Additional Analgesic Medication Research Articles

The safety and efficacy of diclofenac sodium suppository as adjunctive opioids in the treatment of cancer pain: A prospective, multi-center, real-world study.

12055 Background: Cancer pain is one of the most common and unbearable symptoms for cancer patients (pts), seriously affecting their quality of life. Diclofenac sodium is a potent third-generation non-steroidal anti-inflammatory drug known for its significant analgesic, anti-inflammatory, and antipyretic effects. It is commonly used to treat different types of cancer pain. The objective of this study was to assess the safety and effectiveness of diclofenac sodium suppository when used alongside opioids for managing cancer pain in pts with solid tumors. Methods: In this prospective, multi-center, real-world study, we enrolled pts diagnosed with malignancy, Eastern Cooperative Oncology Group (ECOG) performance status of 0-3, numeric rating scale (NRS) score ≥ 3, and sustained cancer pain, who required additional analgesic medication were enrolled. Diclofenac sodium suppository is an anal administration suppository, prescribed once a day at a dosage of 50 mg. This study was conducted across 20 centers to observe the clinical characteristics of pain relief in pts with cancer pain . The primary endpoint of the study was to assess the safety of the medication. The secondary endpoints included evaluating the incidence of breakthrough pain (BP), NRS score, and Brief Pain Inventory (BPI) score on the second and sixth days of medication. Results: Of the 506 pts that were screened, 437 pts met the inclusion criteria. This included 10 pts who did not receive planned treatment and 2 pts who did not undergo post-baseline efficacy evaluation. Among the 425 pts in the full analysis set (FAS), 261 were man, and 169 (39.8%) had baseline BP. The mean age was 63.0±11.3 years old. Among 425 response-evaluable pts, compared to the baseline, the incidence of BP was reduced on the second (20.0% vs 39.8%), and sixth days (14.8% vs 39.8%) of medication and the difference was statistically significant ( P < 0.001, P < 0.001). For pts with baseline BP, 56.2% and 66.9% pts achieved BP relief on the second and sixth days of medication, respectively. From the baseline evaluation, the mean NRS scores for the three visits (baseline, second day, sixth day) were 5.28 ± 1.71, 3.73 ± 1.71, and 2.91 ± 1.88, respectively. The mean pain intensity at each visit was decreased compared to the baseline, and the difference was statistically significant ( P < 0.001, P < 0.001). 427 pts were included for safety analysis and 5 pts experienced any grade treatment emergent adverse events (TEAEs). All TEAEs were grade 1-2. TEAE leading to treatment discontinuation was occurred in one pt. Conclusions: This study demonstrated that diclofenac sodium suppository was an effective treatment option for managing breakthrough pain in patients with persistent cancer pain who required additional analgesic therapy. Moreover, diclofenac sodium suppository was found to be well tolerated when administered anally.

Efficacy of ultrasound-guided pecto-intercostal fascial block and transversus thoracis muscle plane block for postoperative analgesia in cardiac surgery in adult patients: A randomized study

ABSTRACT Background Insufficient management of postoperative pain is a notable issue encountered by individuals after open-heart operations. The study aimed to evaluate the effect of ultrasound-guided pecto-intercostal fascial block (PIFB) and transversus thoracis muscle plane (TTB) on the analgesic efficacy in adult patients undergoing open-heart operations and the duration of mechanical ventilation (MV). Methods A randomized double-blind controlled trial was conducted on a cohort of 90 adult patients with elective open-heart surgery, namely valve replacement, with midline sternotomy. Patients were divided into three groups of similar size. The first group (control group) received conventional systemic analgesia alone, while the second group received bilateral TTB and the third group received bilateral PIFB, using ultra-sound guided technique. Results A significant reduction in NRS (Numeric Rating Scale) values was observed in both the TTB group and the PIFB group as compared to the control group at zero, three and 6-hour postoperative. The PIFB and TTB group exhibited an important delay in the initiation of first rescue analgesia, as well as a reduction in the overall intake of fentanyl for rescue purposes during a twenty-four-hour period. Additionally, the TTB group and the PIFB group demonstrated considerably shorter durations of mechanical ventilation as compared to the control group. Conclusions The utilization of ultrasound TTB and PIFB demonstrated efficacy in providing postoperative analgesia compared to the control group. This was evidenced by the less requirement for additional analgesic medication, reducing postoperative pain scores and a shorter duration of mechanical ventilation.

Additional low-pressure pulmonary recruitment for reducing post-laparoscopic shoulder pain in gynecologic laparoscopy: a randomized controlled trial.

