Administration Of Analgesic Drugs Research Articles

A PROSPECTIVE RANDOMIZED STUDY FOR COMPARISON OF 0.5% LEVOBUPIVACAINE AND 0.5% BUPIVACAINE WITH FENTANYL FOR EPIDURAL ANAESTHESIA IN PATIENTS UNDERGOING HYSTERECTOMY

Epidural: Epidural anaesthesia is one of the best accepted and most versatile procedure in modern anaesthesiology for lower abdominal surgeries as it provides good sensory and motor block with contracted bowels, retaining spontaneous respiration, haemodynamic stability, and also an indwelling catheter which facilitates further administration of analgesic drugs for the postoperative period.Aim: This study was aimed to compare racemic bupivacaine and levobupivacaine in epidural anaesthesia for hysterectomies using fentanyl as common adjuvant.Material and Methods: A randomised prospective study was conducted on sixty patients of age group between 18-60 years of age with ASA grade 1 and 2 undergoing hysterectomy under epidural anaesthesia. Patients were randomly divided into two groups , Group A [n=30] received 0.5% levobupivacaine [15-20ml] with fentanyl[75 mcg] and Group B received 0.5% bupivacaine[15-20ml] with fentanyl [75mcg].In both groups’s onset of sensory and motor block. duration of analgesia, level of sedation ,haemodynamic parameters and complications were assessed perioperatively.Results: Mean duration of onset of sensory block in group A was 6.42 and 6.18 mins in group A and B respectively and mean duration of onset of motor block was 16.62 and 16.40 min in group A and B respectively, which were comparable for both groups as p value was >0.05. The mean duration of analgesia in group A was 5.33 hrs and in group B was 5.45 hrs, which was comparable in both groups with p value of 0.300 [>0.05].Haemodynamic parameters and complications were statistically non significant in both groups [>0.05].Conclusion: combination of levobupivacine and fentanyl is equipotent to bupivacaine and fentanyl in epidural anaesthesia for hysterectomies as both provided stable haemodynamics with adequate sensory and motor anaesthesia devoid of any significant adverse effects.

Brunner's Gland Adenocarcinoma in an Aged Western Gorilla (Gorilla gorilla)

A 50-year-old male western gorilla (Gorilla gorilla) presented with severe bradypragia, anorexia and vomiting. Despite continuous administration of antiphlogistic analgesic drugs and supportive care, the animal died and was submitted for post-mortem examination. Macroscopically, a large mass was located in the duodenum. The mucosal surface of the duodenum was irregular and thickened, and the lumen narrowed. The duodenal lesion was identified as a tubular adenocarcinoma and the neoplastic cells were strongly positive for cytokeratin AE1/AE3, cytokeratin 7, cytokeratin 19 and mucin-6 protein. Ultrastructurally, the apical cytoplasm of neoplastic cells had electron dense granules and apical microvilli. This is the first reported case of Brunner's gland adenocarcinoma in a gorilla.

Machine learning techniques for computer-based decision systems in the operating theatre: application to analgesia delivery

Abstract This work focuses on the application of machine learning techniques to assist the clinicians in the administration of analgesic drug during general anaesthesia. Specifically, the main objective is to propose the basis of an intelligent system capable of making decisions to guide the opioid dose changes based on a new nociception monitor, the analgesia nociception index (ANI). Clinical data were obtained from 15 patients undergoing cholecystectomy surgery. By means of an off-line study, machine learning techniques were applied to analyse the possible relationship between the analgesic dose changes performed by the physician due to the hemodynamic activity of the patients and the evolution of the ANI. After training different classifiers and testing the results under cross validation, a preliminary relationship between the evolution of ANI and the dosage of remifentanil was found. These results evidence the potential of the ANI as a promising index to guide the infusion of analgesia.

Fluoroscopy-Guided Percutaneous Sacroplasty for Painful Metastases at the Sacral Ala.

ObjectivePercutaneous sacroplasty (PSP) is widely used in the clinic for osteoporotic sacral insufficiency fractures; however, few reports have described the safety and effectiveness of PSP for painful sacral metastases at the sacral ala under fluoroscopy alone. We aimed to evaluate the safety and efficacy of fluoroscopy-guided PSP for painful metastases at the sacral ala.Patients and MethodsThirty-five consecutive patients (median age, 60.74 ± 12.74 years), with a total of 41 metastatic lesions at the sacral ala, were treated with PSP. The patients were followed up for periods ranging from 1 month to 30 months (average, 8.23 ± 6.75 months). The visual analog scale (VAS), Oswestry Disability Index (ODI), and Karnofsky Performance Scale (KPS) were used to evaluate pain, mobility, and quality of life before the procedure and at 3 days and 1, 3, 6, 12, and 18 months after the procedure.ResultsTechnical success was achieved in all patients. The minimum follow-up duration was 1 month. The mean VAS scores declined significantly from 7.20 ± 0.93 before the procedure to 3.43 ± 1.38 by day 3 after the procedure, and was 3.13 ± 1.07 at 1 month, 3.17 ± 1.15 at 3 months, 2.91± 1.38 at 6 months, and 2.57 ± 1.51 at 12 months after the procedure (P < 0.001). After PSP, analgesic drug administration had been discontinued in 31 of 35 patients (88.57%). The ODI and KPS also changed after PSP, with significant differences between the baseline scores and those at each follow-up examination (P < 0.001). Extraosseous cement leakage occurred in 12 cases without any major clinical complications.ConclusionPSP is a safe and effective technique for the palliative treatment of painful metastases involving the sacral ala under fluoroscopic guidance alone. It can relieve pain, reduce disability, and improve function, and is associated with minimal complications.

