Assessment of the analgesic efficacy of nefopam hydrochloride after upper abdominal surgery: a study using patient controlled analgesia

A randomized, double-blind, placebo-controlled study was performed to assess the analgesic efficacy of intramuscular nefopam hydrochloride after upper abdominal surgery. Patients received either 20 mg nefopam (n = 23) or matching placebo (n = 26), 90 min before surgery, immediately after surgery, and 6, 12 and 18 h after the end of surgery. The 24-h morphine requirements were measured using a patient-controlled analgesia system delivering on-demand intravenous bolus doses of morphine. Pain was assessed using visual analogue scales. Patients receiving nefopam had a mean (+/- s.e.m.) cumulative morphine consumption of 4.1 +/- 0.8 mg in the first hour, compared with 8.5 +/- 0.8 mg in the control group (P less than 0.01). After 24 h the consumptions were 44.1 +/- 7.2 mg and 62.5 +/- 6.9 mg respectively (P less than 0.05). The pain scores in both groups were similar. This study confirms that nefopam hydrochloride has significant analgesic effects and would be a useful supplement to morphine in the management of postoperative pain.     

Evaluation of the safety and efficacy of epidural ketamine combined with morphine for postoperative analgesia after major upper abdominal surgery

STUDY OBJECTIVE: To evaluate the efficacy of the combination of epidural ketamine and morphine compared with epidural morphine alone for postoperative pain relief following major upper abdominal surgery. STUDY DESIGN: Prospective, randomized, double-blinded study. SETTING: Tertiary care referral and teaching hospital. PATIENTS: 46 ASA physical status I and II patients who underwent major upper abdominal procedures. INTERVENTIONS: Patients were randomly allocated to one of the two treatment groups: patients in Group 1 received epidural morphine 50 microg/kg whereas patients in Group 2 received epidural ketamine 1 mg/kg combined with 50 microg/kg of morphine postoperatively. MEASUREMENTS: A blinded observer using a visual analog scale (VAS) for pain assessment followed up patients for 48 hours postoperatively. Top-up dose of epidural morphine was provided when VAS was higher than 4. Analgesic requirements and side effects were compared between the two groups. RESULTS: Only 40 patients completed the study. There were no differences between the two groups with respect to age, gender, weight, duration, or type of surgical procedure or intraoperative opioid requirements. Onset of analgesia was faster (p < 0.001) in Group 2 (11 min) than in Group 1 patients (25 min). The time for first requirement of analgesia was significantly (p < 0.01) longer (19.8 +/- 9.8 hours) in Group 2 patients than Group 1 (12.8 +/- 6.2 hours). Total number of supplemental doses of epidural morphine required in the first 48 hours postoperatively was also significantly less (p < 0.005) in Group 2 compared to Group 1. Patients in Group 2 had higher sedation scores than Group I patients for the first 2 hours postoperatively. None of the patients in either group developed hallucinations or respiratory depression. Other side effects such as pruritus, nausea, and vomiting were also similar in both groups. CONCLUSIONS: The addition of epidural ketamine 1 mg/kg to morphine 50 microg/kg improved analgesia after major upper abdominal surgery without increasing side effects.     

Analgesic effect of continuous intravenous nefopam after urological surgery

OBJECTIVES:To evaluate the efficacy of continuous infusion of nefopam. Indeed this analgesic is commonly used by continuous infusion by many anaesthetists to reduce its adverse effects. However whether the analgesic effect of an intermittent administration of nefopam has been proven, the efficacy of continuous infusion has not been established. STUDY DESIGN: Double-blind placebo controlled prospective randomised study. PATIENTS AND METHODS: Sixty patients ASA 1 to 3 undergoing planned urological surgery with laparotomy were included. At the end of surgery, bolus doses of placebo (Group 3) or nefopam 20 mg (Group 1 and 2) were administered to all the patients. Placebo (Group 3), nefopam 80 mg (Group 1) or 120 mg (Group 2) was thereafter continuously infused over 24 hours. All patients received additional analgesia with PCA morphine. We measured pain at rest and on cough with VAS.Adverse side effects such as nausea and vomiting, sedation and respiratory depression were evaluated. Mental performance was measured with mini mental status tests. RESULTS: Patients were older in the placebo group by approximately six years but anesthetic and surgical variables were not different between groups. Pain at rest and on cough was not statistically different between groups. In the placebo group, the median (interquartile range) morphine consumption reached 29 mg (13-53) whereas in patients receiving 80 and 120 mg nefopam, it levelled to 44 mg (11-54) and 35 mg (9-82) respectively (p > 0.05). Patients needed morphine during the same time period whether they received nefopam or not. Patients suffering from adverse effects were similar between groups. CONCLUSION: In this study, continuous administration of nefopam did not reduce morphine consumption nor ameliorate analgesia and thus may not be recommended in urological surgery. Nefopam pharmacokinetics when used with continuous infusion as well as surgery types and differences in age between groups may explain these results.     