To evaluate the effectiveness of additional low-pressure pulmonary recruitment in reducing postoperative shoulder pain. A double-blind randomized controlled trial was conducted at Srinagarind Hospital between May 2021 and October 2021. Forty patients who underwent laparoscopic gynecologic surgery were randomized into either an intervention group that received additional low-pressure pulmonary recruitment (30 cmH2O) (n=20) or a control group (n=20). Shoulder pain was evaluated using a numerical rating scale from 0 to 10, 24, and 48 hours after the operation. The mean±standard deviation of shoulder pain at 24 hours after the operation of both the intervention and control groups were 2.10±2.27 and 1.45±1.73 points, respectively. The shoulder pain at 48 hours after the operation of the intervention and control groups were 1.15±1.46 and 0.85±1.73 points, respectively. There were no statistical differences in the mean difference between the two groups at 24 and 48 hours after operation (P=0.49; 95% confidence interval [CI], -0.61 to 1.91 and P=1.00; 95% CI, -0.96 to 1.56, respectively). No statistically significant differences were observed in additional analgesic medications used in either group, such as intravenous morphine or oral acetaminophen. Additional low-pressure pulmonary recruitment to reduce shoulder pain after laparoscopic surgery for benign gynecologic diseases did not show a significant benefit compared to the control group, especially when administering postoperative around-the-clock analgesia.

Case report: Surgical treatment of an astrocytoma in the thoracic spinal cord of a cat

A 15-year-old spayed female domestic shorthaired cat was evaluated for chronic progressive paraparesis and proprioceptive ataxia. Neurological examination was consistent with a T3–L3 myelopathy. Plain thoracolumbar vertebral column radiographs and CT without intravenous contrast or myelography performed at another facility did not highlight any abnormalities. MRI of the thoracolumbar spinal cord identified an intraparenchymal space-occupying lesion extending from T10–T12. Surgery was performed to remove as much of the mass as possible, and to submit samples for histopathology. A dorsal laminectomy was performed over T9–T13. A midline myelotomy provided access to the mass, which was debrided with an intraoperative estimate of 80% removal. Histopathologic examination was consistent with a diagnosis of an astrocytoma. Post-operative treatment consisted of amoxicillin clavulanic acid, prednisolone, gabapentin, and additional analgesic medications in the direct post-operative period. Over the following 4 months, slow recovery of motor function was seen with continued physiotherapy. During the following 2 months, renal and cardiopulmonary disease were diagnosed and treated by other veterinarians. The cat was also reported to have lost voluntary movement in the pelvic limbs during this period, suggesting regression to paraplegia. Finally, 6 months post-surgery, the owner elected humane euthanasia. This is the second documentation of surgical treatment and outcome of an astrocytoma in the spinal cord of a cat.

A Randomized Study of Intravenous Hydromorphone Versus Intravenous Acetaminophen for Older Adult Patients with Acute Severe Pain

We conducted a randomized study to compare the efficacy and adverse event profile of 1,000 mg of intravenous acetaminophen to that of 0.5 mg of intravenous hydromorphone among patients aged 65 years or more with acute pain of severity that was sufficient enough to warrant intravenous opioids. This randomized comparative effectiveness study with 162 participants was conducted in 2 urban emergency departments (EDs). The primary outcome was an improvement in a 0 to 10 pain scale from baseline to 60 minutes later. Secondary outcomes included the need for additional analgesic medication and adverse events that were attributable to the investigational medication. The minimum clinically important difference was an improvement of 1.3 on the 0 to 10 pain scale. The median baseline pain score was 10 (interquartile range 8 to 10) in both the groups. By 60 minutes, patients taking acetaminophen improved by 3.6 (standard deviation 2.9) on the 0 to 10 pain scale, whereas patients taking hydromorphone improved by 4.6 (standard deviation 3.3) (95% confidence interval [CI] for the difference of 1.0 was 0.1 to 2.0). Additional analgesic medications were required for 37 (46%) of 81 patients taking acetaminophen and 31 (38%) of 81 patients taking hydromorphone (95% CI for the rounded difference of 7% was-8% to 23%). Adverse events were reported by 6 (7%) of 81 patients taking acetaminophen and 10 (12%) of 81 patients taking hydromorphone (95% CI for the difference of 5% was-4% to 14%) and included dizziness, drowsiness, headache, and nausea. Although 0.5 mg of the intravenously administered hydromorphone was statistically superior to 1,000 mg of intravenous acetaminophen administered in older patients with acute severe pain in the ED, this difference was not clinically significant. Regardless of the medication received, many participants experienced minimal or incomplete pain relief.

