 patients

The aim of the study was to determine some factors affecting pain during intravenous (i.v.) catheter placement in an emergency department (ED). A cross-sectional, observational study was conducted at an academic ED. Nine hundred and twenty five adult patients who had a 20 gauge i.v. catheter placed were enrolled the study. Patients were excluded for the following conditions: more than one i.v. attempt, altered mental status, head trauma, lack of contact due to visual impairment, hearing or speech disorder, intoxication, distracting injury or physical abnormality at the i.v. site. The magnitude of pain of i.v. catheter placement was not related to age, sex, experience of the individual placing the i.v. catheter, site of i.v. catheter insertion and use of analgesic or antidepressive drugs (p > 0.05). Patients with a history of depression reported significantly higher pain than non-depressive patients (p = 0.001). Depressive patients reported higher severity of pain during i.v. catheter placement than nondepressed ones. This may influence the decision on whether or not to use local anaesthesia for catheter insertion.     

Peripheral nerve injury from intravenous cannulation: a case report

The following is a case report of a patient who had an intravenous (i.v.) catheter inserted into her cephalic vein and thereafter sustained an injury to the superficial branch of the radial nerve. When an i.v. catheter penetrates a nerve, it can cause temporary or permanent damage. After sustaining an injury, a nerve will regenerate in an attempt to reconnect with the fibers it once innervated. Recovery from nerve damage may take only weeks or a year or more. Some patients, however, may sustain lifelong damage depending on the severity of the needle stick to the nerve. To avoid injury to peripheral nerves when inserting i.v. catheters, a few recommendations should be followed. First, if inserting an i.v. catheter in the cephalic vein, be conscious of the proximity of the superficial peripheral nerves. Second, if a paresthesia is elicited when inserting an i.v. catheter, withdraw the catheter immediately. Third, if a patient complains of paresthesias or numbness near the i.v. site, remove the i.v. catheter immediately. Fourth, limit the amount of probing after inserting the catheter into the skin. Finally, if nerve damage is suspected from a peripheral i.v. cannulation, consult a hand specialist promptly.     

The analgesic effects of subhypnotic doses of propofol in human volunteers with experimentally induced tourniquet pain

This double-blind, placebo-controlled study was performed to determine whether subhypnotic doses of propofol have analgesic or sedative effects. Of 48 subjects randomly assigned to 1 of 4 bolus-infusion treatment groups, group 1 (n = 16) received propofol at 16 micrograms/kg per minute; group 2 (n = 16) received propofol at 32 micrograms/kg per minute; and group 3 (n = 8) received 10% intralipids at 16 micrograms/kg per minute; and group 4 (n = 8) received 20% intralipids at 32 micrograms/kg per minute. Following a bolus of the study drug, a maintenance infusion was started and continued throughout the study. Thirty minutes after the study drug began infusing, an Observer's Assessment of Alertness/Sedation Scale was completed, a tourniquet was inflated, and a maximum tourniquet tolerance time (TTT) was obtained. Pain was assessed every 5 minutes while the tourniquet was inflated and immediately before deflation using a 0 to 10 verbally administered numeric rating scale (NRS). No significant differences in TTT were noted between the 2 propofol groups. However, the TTT for both propofol groups differed significantly from the control group (intralipid groups combined) (P < .05). There was a statistically significant difference in the time it took the propofol groups to reach a NRS score of 8 or greater when compared with the control group (P < .05). Sedation scores differed significantly between the control and the propofol at 32 micrograms/kg per minute groups (P < .05). The results of this study suggest that propofol given at subhypnotic doses could serve as a valuable adjunct for acute postoperative pain management.     

A comparison of EMLA cream and amethocaine gel for topical cutaneous analgesia in children

The efficacy of EMLA cream and amethocaine gel was compared using application times of greater than 60 minutes. Eighty eight patients received EMLA cream and 89 received amethocaine gel. Pain during venous cannulation was assessed by a single observer using a four point observational scale. Sixty nine (78%) patients in the amethocaine group underwent pain-free venepuncture compared with 46 (52%) patients in the EMLA cream group (p<0.001). No serious side effects occurred in any patient. As well as having a faster onset of action, amethocaine gel also appears to be a more effective analgesic than EMLA cream prior to venous cannulation in children.     