Combined use of intrathecal morphine and diclofenac suppository for postoperative analgesia after caesarean section

BACKGROUND: Intrathecal morphine for postoperative analgesia after caesarean section has been used in Europe and North America, but its use is not common in Japan. METHODS: We randomized 40 parturients to two groups, given either intrathecal saline (control group) or intrathecal morphine 0.05 mg (morphine group) for caesarean section. To both groups, we gave a diclofenac suppository 50 mg every 8 hours after surgery. RESULTS: The area under curve for the visual analogue scale for pain during 24 hours after operation was significantly lower (P < 0.01) in the morphine group than the control group. In addition, the parturients who required pentazocine as a rescue analgesia was significantly fewer in the morphine group (5 parturients) than the control group (11 parturients). There was no significant difference between the two groups in the Apgar score of infants, pH in umbilical cord arterial and venous blood and the incidence of postoperative nausea and vomiting. The incidence of pruritus was significantly higher in the morphine group (11 parturients) than the control group (no parturient). CONCLUSIONS: Intrathecal morphine 0.05 mg and diclofenac suppository 50 mg given every 8 hours produced effective postoperative analgesia with minimum side effects after caesarean section.     

Postoperative analgesia with morphine with or without diclofenac after shoulder surgery

Balanced analgesia using a narcotic and a nonsteroidal anti-inflammatory drug has been successfully tested for postoperative analgesia. This study was designed to examine the efficacy of such combination therapy after shoulder surgeries. Twenty ASA physical status I or II patients, scheduled for shoulder surgeries under general anesthesia, were randomly assigned to either morphine (M) group (n = 10), who received IV morphine patient-controlled analgesia (PCA) alone (2 mg as a bolus, lock-out interval of 10-minutes, and 10 mg as 1-hour limit for 48 hours), or morphine + diclofenac (M + D) group (n = 10), who received, in addition to morphine PCA, diclofenac suppositories 50 mg.8 h-1 starting immediately before surgical incision for 48 hours. Postoperative analgesic profiles, such as visual analog scale (VAS) at rest and on movement, and cumulative morphine consumption, the incidence and extent of side effects (nausea, vomiting, and time till the first bowel movement), and other complications were recorded. The two groups were similar demographically. Patients in the M + D group required 15.1 +/- 9.0 mg of morphine within 48 hours after surgery, while those in the M group required 30.5 +/- 21.0 mg of morphine (P < 0.05). No significant differences in VAS at rest and on movement were observed between the two groups. The time till the first bowel movement was significantly shorter in the M + D group. Our data suggest that diclofenac suppositories 50 mg.8 h-1 starting immediately before surgery for 48 h are effective adjuvant in reducing post-shoulder surgery morphine requirement and retardation of bowel movement.     

The effect of nefopam on morphine overconsumption induced by large-dose remifentanil during propofol anesthesia for major abdominal surgery

Opioids may activate pain facilitatory systems opposing analgesia. We investigated whether large-dose remifentanil given during IV anesthesia caused postoperative morphine overconsumption and whether nefopam (a centrally acting analgesic) could reduce this. Sixty patients scheduled for abdominal surgery were included in this prospective, randomized study. The first 30 patients received either small-dose (Group S: 3 ng/mL) or large-dose (Group L: 8 ng/mL) remifentanil administrated by a target-controlled infusion during propofol anesthesia. Before skin closure, patients received morphine 0.15 mg/kg. Another 30 patients also received nefopam 20 mg intraoperatively. Postoperative pain was controlled by titration of morphine, followed by patient-controlled morphine analgesia (PCA). Morphine was requested earlier in Group L than in Group S (10 [1-63] min versus 37 [5-90] min, median [range]; P < 0.002). The dose of morphine by titration was larger in Group L than in Group S (0.28 [0.04-0.38] mg/kg versus 0.16 [0.03-0.41] mg/kg; P < 0.05). PCA morphine consumption and pain scores were similar. There were no differences between the nefopam groups in the time to first morphine request or in the dose of morphine by titration. Postoperative morphine overconsumption occurred after large-dose remifentanil and propofol anesthesia during the early postoperative period. Pretreatment with nefopam could be useful to prevent pain sensitization induced by opioids.     