Attitudes, beliefs, and practices among Swiss chiropractors regarding medication prescribing for musculoskeletal conditions: a national Q-methodology study

BackgroundSwiss chiropractors have been licensed since 1995 to prescribe from a limited formulary of medications for treating musculoskeletal (MSK) conditions. In January 2018, this formulary was expanded to include additional muscle relaxant, analgesic, and anti-inflammatory medications. Internationally, controversy remains over whether or not medication prescribing should be pursued within the chiropractic profession.ObjectiveThe purpose of this study was to assess Swiss chiropractors’ attitudes, beliefs, and practices regarding their existing medication prescription privileges. This information will provide new insights on the topic and help inform research and policy discussions about expanding chiropractic prescription rights in other jurisdictions.MethodsA 13-item questionnaire and Q-methodology approach were used to conduct the assessment. Recruitment was conducted by e-mail between December 2019 and February 2020, and all members of the Swiss Chiropractic Association were eligible to participate. Data were analyzed using by-person factor analysis and descriptive statistics.ResultsIn total, 187 Swiss chiropractors participated in this study (65.4% response rate). Respondents reported prescribing analgesics, anti-inflammatories, and muscle relaxants to a median of 5, 5, and 0% of patients, respectively. Forty-two percent of respondents expressed interest in further expanding the range of current medications available to Swiss chiropractors for treating MSK conditions. Only 15% expressed interest in expanding this range to include medications for treating non-MSK conditions. In the Q-methodology analysis, four salient viewpoints/groups regarding medication prescribing emerged: prescribers, non-prescribers, collaborators, and integrators. All except non-prescribers thought medication prescription privileges were advantageous for the chiropractic profession in Switzerland. There was also strong consensus among all four groups that medication prescribing should not replace manual therapy in chiropractic practice.ConclusionThis was the first national survey on attitudes toward prescribing medications among Swiss chiropractors since the year 2000, and the first using Q-methodology. With this approach, four unique groups of chiropractic prescribers were identified. Even with diversity among clinicians, the findings of this study showed general support for, along with conservative use of, prescribing privileges within the Swiss chiropractic profession. Studies in jurisdictions outside of Switzerland are needed to assess whether chiropractors are interested in expanding their scopes of practice to include similar prescribing privileges.

A Randomized, Double‐Dummy, Emergency Department‐Based Study of Greater Occipital Nerve Block With Bupivacaine vs Intravenous Metoclopramide for Treatment of Migraine

Greater occipital nerve blocks (GONB) are used increasingly to treat acute migraine. We conducted a randomized controlled trial to determine whether GONB was as effective as intravenous metoclopramide for migraine. This was a double-dummy, double-blind, parallel-arm, non-inferiority study conducted in 2 emergency departments (EDs). Patients with migraine of moderate or severe intensity were randomized to receive bilateral GONB with each side administered 3mL of bupivacaine 0.5% or metoclopramide 10mg IV, the putative standard of care. The primary outcome was improvement in pain on a 0-10 scale between time 0 and 1hour later. To reject the null hypothesis that metoclopramide would be more efficacious in relieving pain, we required that the lower limit of the 95% CI for the difference in pain improvement between those randomized to GONB vs those randomized to metoclopramide be >-1.3, a validated minimum clinically important difference. Secondary outcomes included sustained headache relief, defined as achieving and maintaining for 48hours a headache level of mild or none without the use of additional analgesic medication, and the use of rescue medication in the ED. Over a 2.5-year study period, 1358 patients were screened for participation and 99 were randomized, 51 to GONB and 48 to metoclopramide. All of these patients were included in the primary analysis. Patients who received the GONB reported mean improvement of 5.0 (95% CI: 4.1, 5.8) while those who received metoclopramide reported a larger mean improvement of 6.1 (95% CI: 5.2, 6.9). The 95% CI for the between group difference of -1.1 was -2.3, 0.1. Sustained headache relief was reported by 11/51 (22%) GONB and 18/47 (38%) metoclopramide patients (95% CI for rounded difference of 17%: -1, 35%). Of the 51 GONB patients, 17 (33%) required rescue medication in the ED vs 8/48 (17%) metoclopramide patients (95% CI for rounded difference of 17%: 0, 33%). An adverse event was reported by 16/51 (31%) GONB patients and 18/48 (38%) metoclopramide patients (95% CI for (rounded) difference of 6%: -13, 25%). GONB with bupivacaine was not as efficacious as IV metoclopramide for the first-line treatment of migraine in the ED.