The analgesic effect of dexketoprofen when added to lidocaine for intravenous regional anaesthesia: a prospective, randomized, placebo-controlled study

This prospective, randomized, placebo-controlled study evaluated the effects of dexketoprofen as an adjunct to lidocaine in intravenous regional anaesthesia (IVRA) or as a supplemental intravenous (i.v.) analgesic. Patients scheduled for elective hand or forearm soft-tissue surgery were randomly divided into three groups. All 45 patients received 0.5% lidocaine as IVRA. Dexketoprofen was given either i.v. or added into the IVRA solution and the control group received an equal volume of saline both i.v. and as part of the IVRA. The times of sensory and motor block onset, recovery time and postoperative analgesic consumption were recorded. Compared with controls, the addition of dexketoprofen to the IVRA solution resulted in more rapid onset of sensory and motor block, longer recovery time, decreased intra- and postoperative pain scores and decreased paracetamol use. It is concluded that coadministration of dexketoprofen with lidocaine in IVRA improves anaesthetic block and decreases postoperative analgesic requirements.     

Postoperative transkutane elektrische Nervenstimulation (TENS)

BACKGROUND: The aim of this study was to determine whether 3 days of TENS therapy postoperatively after shoulder operations would result in better pain relief and/or reduced analgesic intake when compared to placebo. METHOD: The study was carried out randomized, double-blind and placebo controlled. Thirty patients were randomized to two groups. The verum group received TENS SM1AKS 80 Hz 6 mA and the placebo group received TENS SM1AKS 80 Hz 0 mA. The pain was assessed pre-operatively using the Hamburg Pain Adjective List. Premedication and Anaesthesia were standardized. TENS was applied to the patients immediately postoperatively for 8 hours and then on the following days 5 times daily for 45 minutes. The effectiveness was evaluated postoperatively using a visual analogue scale (rest, activity), the Hamburg Pain Adjective List and postoperative analgesic consumption. RESULTS: The visual analogue scale at rest and on activity showed no significant difference between the groups. Postoperative analgesic consumption of morphine hydrochloride in the first 24 hours was at time 8 hours postoperative significantly and at all other time points markedly less in the verum group compared to the placebo group. The sensory secondary scale score of the "Hamburg Pain Adjective List" was significantly lower postoperatively compared to preoperatively in the verum group. CONCLUSION: We were able to show in this study that TENS applied postoperatively after shoulder surgery clearly reduced analgesic consumption in the first 72 hours. Furthermore there was a significant difference in the pain scores using the "Hamburg Pain Adjective List" in favour of the verum group. TENS applied postoperatively is a effective, simple modality with few side-effects.     

Intravenous parecoxib sodium as an analgesic alternative to morphine in acute trauma pain in the emergency department

Background

Parecoxib sodium is the first parenteral COX-2 inhibitor used for pain management licensed for postoperative pain. However, no study has assessed the usage of parecoxib for acute traumatic pain in the emergency department (ED). The objective of this study was to investigate a potential alternative analgesic agent in the ED by determining the mean reduction of pain score between acute traumatic pain patients who were administered with intravenous (IV) parecoxib sodium versus IV morphine sulfate. The onset of perceptible analgesic effect and side effects were also evaluated.

Methods

A randomized, double-blinded study comparing IV parecoxib 40 mg versus IV morphine at 0.10 mg/kg was conducted in adult patients presented with acute traumatic pain with numeric rating scale (NRS) of 6 or more within 6 hours of injury. Patients were randomized using a computer-generated randomization plan. Drug preparation and dispensing were performed by a pharmacist. Periodic assessment of blood pressure, pulse rate, oxygen saturation, and NRS were taken at 0, 5, 15, and 30 minute intervals after the administration of the study drug. The primary outcome was the reduction of NRS. Side effect and drug evaluation was conducted within 30 minutes of drug administration.