KETOROLAC TROMETAMOL FOR POSTOPERATIVE ANALGESIA AFTER ORTHOPAEDIC SURGERY

We have compared the postoperative morphine requirements andanalgesic efficacy of four doses of i.m. ketorolac 30 mg administered6-hourly with placebo in a double-blind study of patients undergoingmajor or minor orthopaedic surgery. During the 24-h postoperativestudy period which began at the end of surgery, patients wereprescribed i.m. morphine 10 mg as required 2-hourly and assessmentswere made of pain at 4 and 24 h. After major surgery, the medianmorphine consumption over 24 h was 10 mg in patients who receivedketorolac, compared with 30 mg in those who received placebo(P = 0.008). Visual analogue pain scores and verbal pain assessmentswere better than placebo at 4 h (P = 0.028 and P = 0.008, respectively),but were not statistically different between the groups at 24h. Overall assessment of pain was similar in both groups whohad undergone major surgery. In the minor surgery groups, medianmorphine consumption was 0 mg in patients who received ketorolac,compared with 10 mg in those given placebo (ns). Visual analoguepain scores at 24 h after surgery were significantly less inpatients who had received ketorolac compared with placebo (P= 0.046) and the overall assessment of pain relief was betterin the ketorolac group (P = 0.0007). Mandatory administrationof ketorolac appeared to be of benefit in both major and minororthopaedic surgery, although the principal effects were reductionin requirement for supplementary morphine for major surgeryand better overall analgesia for minor surgery.     

Opioid-sparing effects of diclofenac and paracetamol lead to improved outcomes after cardiac surgery

OBJECTIVE: This study assessed the analgesic efficacy, side effects, time to extubation, and oxygenation of 3 analgesic regimens after coronary artery bypass surgery using diclofenac, paracetamol, and placebo suppositories. DESIGN: Prospective, randomized, double-blind, placebo-controlled study. SETTING: Referral center for cardiothoracic surgery at a university hospital. PARTICIPANTS: Sixty consenting adults scheduled for elective coronary artery bypass grafting (CABG). INTERVENTIONS: Patients were divided into 3 groups postoperatively: diclofenac/paracetamol: diclofenac, 100 mg rectally, and paracetamol, 1 g rectally. Diclofenac was repeated after 18 hours and paracetamol every 6 hours for 24 hours; diclofenac: diclofenac as in diclofenac/paracetamol, with placebos replacing paracetamol; and placebo: 2 placebo suppositories at same times as diclofenac/paracetamol. All patients received morphine patient-controlled analgesia. RESULTS: Twenty-four hour morphine consumption with diclofenac/paracetamol was 12 +/- 6 mg, diclofenac 22 +/- 13 mg, and placebo 37 +/- 15 mg (diclofenac/paracetamol and diclofenac, p = 0.0003 and p = 0.0159 compared with placebo). Patients in the placebo group had significantly greater pain scores at 12 and 24 hours compared with diclofenac/paracetamol and diclofenac. Extubation time was significantly prolonged in the placebo group compared with the diclofenac/paracetamol and diclofenac groups (mean [SD] minutes diclofenac/paracetamol, diclofenac, and placebo 478 [150], 487 [257], and 710 [326], respectively). Oxygenation following extubation was significantly lower in the placebo group compared with the diclofenac/paracetamol and diclofenac groups (mean [SD] mmHg: diclofenac/paracetamol, diclofenac, and placebo 175 [44], 157 [43], and 117 [22], respectively). Episodes of nausea and vomiting were significantly less in the diclofenac/paracetamol and diclofenac groups than in the placebo group (46% and 51% reduction, respectively). all groups had similar blood loss and change in serum creatinine. CONCLUSION: Diclofenac alone or with paracetamol has a significant opioid-sparing effect after CABG, producing more rapid extubation and better oxygenation.     