Effect of scheduled intravenous acetaminophen on postoperative nausea and vomiting in patients undergoing laparoscopic gynecologic surgery.

The aim of this study was to assess the effect of scheduled intravenous acetaminophen (SIVA) on the incidence of postoperative nausea and vomiting (PONV) in patients undergoing laparoscopic gynecologic surgery (LGS). This retrospective observational study identified consecutive patients who underwent LGS at our institution from January to November of 2017 and were managed with either our hospital's old protocol (Group H) or a new protocol using SIVA (Group S). Primary outcomes included the incidences of PONV and the amount of additional antiemetic required in the postoperative period. The secondary outcomes included the pain score on postoperative day 1, the requirement for additional analgesic medications, and the length of hospitalization (LOH). Patients in Group S had significantly lower incidences of PONV from postoperative days 0 to 1 and required significantly less antiemetics or tramadol than those in Group H (P = 0.0085). Patients at a low risk for PONV in Group S had significantly lower incidences of PONV than those in Group H (P = 0.0129). Further, the amount of additional tramadol required was lower in Group S than in Group H (P = 0.0021). Introduction of SIVA into the postoperative pain management protocol of LGS may reduce the incidence of PONV and the amount of adjunctive antiemetic medication required from postoperative days 0 to 1. In patients undergoing LGS, PONV prophylaxis using antiemetics should be prescribed depending on PONV risk profile; however, SIVA prophylaxis can be used in all patients regardless of PONV risk profile.

Comparative analysis of the effects of combined spinal epidural anesthesia versus psoas compartment and sciatic nerve block for partial hip prosthesis in the geriatric population

Aim: We aimed to compare combined spinal-epidural anesthesia (CSE) and combined psoas compartment & sciatic nerve block (PCSNB) peripheral nerve blocks, in terms of intraoperative and postoperative pain, hemodynamics and side effects in geriatric population who underwent partial hip prosthesis.Material and Methods: A total of 50 patients who underwent elective partial hip prosthesis and PCSNB or CSE were included. The age range was between 60-99 years and ASA scores were ≤ 3. Twenty-five patients underwent CSE anesthesia with 1 mL plain bupivacaine, while PCSNB and iliac crest blocks were employed in 25 patients. Perioperative anesthetic efficacy, blood pressures, pulse rates, saturation values, need for postoperative analgesia and side effects were compared. Results: At the end of the operation, the mean arterial pressure was lower in both groups compared to the baseline (initial) values and the decline in the CSE group was statistically significant. Hypotension was detected in 11 patients (44%) in the CSE group and 2 patients (8%) in the PCSNB group. Effective analgesia was provided in all patients in the CSE group, while 5 patients (20%) required additional analgesic medications through the epidural catheter in the follow-up. The first postoperative analgesic hour was remarkably longer in the PCSNB group (4.84 ± 2.54 hours vs. 1.64 ± 0.9 hours).Conclusion: Our data demonstrated that the combination of the psoas compartment, parasacral, sciatic and iliac crest blocks provides effective analgesia and maintains hemodynamic stability after hip prosthesis operations in elderly patients.

Nerve Stimulator-Guided Ciatic and Femoral Nerve Block during Tibial Osteosynthesis in Chinchilla lanigera