Results

There was no statistically significant difference in the reduction of mean NRS between patients in the IV parecoxib group or IV morphine group (P?=?0.095). The mean NRS for patients treated with IV morphine were 7.1 at 0 minutes, 4.5 at 5 minutes, 3.1 at 15 minutes, and 2.0 at 30 minutes. Whereas mean NRS for patients who received IV parecoxib were 7.8 at 0 minutes, 5.7 at 5 minutes, 4.7 at 15 minutes, and 3.9 at 30 minutes. The onset of perceptible analgesic effects could be seen as early as 5 minutes. Dizziness was experienced in 42.9% of patients who received IV morphine compared to none in the parecoxib group.

Conclusions

There was non-significant trend toward superiority of IV morphine over IV parecoxib. Looking at its effectiveness and the lack of opioid-related side-effects, the usage of IV parecoxib sodium may be extended further to a variety of cases in the ED.     

The use of a questionnaire for improvement of postoperative analgesia after transurethral resection of the prostate

Background: Postoperative analgesic studies with methods like i.v. patient controlled analgesia (i.v. PCA) or epidural analgesia have reported effective pain relief after major surgery, also after urologic cancer surgery. In contrast, systematic results after minor urologic surgery are widely unknown, although the pain intensities may be high for a short time. The aim of the study was to evaluate the usefulness of a pain questionnaire as a measurement tool of postoperative analgesic quality after transurethral resection of the prostate (TUR-P). Methods: A questionnaire of the American Pain Society (APS) for quality assurance of postoperative pain therapy was adapted to estimate the pain profile, analgesic demand, satisfaction and side effects of analgesic therapy at the morning of the first postoperative day in two groups after TUR-P. In one group (group 1; n=50) the efficacy of a routinely used (but non-standardized) analgesic regimen with different analgesics administered only on demand was estimated with the questionnaire. These results were compared with a new and standardized analgesic approach (group 2; n=50), designed as a follow-up study. These patients received an intravenous infusion of the weak opioid tramadol (500 mg) in combination with the spasmolytic butylscopolamine (50 mg) immediately after the surgery until the morning of first postoperative day. Also the effectivity of this standardized regimen was estimated with the questionnaire. Results: In group 1, an evident analgesic undersupply with high pain intensities as well as frequent and long lasting breakthrough pain was documented. In contrast, in group 2 with a standardized approach the questionnaire did indicate impressing clinical improvement. In addition, patient satisfaction was significantly higher, despite some typical side effects of tramadol, such as drowsiness and dizziness. Conclusions: The modified questionnaire of the American Pain Society allows important insights into the analgesic quality after defined surgery without special methods of an Acute Pain Service. The questionnaire is easy to handle and takes only a few minutes. The presented data after TUR-P can not substitute randomized controlled trials.     

Emergency Department Management of Acute Pain Episodes in Sickle Cell Disease

Objectives To characterize the initial management of patients with sickle cell disease and an acute pain episode, to compare these practices with the American Pain Society Guideline for the Management of Acute and Chronic Pain in Sickle-Cell Disease in the emergency department, and to identify factors associated with a delay in receiving an initial analgesic.
Methods This was a multicenter retrospective design. Consecutive patients with an emergency department visit in 2004 for an acute pain episode related to sickle cell disease were included. Exclusion criteria included age younger than 18 years. A structured medical record review was used to abstract data, including the following outcome variables: analgesic agent and dose, route, and time to administration of initial analgesic. Additional variables included demographics, triage level, intravenous access, and study site. Mann–Whitney U test or Kruskal–Wallis test and multivariate regression were used to identify differences in time to receiving an initial analgesic between groups.
Results There were 612 patient visits, with 159 unique patients. Median time to administration of an initial analgesic was 90 minutes (25th to 75th interquartile range, 54–159 minutes). During 87% of visits, patients received the recommended agent (morphine or hydromorphone); 92% received the recommended dose, and 55% received the drug by the recommended route (intravenously or subcutaneously). Longer times to administration occurred in female patients (mean difference, 21 minutes; 95% confidence interval = 7 to 36 minutes; p = 0.003) and patients assigned triage level 3, 4, or 5 versus 1 or 2 (mean difference, 45 minutes; 95% confidence interval = 29 to 61 minutes; p = 0.00). Patients from study sites 1 and 2 also experienced longer delays.
Conclusions Patients with an acute painful episode related to sickle cell disease experienced significant delays to administration of an initial analgesic.