Comparison of the morphine-sparing effects of diclofenac sodium and ketorolac tromethamine after major orthopedic surgery

STUDY OBJECTIVES: To compare the efficacy of diclofenac sodium with ketorolac tromethamine in reducing postoperative morphine use after major orthopedic surgery. DESIGN: Double-blind, randomized, placebo-controlled study. SETTING: Major teaching institution. PATIENTS: 102 ASA physical status II patients undergoing hip and knee replacement with general anesthesia. INTERVENTIONS: Before induction of anesthesia, patients were randomly allocated to receive intravenously either diclofenac sodium 75 mg (Group D), ketorolac tromethamine 60 mg (Group K), or placebo (Group P). Patient-controlled analgesia was supplied postoperatively using morphine. MEASUREMENTS: Visual analog scale (VAS), verbal pain score (VPS), sedation score, frequency of opioid side effects, and morphine consumption were recorded every 4 hours. MAIN RESULTS: There was a highly significant downward trend for VAS, VPS, and sedation scores over time, p = 0.001. The mean VAS and VPS scores were significantly lower in Groups D and K compared with Group P at time 0, p = 0.009 and 8 hours, p = 0.026. The mean (SD) 24-hour morphine requirements were 36.3 mg (16.9), 47.2 mg (34.9), and 51.6 mg (22.2) for Groups D, K, and P, respectively, p = 0.032. Fewer patients suffered from postoperative nausea and vomiting in the treatment groups (Groups D and K) compared with Group P (9, 8, and 19, respectively), p < 0.05. Fewer patients also suffered from pruritus in Groups D and K compared with Group P (3, 4, and 11, respectively), p < 0.01. CONCLUSIONS: Preoperative administration of intravenous diclofenac 75 mg or ketorolac 60 mg significantly reduces morphine requirements and associated side effects after major orthopedic surgery.     

The morphine sparing effects of diclofenac sodium following abdominal surgery

A randomised, double-blind placebo controlled study was undertaken to assess the analgesic efficacy of diclofenac. Following major abdominal surgery and 12 hours later, patients received either placebo or diclofenac 75 mg intramuscularly and their cumulative morphine requirements administered by a patient-controlled system over 24 hours were compared. Pain scores were also measured. Arterial blood gases and coagulation studies were assessed pre- and postoperatively. Morphine consumption was significantly greater in the placebo group (59.5 compared to 38.5 mg, p less than 0.01). Pain scores were significantly lower in the diclofenac group at 4 hours, but not thereafter. Arterial carbon dioxide was significantly increased in the control groups. There was no significant change in platelet count within each group, but a significant difference between the groups (p less than 0.05).     

Analgesic efficacy and safety of nefopam vs. propacetamol following hepatic resection*

In order to compare the morphine-sparing effect, analgesic efficacy and tolerance of nefopam and propacetamol given at their highest recommended doses, 120 patients undergoing elective hepatic resection were randomly assigned to receive postoperative intravenous patient-controlled analgesia with morphine alone, or in combination with nefopam (20 mg.4 h-1) or propacetamol (2 g.6 h-1). Compared with the control group (43 [7-92] mg), median [range] cumulative morphine consumption for 24 h after the study started was halved in the nefopam group (21 [3-78] mg, p <0.001) and 20% lower in the propacetamol group (35 [6-84] mg, p = 0.15). Analgesia was superior in the nefopam group despite the lower morphine consumption. Adverse effects were comparable in the three groups, except for significantly more nausea in the control group (39% vs. 17 and 26% in the nefopam and propacetamol groups, respectively) and more sweating in the nefopam group (17% vs. 0 and 3% in the control and propacetamol groups, respectively). Overall patient satisfaction was better (p < 0.001) in patients given nefopam (97%) than those receiving morphine alone (82%) or propacetamol (74%).     

Postcesarean analgesia: the efficacy of bupivacaine wound instillation with and without supplemental diclofenac