Background: Nociceptive stimulation in orthopedic surgery requires effective pain management to ensure trans and postoperative patient comfort. Several techniques can be used for this, and multimodal analgesia protocols such as guided locoregional blocks provide a balanced effect, as they enable the use of low-dose anesthetics and offer rapid recovery. The benefits of specific nerve blocks in domestic animals are well known; however, there are few reports that have ascertained their safety in wild species. This report is aimed at describing the successful use of neurolocalizer-guided sciatic and femoral nerve blocks during tibial osteosyntheses in a chinchilla.Case: A 9-month-old chinchilla weighing 0.56 kg was referred for surgery for proximal and mid-diaphyseal tibia fractures resulting from trauma. Following preanesthetic evaluation, the animal received intramuscular dexmedetomidine (15 µg kg-1) as preanesthetic medication. Sedation was apparent after 15 min and was verified by a decreased activity, the animal allowing manipulation, absence of the eyelid and righting reflexes, and limb movement after clamping removal of limb after clamping. After achieving sedation, anesthesia was induced and maintained with sevoflurane (FiO2 = 1.0), supplied through a nasoral mask. Sciatic and femoral nerve blocks were performed with the aid of a neurostimulator. A needle was inserted into the femoral triangle, cranial to the femoral artery, and into the depression between the sciatic tuberosity and the greater femoral trochanter. The neurostimulator was set at a pulse frequency of 1 Hz, pulse duration of 0.1 ms and initial current of 0.6 mA. The needle was advanced toward the nerves until muscle contractions were observed, and the current was gradually reduced until contractions were manifested at a minimum current of 0.2 mA. Ropivacaine 0.2% (1 mg kg-1) was injected at each point. Intraoperative physiological parameters remained stable and within the reference limits while the animal was under light anesthesia. Signs of recovery appeared soon after the inhaled anesthesia was stopped; awakening was gradual and without any signs of excitement or other adverse effects, eliminating the need for additional analgesic medication. Subcutaneous fluid therapy, antibiotics, and anti-inflammatory medications were administered immediately postoperatively.Discussion: This report is groundbreaking in describing neurostimulation-guided sciatic and femoral nerve blocks as an alternative to epidural anesthesia for hind limb surgery; furthermore, it demonstrates the efficacy and safety of ropivacaine in Chinchilla lanigera, which is relevant to the clinical use of the drug as part of a rodent anesthetic protocol. Sevoflurane associated dexmedetomidine use and locoregional anesthesia resulted in cardiorespiratory stability and the absence of behavioral signs of pain in the immediate postoperative period. The technique was easy to apply, and the use of the neurolocalizer increased blockade safety by allowing anesthesia administration as close as possible to the nerve. The ability to use low doses is a significant benefit in patients with low body weights. Therefore, the chosen protocol resulted in a safe and balanced anesthesia with an effective regional block that provided trans and postoperative analgesia and allowed rapid recovery for chinchilla tibial osteosynthesis.

Opioid Consumption Following Outpatient Foot and Ankle Surgery: A Prospective Analysis

Category:Prescription PracticesIntroduction/Purpose:Opioid abuse has recently reached the conscience of the US healthcare system and news cycle. This epidemic is in part propagated by surgeon over-prescription for common procedures. The purpose of this study is to examine postoperative opioid use following outpatient foot and ankle surgery in order to potentially guide prescription patterns of postoperative narcotics.Methods:Patients undergoing outpatient foot or ankle surgery, performed by one of four fellowship-trained orthopedic foot and ankle surgeons from a single institution, were prospectively enrolled from January to November 2018. Subjects were consented to participate in a phone interview within 7 days of their surgery, with subsequent interviews as needed for continued monitoring. Information collected included: age, gender, procedure, smoking status, payor type, analgesic regimen, number of tablets remaining, pain scale, pain control satisfaction, additional analgesic medications taken, reason for stopping opioid medications, and any adverse reactions encountered.Results:A total of 94 subjects were consented to participate. Of these, 11 were lost to follow up and 2 withdrew from the study, leaving 81 (86%) subjects for analysis. The mean (± standard deviation) number of opioid pills prescribed was 52.2 (±16.4; range: 6-80) pills. Subjects were satisfied or somewhat satisfied with their pain control in 91% of cases. On average, 18.4 (±14.9) pills were consumed by subjects, stopping consumption on post-operative day 4.8 (±3.6). There was no statistically significant difference in narcotic medications consumed whether undergoing ankle surgery (16.4, ±13.7) or foot surgery (20.7, ±15.9) (p=0.11). Overall, an average of 34.3 (±19.3) pills remained unconsumed at the completion of narcotic use, equaling a total of 2,706 excessively prescribed pills in the study cohort.Conclusion:There is a substantial excess of opioid pain medication prescribed to patients for outpatient foot and ankle surgeries, with a wide variation in prescription patterns. Based on our institutional data, a prescription of 35 opioid pills should be sufficient for approximately two-thirds of outpatient procedures and 50 pills should be sufficient for approximately 95% of patients regardless of whether the procedure is for the ankle or foot. This quality improvement assessment has influenced physician practice in our group and prospective follow-up analysis after intervention is warranted.