Risk factors of inadequate emergence following general anesthesia with an emphasis on patients with substance dependence history.

BackgroundThis study aims to define the incidence and risk factors of both emergence agitation and hypoactive emergence in adult patients and substance-dependent patients following general anesthesia to elaborate on the risk factors and precise management of them. MethodsThe study recruited 1,136 adult patients who received elective surgeries under general anesthesia for this prospective observational study. Inadequate emergence was determined according to the Richmond Agitation-Sedation Scale (RASS). Emergence agitation was defined as a RASS ≥ +1 point, and hypoactive emergence was defined as a RASS ≤ –2 points. Subgroup analyses were then conducted on patients with substance dependence.ResultsInadequate emergence in the post-anesthesia care unit (PACU) occurred in 20.3% of patients, including 13.9% with emergence agitation and 6.4% with hypoactive emergence. Ninety-five patients had a history of substance dependence. Compared to divorced patients, never-married and presently married patients, who underwent gynecological and thoracic surgeries, had a lower risk of agitation. Neurologic disorders, intraoperative blood loss, intraoperative morphine, and PACU analgesic drug administration were associated with increased agitation risk. Hypertension and psychological disorders, intraoperative opioids, and PACU Foley catheter fixation were associated with increased hypoactive emergence risk. Substance-dependent patients had higher risk for agitation (21.1%, P = 0.019) and hypoactive emergence (10.5%, P = 0.044). ConclusionsInadequate emergence in PACU following general anesthesia is a significant problem correlated with several perioperative factors. Patients with a history of substance dependence appear to be more at risk of inadequate emergence than the general population.

Use of preperitoneal wound catheter for continuous local anaesthesia after laparoscopic colorectal surgery.

The main cause of postoperative pain after abdominal surgery is the wound where laparotomy is made. Recently, laparoscopic procedures have become common in colorectal surgery. Although improving the tolerance of the surgery, postoperative pain management still remains adiscussed problem. The use of an epidural catheter used to be generally recommended in the open surgery era; however, an ideal strategy for postoperative analgesic therapy after laparoscopy remains unclear. Reduced administration of opioid analgesic drugs after colorectal resection is agenerally accepted goal. Preperitoneal catheter insertion for continuous local anaesthetic (LA) infusion in the wound after surgery is asimple alternative to other pain management methods. Retrospective analysis of analgotherapy outcomes in patients undergoing laparoscopic colorectal resection procedures, divided in three patient groups according to the type of analgesia: Group 1: use of acatheter for local wound infusion (KAT) n=73; group 2: epidural analgesia (EPI) n=23; and control group 3 with combined parenteral and subcutaneous analgesia (CON) n=66. The main objective of this study was to analyse postoperative pain and the consumption of opioid analgesics in the first three days from the surgery and the incidence of any complications related to the analgesic therapy. Opioid consumption in KAT and EPI groups was significantly lower compared to CON in the first 72 hours from the surgery. The lowest postoperative pain was measured in the EPI group. Subjective perception of pain, measured using VAS, was not significantly different between the KAT and CON groups. In KAT patients, vomiting was statistically less frequent than in CON patients. There was no significantly different incidence of paralytic ileus in the KAT and CON groups and no paralytic ileus was observed in the EPI group. There was no increased incidence of SSI (surgical site infections) in the KAT group compared to the other groups. The use of the catheter was assessed as safe. Insertion and management of the catheter is unsophisticated, and we did not observe any complications in terms of application of the catheter or toxic side effects of the LA. The use of the catheter clearly reduced opioid administration in the postoperative period compared to the control group (CON) with combined parenteral and subcutaneous analgesics. The best pain control measured using the visual analog scale (VAS) was observed in the EPI group.

Device-Related Error in Patient-Controlled Analgesia: Analysis of 82,698 Patients in a Tertiary Hospital.