STUDY OBJECTIVE: To assess the analgesic efficacy of diclofenac when administered as an adjuvant to bupivacaine wound instillation. DESIGN: Prospective, randomized, double blind, placebo-controlled study. SETTING: Large referral hospital. PATIENTS: 90 women recovering from cesarean delivery performed via a Pfannenstiel incision. INTERVENTIONS: A standard intrathecal anesthetic was administered. On completion of surgery, a multiorifice 20-gauge epidural catheter was placed within the surgical wound. Postoperatively, the catheter was attached to a patient-controlled analgesia (PCA) device programmed to deliver 9 mL with a 60-minute lockout time and no basal infusion. In group bupivacaine-diclofenac, the PCA device delivered 0.25% bupivacaine, and 20 minutes before the end of surgery, patients received intravenous diclofenac (75 mg/100 mL saline). Thereafter, oral diclofenac (50 mg) was administered every 8 hours. In group bupivacaine-placebo, 0.25% bupivacaine and an equal volume of intravenous saline or oral placebo were administered 20 minutes before the end of surgery and every 8 hours thereafter. In group placebo-diclofenac, wound instillation was with sterile water, and 20 minutes before the end of surgery, patients received intravenous diclofenac (75 mg/100 mL saline) and thereafter oral diclofenac (50 mg) at 8-hour intervals. During the first 6 postoperative hours, a coinvestigator administered "rescue" morphine (2 mg, intravenously). Thereafter, subcutaneous morphine (0.05 mg/kg) was administered on patient request for additional analgesia. MEASUREMENTS AND MAIN RESULTS: The number of attempts to activate the PCA device was significantly higher in group bupivacaine-placebo (39 +/- 32) when compared with group bupivacaine-diclofenac (24 +/- 28). During the first 6 postoperative hours, the number of patients requiring rescue morphine and the total rescue morphine administered were significantly different between the groups. During the subsequent 18 hours, subcutaneous morphine administration was significantly higher in group bupivacaine-placebo. Postoperative pain scores were significantly higher in group bupivacaine-placebo when compared with those recorded in groups placebo-diclofenac and bupivacaine-diclofenac. Finally, patient satisfaction was significantly lower in group bupivacaine-placebo. CONCLUSION: In the context of this study, the bupivacaine wound instillation with adjuvant diclofenac administration is associated with similar postoperative analgesia to that induced by diclofenac alone.     

Analgesic efficacy of paracetamol and diclofenac in children receiving PCA morphine

We studied 80 children, aged 5-13 yr, who received PCA with morphine after appendicectomy using a standardized tracheal general anaesthetic. All patients received morphine 0.1 mg kg-1 before surgical incision and all had wound infiltration with bupivacaine 1 mg kg-1 at the end of surgery. Patients were allocated randomly to receive postoperative analgesia with PCA morphine alone, morphine plus diclofenac 1 mg kg-1, morphine plus paracetamol 15-20 mg kg-1 or morphine plus a combination of both diclofenac and paracetamol. Cumulative morphine consumption was significantly reduced by concurrent administration of diclofenac but no additive effect of paracetamol was demonstrable with the doses used in the study. Analgesia, as assessed by movement pain scoring, was significantly improved by the addition of diclofenac despite lower morphine consumption. Adverse effects and duration of PCA were comparable in the four groups.      

Efficacy of low-dose intrathecal morphine for postoperative analgesia after abdominal aortic surgery: a double-blind randomized study

BACKGROUND AND OBJECTIVES: Several studies suggest that intrathecal morphine (ITM) improves analgesia after aortic surgery. We tested the hypothesis that in combination with multimodal postoperative pain management, low-dose ITM associated with general anesthesia would decrease postoperative analgesic requirements in patients undergoing abdominal aortic surgery. METHODS: Thirty patients were randomized to receive either general anesthesia alone or preceded by low-dose ITM (0.2 mg) administration. Patients and providers were blinded to treatment. Postsurgical multimodal pain management was similar in both groups, including parenteral paracetamol, followed by intravenous nefopam and then morphine if not sufficient. Intravenous analgesic requirements, visual analog scale (VAS) scores, and the incidence and severity of side effects were recorded for 48 hours after surgery. RESULTS: Intraoperative data were comparable between the 2 groups, except sufentanil consumption, which was significantly lower in the ITM group when compared with the control group (P = .023). ITM decreased postoperative total-morphine requirements with respect to both the number of patients who received morphine (4 v 12 patients, P = .003) and the cumulative dose of morphine administered (0 [0-12.4] v 23 [13.9-45.6] mg, P = .006). VAS scores at rest were higher in the control group than in the ITM group at awakening (P < .01), at 4 hours (P < .01) after surgery, and at 8 hours (P < .05) after surgery but did not differ between groups after this period. Whereas VAS scores on coughing were higher in the control group at awakening (P < .01) and 4 hours after surgery (P < .05), no differences were found between groups from 8 hours after surgery. CONCLUSION: In patients undergoing abdominal aortic surgery, intrathecal morphine (0.2 mg) improves postoperative analgesia and decreases the need in intraoperative and postoperative analgesics. Further studies are indicated to evaluate the role of ITM in postoperative recovery.     