Comparison of the Anesthetic Efficiency of Lidocaine and Tramadol Hydrochloride in Orthodontic Extractions: A Split-Mouth, Prospective, Randomized, Double-Blind Study

The aim of the present randomized controlled split-mouth clinical study was to evaluate and compare the clinical anesthetic efficacy of lidocaine and tramadol hydrochloride in orthodontic extractions. A total of 32 systemically healthy patients requiring bilaterally maxillary first premolar extractions for orthodontic reasons were included. Each patient received 1.8mL of lidocaine (36mg lidocaine HCI and 0.0225mg epinephrine) on 1 side and 1.8mL tramadol (50mg tramadol HCl and 0.0225mg epinephrine diluted to 1.8mL by distilled water) on the other side. The anesthetic solutions were infiltrated into the buccal vestibule (local infiltration) based on a computer-generated list. In each patient, the time of anesthetic onset and finish, anesthetic activity, duration of postoperative analgesia, additional analgesic medication, wound healing, possible side effects, and satisfaction levels were recorded intraoperatively and postoperatively for both sides. Although no relevant differences were found between the solutions for anesthetic onset, lidocaine was significantly more effective statistically for the total anesthesia duration. Comparing the anesthetic activity at 5minutes before extraction, we found that tramadol was significantly more effective statistically compared with lidocaine. Similarly, tramadol was significantly more effective statistically than lidocaine for satisfaction level and wound healing. Moreover, compared with tramadol, in terms of postoperative pain, the visual analog scale scores with lidocaine were significantly higher at statistically 7, 8, 9, and 10hours during the first 12hours. In general, the lidocaine values were dramatically higher than were the tramadol values. The results of the present study suggest that using tramadol combined with epinephrine can be an alternative local anesthetic for maxillary first premolar tooth extractions in oral-maxillofacial surgery.

Topic anaesthesia with a eutectic mixture of lidocaine/prilocaine cream after elective caesarean section: a randomised, placebo-controlled trial.

Aim of the study was to investigate the topical application of a eutectic mixture of lidocaine/prilocaine (EMLA®) cream after caesarean section (CS) and its effect on postoperative pain, time to mobilisation, and time to discharge. A total of 189 pregnant women were enrolled; full data sets were available for 139 of them, who were prospectively randomised to receive either placebo (control group) or EMLA® cream (study group) on the CS lesion directly as well as 24h after surgery. Postoperative pain was assessed 24 and 48h after surgery using the short form of the McGill Pain Questionnaire (SF-MPQ). Additional analgesic pain medication on demand was assessed in both groups. A total of 62 women were allocated randomly to the study and 77 patients to the control group before primary CS. There were no statistically significant differences regarding demographic and surgical parameters comparing both collectives. In addition, the postoperative total pain scores after 24h [McGill total: 38.5 (0-102) vs. 50 (0-120) p=0.0889] as well as after 48h [24 (0-79) vs. 30.5 (0-92); p=0.1455] showed no significant differences. Furthermore, time to mobilisation (hours) [9.68 (2.18-51.38) vs. 9.47 (4.18-41.77); p=0.5919] and time to discharge (hours) [98.6 (54.08-170.15) vs. 98.2 (43.45-195.87); p=0.5331] were comparable. The postoperative application of EMLA® cream after CS did not reduce postoperative pain or time to mobilisation or discharge, so that its use in this context has to be seen critically.

A Retrospective Review of Femoral Nerve Block for Postoperative Analgesia After Knee Surgery in the Pediatric Population

To investigate the outcomes of pediatric patients receiving a femoral nerve block (FNB) in addition to general anesthesia for arthroscopic knee surgery compared with those receiving general anesthesia alone. This retrospective review included all patients undergoing arthroscopic knee surgery from January 2009 to January 2011 under general anesthesia both with and without a FNB. After the induction of general anesthesia, those patients selected for regional anesthesia received a FNB using real-time ultrasound or nerve stimulator guidance. For the FNB, 0.2 to 0.4 mL/kg of local anesthetic solution was injected around the femoral nerve at the level of the inguinal crease. Intra-articular injection of bupivacaine (0.25%, 10 mL) was administered by the surgeon for all patients not receiving a FNB. Additional analgesic medications, PACU length of stay, duration of hospitalization, hospital course, and any acute or nonacute complications were recorded and evaluated. There were no adverse effects related to the FNB. Using a 0 to 10 visual analogue scale (0=no pain), there was a statistically significant difference in both the high (4.0 ± 4.0 vs. 5.3 ± 3.1, P=0.0004) and low (1.5 ± 1.8 vs. 2.1 ± 2.0, P=0.002) pain scores in patients who received a FNB versus those who did not with the scores being lower in those who had received a FNB. There was a decreased need for the use of opioids postoperatively (61% vs. 71%, P=0.04) and a decreased duration of postoperative stay in patients who were admitted to the hospital (11.7 ± 8.1 vs. 15.8 ± 10 h, P=0.044) in individuals who had a FNB. There was a significantly lower admission rate in patients undergoing anterior cruciate ligament repair in the FNB group (72% vs. 95%, P=0.001). There was no difference in the incidence of postoperative nausea and vomiting between the groups. After arthroscopic knee surgery in pediatric patients, a FNB shortens hospital stay, reduces opioid requirements, and decreases postoperative pain scores. For anterior cruciate ligament repairs, FNB lowers postoperative admission rates. Level III.

Single-Dose Intra-Articular Morphine After Arthroscopic Knee Surgery: A Meta-Analysis of Randomized Placebo-Controlled Studies

The purpose of this quantitative meta-analysis is to appraise the efficacy and side effects of intra-articular morphine in patients undergoing arthroscopic knee surgery. The comprehensive literature search, using Medline (1966 to 2013), the Cochrane Central Register of Controlled Trials, and EMBASE databases, was conducted to identify randomized placebo-controlled trials that used single-dose intra-articular morphine for postoperative pain. The relative risk (RR), standardized mean difference (SMD), and their corresponding 95% confidence intervals (CIs) were calculated using statistical software. Twenty-six articles were included in the meta-analysis. The acute postoperative visual analog scale (VAS) pain scores of the morphine group compared with the control group were significantly lower (SMD,-1.16; 95% CI,-1.79 to-0.53; P= .0003). The number of patients requiring supplementary analgesia was also significantly reduced (RR, 0.80; 95% CI, 0.70 to 0.93; P= .008), and there was a significant difference in the time to first analgesic request (SMD, 1.47; 95% CI, 0.49 to 2.44; P= .003) when the morphine group was compared with the placebo group. However, there was no significant difference in side effects between the morphine group and the control group (RR, 0.93; 95% CI, 0.67 to 1.28; P= .65). The key findings of the present study were that the administration of single-dose intra-articular morphine at the end of arthroscopic knee surgery provided better pain relief, reduced the need for supplementary analgesics, and lengthened the time interval before the first request for additional analgesic medication, all with short-term side effects similar to those of the saline placebo. Level II, meta-analysis of Level I-II studies.

Comparing the duration of the analgesic effects of intravenous and rectal acetaminophen following tonsillectomy in children.

Background:Postoperative pain control (especially, after adenotonsillectomy) has a very important effect on recovery time, hospitalization duration, hemodynamic disorders, bleeding, nausea, vomiting and medical costs.Objectives:The aim of this study was to investigate and compare the effects of intravenous and rectal acetaminophen on controlling post-adenotonsillectomy pain in children, and duration of their analgesic effects.Patients and Methods:In this randomized double-blinded clinical trial, 96 children aged 4 - 10 years old with ASA physical status I or II who were candidates for adenotonsillectomy surgery in Amir-al-Momenin Hospital, Rasht, Iran were entered into the study and randomly divided into two equal groups. Anesthesia in both groups was induced injecting fentanyl-thiopental and at racurium; afterwards is of lurane was used to maintain anesthesia. After anesthesia induction, one group received intravenous and the other one, rectal acetaminophen, and were later compared based on CHIPPS criteria.Results:Data analysis indicated a significant relationship between reduction of postoperative pain and the use of intravenous or rectal acetaminophen (P = 0.0001); in group receiving IV acetaminophen, only 10.4% of patients had no pain whereas in group receiving rectal acetaminophen, this number reached 43.8%. Also, on 4 and 6 hour time intervals, pain in rectal acetaminophen receiving group was less than that in IV acetaminophen receiving group (P < 0.05). Demand for additional analgesic medication in rectal acetaminophen receiving group was less than that in IV group (P = 0.0001).Conclusions:Post-operative pain in rectal acetaminophen group was less than that in intravenous acetaminophen group, and rectal acetaminophen group demanded their first additional analgesic medication later.

Intraperitoneal lignocaine (lidocaine) versus bupivacaine after laparoscopic cholecystectomy: Results of a randomized controlled trial