Morphine consumption in patients receiving rectal paracetamol and diclofenac alone and in combination

Paracetamol and diclofenac have different mechanisms of action, and the combination may be more effective than each drug used alone in treating postoperative pain. In a double-blind, controlled design, we studied 60 patients undergoing elective abdominal gynaecological surgery, who received suppositories of paracetamol 1.5 g, diclofenac 100 mg or a combination of the two before the start of surgery. Patients received morphine in the intraoperative period, and cumulative morphine use from a patient-controlled analgesia system was recorded to measure the analgesic effect of the suppositories. Morphine consumption was greatest in the group that received paracetamol alone and lowest in the group given the combination (P < 0.01). There was no difference in the incidence of morphine-related side effects between the groups. We conclude that a diclofenac-paracetamol combination reduced the amount of morphine used compared with paracetamol alone.      

Patient-controlled epidural analgesia with morphine or morphine plus ketamine for post-operative pain relief

Sixty patients were randomly assigned to two equal groups. Group I received epidural morphine 1 mg after surgery and used a patient-controlled analgesia device programmed to deliver morphine 0. 2 mg h-1, 0.2 mg per bolus. Group II received an epidural loading dose of morphine 1 mg plus ketamine 5 mg and used a patient-controlled analgesia device programmed to deliver morphine 0. 2 mg+ketamine 0.5 mg h-1, morphine 0.2 mg+ketamine 0.5 mg per bolus with a lockout time of 10 min. The mean morphine consumption was 8. 6+/-0.7 mg for group I and 6.2+/-0.2 mg for group II. Although group II utilized significantly less morphine (P < 0.05), pain relief was significantly better in group II than in group I (P < 0.05) in the first 3 h. Vomiting occurred more frequently in group I (26%) than in group II (13%). The frequency and severity of pruritus and level of sedation were similar in the two groups. These findings suggest that patient-controlled epidural analgesia with morphine plus ketamine may provide effective analgesia with a lesser dose of morphine and fewer subsequent side effects, compared with patient-controlled epidural analgesia with morphine alone after lower abdominal surgery.     

The efficacy of intramuscular ketorolac in combination with intravenous PCA morphine for postoperative pain relief.

STUDY OBJECTIVE: To examine the efficacy of intramuscular (IM) ketorolac used in combination with intravenous (IV) patient-controlled analgesia (PCA) morphine for postoperative pain relief following intra-abdominal gynecologic surgery. DESIGN: Randomized, double-blind, placebo-controlled study. SETTING: Patient care unit at a university medical center. PATIENTS: Thirty-five healthy women undergoing intra-abdominal gynecologic surgery who requested postoperative PCA. INTERVENTIONS: Postoperatively, all patients received IV PCA morphine, with the PCA device programmed to deliver a maximum of 1 mg every 6 minutes (maximum of 30 mg over 4 hours). In addition, patients received one of three regimens: (1) IM saline every 6 hours; (2) IM ketorolac 30 mg while in the postanesthesia care unit (PACU), followed by 15 mg every 6 hours; or (3) IM ketorolac 60 mg while in the PACU, followed by 30 mg every 6 hours. MEASUREMENTS AND MAIN RESULTS: Patients were assessed at regular intervals. Visual analog scale (VAS) scores were used to assess analgesia and patient satisfaction with therapy. Data on morphine usage were obtained from the PCA device, and the frequency and severity of adverse effects were assessed for the presence or absence of side effects. Cumulative morphine dosages were lower (p less than 0.05) in both ketorolac groups at 12, 18, and 24 hours. VAS scores and the frequency of side effects did not differ significantly among groups. CONCLUSIONS: IM ketorolac significantly decreased PCA morphine requirements. The analgesic effects of the two drugs appear to be additive.     