BackgroundIntraperitoneal local anesthetics have been shown to improve postoperative pain after laparoscopic cholecystectomy (LC). However, the choice of local anesthetic agent is debatable. We compared the analgesic efficacy of intraperitoneal lignocaine (lidocaine) versus bupivacaine after elective LC. MethodsWe conducted a double-blind, randomized, controlled trial. We randomized consecutive patients undergoing LC into two groups. Group L received 10 mL 2% lignocaine (lidocaine), whereas Group B received 10 mL 0.5% bupivacaine, each diluted in 10 mL normal saline. All patients underwent standard perioperative anesthesia and analgesia protocol. We assessed patients at 0, 4, 8, 12, and 24 h postoperatively for pain using the visual analogue scale and verbal rating scale, and the need for additional analgesic medications. ResultsWe analyzed a total of 206 patients: 106 in Group L and 100 in Group B. Demographic details were similar between groups (P > 0.05). Abdominal pain decreased significantly with time in both groups, with a similar mean response profile (P < 0.001). There was no statistically significant difference between groups with regard to abdominal or shoulder pain by both visual analogue scale and verbal rating scale at all five time intervals (P > 0.05). There was also no significant difference in the side effect profile of both drugs (P > 0.05). A lower proportion of patients in Group B required additional narcotic analgesia (87%) compared with Group L (94%). This difference was marginally significant (P = 0.057). ConclusionsBupivacaine and lignocaine (lidocaine) are both safe and equally effective at decreasing postoperative pain after LC.

Good Evidence Supports Acetaminophen As an Effective and Safe Reliever of Acute Postoperative Pain

Good Evidence Supports Acetaminophen As an Effective and Safe Reliever of Acute Postoperative Pain

Continuous Intrathecal Morphine Infusion in Patients With Vertebral Fractures Due to Osteoporosis

Vertebral fractures are the most common consequences of severe osteoporosis. The chronic pain from collapse of osteoporotic vertebrae affects quality of life (QOL) and autonomy of patients. The management of pain with oral or transdermal opiates can cause severe side effects. Continuous intrathecal administration of morphine via an implantable pump might represent an alternative therapy to conventional oral or transdermal administration of opioids and has some advantages and disadvantages for pain relief and improvement in QOL when compared with conventional opioid delivery. It is our objective to report our experience using intrathecal delivery of analgesics in a population of patients with refractory pain due to vertebral fractures. In 24 patients, refractory to conventional delivery of opioids, we used intrathecal analgesic therapy. To test for efficacy and improvement in QOL, we administered the visual analog scale for pain and the Questionnaire of the European Foundation of Osteoporosis (QUALEFFO). Before patients were selected for pump implantation, an intraspinal drug delivery trial was performed to monitor side effects and responses to intrathecal therapy. Significant pain relief was obtained in all implanted patients. Using the QUALEFFO, we observed significant improvement of all variables such as quality of daily life, domestic work, ambulation, and perception of health status, before and after 1 year after pump implantation. With intrathecal morphine infusion, none of the 24 patients required additional systemic analgesic medication. The mean morphine dose during the spinal trial was 11.28 mg/d, 7.92 mg/d at pump implantation, and 16.32 mg/d at 1-year follow-up. Our results show that intrathecal administration of morphine efficiently relieves the symptoms of pain and improves QOL. Continuous intrathecal administration of morphine appears to be an alternative therapy to conventional analgesic drug delivery and has advantages in those patients who have severe side effects with systemic administration of analgesics.

The Management of Pain From Collapse of Osteoporotic Vertebrae With Continuous Intrathecal Morphine Infusion

Objectives. Vertebral fractures are the most common consequences of severe osteoporosis. The chronic pain from collapse of osteoporotic vertebrae affects quality of life (QoL) and autonomy of patients. The management of pain with oral or transdermal opiates can cause severe side-effects. Continuous intrathecal administration of morphine through an implantable pump might represent an alternative therapy to conventional oral or transdermal administration of opioids and has some advantages and disadvantages for pain relief and improvement in QoL when compared to conventional opioid delivery. It is our objective to report our experience using intrathecal delivery of analgesics in a population of patients with refractory pain due to vertebral fractures. Materials and Methods. In 24 patients, refractory to conventional delivery of opioids, we used intrathecal analgesic therapy. To test for efficacy and improvement in QoL, we administered the visual analog scale (VAS) for pain and the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO). Before patients were selected for pump implantation, an intraspinal drug delivery trial was performed to monitor side-effects and responses to intrathecal therapy. Results. Significant pain relief was obtained in all implanted patients. Using the QUALEFFO, we observed significant improvement of all variables such as QDL (quality of daily life), DW (domestic work), ambulation, and PHS (perception of health status), before and after oneyear after pump implantation. With intrathecal morphine infusion, none of the 24 patients required additional systemic analgesic medication. The mean morphine dose during the spinal trial was 11.28mg/day, 7.92mg/day at pump implantation, and 16.32mg/day at one-year follow-up. Conclusions. Our results show that intrathecal administration of morphine efficiently relieves the symptoms of pain and improves QoL. Continuous intrathecal administration of morphine appears to be an alternative therapy to conventional analgesic drug delivery and has advantages in those patients who have severe side-effects with systemic administration of analgesics.