Effects of diclofenac and intra-articular morphine/bupivacaine on postarthroscopic pain control

BACKGROUND: This study was undertaken to compare analgesic effects and requirements for supplemental analgesic therapy after knee arthroscopy in patients given intraarticular morphine/bupivacaine, diclofenac i.m., or both compared with placebo. METHOD: In a randomised, double-blind controlled trial 40 patients were divided into four groups. Patients received 25 ml of 0.25% bupivacaine and 2 mg of morphine intraarticularly in group I, 75 mg of diclofenac i.m. in group III, the combination of 75 mg of diclofenac i.m. and 25 ml of 0.25% bupivacaine and 2 mg of morphine intraarticularly in group II, and placebo in group IV. Postoperative analgesia was provided with fentanyl in the recovery room and acetaminophen was given for subsequent pain relief. RESULTS: In the postoperative period, VAS scores for pain were highest in the placebo group, whereas they were lowest in the combination group. VAS scores were significantly lower in group I and II than group IV at the postoperative 2nd hour (p < 0.05). VAS score was significantly lower in group II than groups III and IV at the postoperative 3rd hour (p < 0.01). VAS scores were significantly lower in group I, II and III than group IV at the postoperative 6th hour (p < 0.05). Fentanyl consumption was significantly lower in group II than group IV (p < 0.05). Acetaminophen consumption in groups II and III were significantly lower than group IV (p < 0.05). CONCLUSION: The combination of diclofenac i.m. and intraarticular morphine/bupivacaine appears to be the most beneficial analgesic combination due to its lower VAS scores and supplemental analgesic requirements in the postoperative period.     

Randomized prospective study of the analgesic effect of nefopam after orthopaedic surgery

Background. Balanced postoperative analgesia combines non-narcoticdrugs and opioids. We organized a large study to evaluate nefopamanalgesia and tolerance in combination with morphine for patient-controlledanalgesia (PCA) after orthopaedic surgery. Methods. Two hundred and one patients scheduled to undergo hiparthroplasty were included in this multicentre (n=24), double-blind,randomized study comparing nefopam (20 mg every 4 h for 24 h)with placebo, the first dose being infused peroperatively. Theprimary outcome measure was the cumulative morphine dose receivedpostoperatively by PCA over 24 h. Secondary outcome measureswere the amount of morphine received as a loading dose in thepostanaesthesia care unit (PACU) and during the 24-h observationperiod, and pain assessments using a visual analogue scale (VAS)and a verbal pain scale (VPS), patient’s satisfactionwith analgesia and treatment tolerance. Results. The two groups were comparable with respect to theircharacteristics and preoperative pain assessment. PCA-administeredmorphine over 24 h was significantly less for the nefopam groupthan the control group (21.2 (15.3) and 27.3 (19.2) mg respectively;P=0.02). This morphine-sparing effect was greater (35.1%) forpatients with severe preoperative pain (VAS>30/100). Forthe entire study period (loading dose and PCA), morphine usewas less for the nefopam group (34.5 (19.6) vs 42.7 (23.6) mg;P=0.01). Pain VAS at PACU arrival and during the whole PACUperiod was significantly lower for the nefopam than for theplacebo group (P=0.002 and 0.04 respectively). Patient satisfactionwas similar for the nefopam and placebo groups. Conclusion. In combination with PCA morphine, nefopam givessignificant morphine-sparing with lower immediate postoperativepain scores without major side-effects. This analgesic effectseems to be particularly notable for patients with intense preoperativepain. Br J Anaesth 2003; 91: 836–41     

Post operative analgesia with intrathecal morphine

INTRODUCTION: Sixty eight ASA I and II patients between 18 and 84 years who underwent minor to medium surgery were studied retrospectively. They were divided into 2 groups, on basis on intrathecal morphine administration. MATERIALS AND METHODS: Group I received spinal anesthesia with bupivacaine 12.5-15 mg. Group II received in addition 0.1 mg morphine (preservative free) [MO PF]. Pain assessment, up to 24 hours, was evaluated by the need of salvage medication namely pethidine i.m. (intramuscular). RESULTS: The groups matched for demographic distribution. Twenty one out of 30 patients in Group I needed salvage medication, compared to 6 out of 38 patients in Group II (p < 0.005). Minor complications of intrathecal morphine were noted. These were higher in Group II compared to Group I; itching and pruritis (14 vs. 1); urinary retention (2 vs. 0); nausea and vomiting (1 vs. 0) (p < 0.005). CONCLUSION: This study showed that a single low dose of intrathecal morphine with bupivacaine provides better quality post-operative analgesia than bupivacaine alone, and might offer enough analgesia for minor to medium cases up to 24 hours post-op. However, some side effects have to be taken into consideration.