Patient-controlled analgesia (PCA) is one of the most popular and effective methods for managing postoperative pain. Various types of continuous infusion pumps are available for the safe and accurate administration of analgesic drugs. Here we report the causes and clinical outcomes of device-related errors in PCA. Clinical records from January 1, 2011 to December 31, 2014 were collected by acute pain service team nurses in a 2715-bed tertiary hospital. Devices for all types of PCA, including intravenous PCA, epidural PCA, and nerve block PCA, were included for analysis. The following 4 types of infusion pumps were used during the study period: elastomeric balloon infusers, carbon dioxide-driven infusers, semielectronic disposable pumps, and electronic programmable pumps. We categorized PCA device-related errors based on the error mechanism and clinical features. Among 82,698 surgical patients using PCA, 610 cases (0.74%) were reported as human error, and 155 cases (0.19%) of device-related errors were noted during the 4-year study period. The most common type of device-related error was underflow, which was observed in 47 cases (30.3%). The electronic programmable pump exhibited the high incidence of errors in PCA (70 of 15,052 patients; 0.47%; 95% confidence interval, 0.36-0.59) among the 4 types of devices, and 96 of 152 (63%) patients experienced some type of adverse outcome, ranging from minor symptoms to respiratory arrest. The incidence of PCA device-related errors was <0.2% and significantly differed according to the infusion pump type. A total of 63% of patients with PCA device-related errors suffered from adverse clinical outcomes, with no mortality. Recent technological advances may contribute to reducing the incidence and severity of PCA errors. Nonetheless, the results of this study can be used to improve patient safety and ensure quality care.

Intracranial Pharmacotherapy and Pain Assays in Rodents.

Pain is a salient sensory experience with affective and cognitive dimensions. However, central mechanisms for pain remain poorly understood, hindering the development of effective therapeutics. Intracranial pharmacology presents an important tool for understanding the molecular and cellular mechanisms of pain in the brain, as well as for novel treatments. Here we present a protocol that integrates intracranial pharmacology with pain behavior testing. Specifically, we show how to infuse analgesic drugs into a select brain region, which may be responsible for pain modulation. Furthermore, to determine the effect of the candidate drug in the central nerve system, pain assays are performed after intracranial treatment. Our results demonstrate that intracranial administration of analgesic drugs in a targeted region can provide relief of pain in rodents. Thus, our protocol successfully demonstrates that intracranial pharmacology, combined with pain behavior testing, can be a powerful tool for the study of pain mechanisms in the brain.

Nurses Journey of Postoperative Pediatric Pain Care: A Qualitative Study Using Participation Observation in Indonesia

BACKGROUND: Unrelieved post-operative pain in children continues to be a major clinical problem, despite advances in pain management in Indonesia. The significance of the study is to address the gap in nurses&amp;rsquo; knowledge of pain management may be having. The study aim was to examine nurses post-operative pain care in an Indonesian Hospital.&#x0D; &#x0D; METHODS: A naturalistic, observational qualitative approach was undertaken to observe16 participating nurses who cared for 16 children post-surgery. Each participant was observed continuously during three to four shifts of 5 h each over a 2-month period. Content analysis was performed to interpret the results.&#x0D; &#x0D; RESULTS: We found that, in general, the nurses did not routinely and comprehensively assess the extent to which the children were in pain post-surgery and that they rarely used non-pharmacological interventions. Such these interventions were often conducted by parents. However, the nurses readily provided analgesic drugs as needed to the children, especially during the first 48 h post-operative period. Our findings support those of previous studies that found the role of nurses in pain management is primarily administration of analgesic drugs. Moreover, such pain care did not conform to recommendations based on current evidence.&#x0D; &#x0D; CONCLUSIONS: Post-operative pain care by nurses in a pediatric surgical ward were still un-optimal. These findings increase our knowledge and understanding about the complexities of postoperative pain care of children in Indonesia. Post-operative pain management in pediatric patients could be improved by increasing cooperation among healthcare professionals and parents. Post-operative pain management should be always put as a priority

Efficacy of intradermal administration of diclofenac for the treatment of nonspecific chronic low back pain: results from a retrospective observational study.

Intradermal administration of analgesic drugs with mesotherapy is effective for the local treatment of musculoskeletal pain. Few studies analyzed the effects of different drugs administrated with this technique. The aim of this study was to compare the efficacy of diclofenac versus lysine acetylsalicylate-based mesotherapy in relieving pain (primary outcome), and disability (secondary outcome) in patients with nonspecific chronic low back pain. Retrospective observational study. Outpatient rehabilitation medicine center. Records of 101 patients with nonspecific chronic low back pain. Data were extracted from the outpatients records of patients affected by nonspecific chronic low back pain since 12 weeks before, treated with 5 sessions of mesotherapy with diclofenac mixtures (group A) or aspirin-lysine acetylsalicylate mixture (group B). Assessments recorded were taken before the first treatment (T0), at the end of the 5-week treatment (T1), and at 4 (T2) and 12 weeks (T3) of follow-up after the last treatment, using a pain visual analogue scale (VAS) primary outcome, Oswestry Disability Index (ODI) secondary outcome, and the Short-Form McGill Pain Questionnaire (SF-MPQ) Comparisons within and between groups were performed using the t-test, the χ2 test, and analysis of variance (ANOVA) models, as appropriate. Records from 101 patients consecutively were analyzed, 51 in group A (mean age and standard deviation [SD]=62.8±10.7; F/M=33/18) and 50 in group B (mean age±SD=64.1±15.8; F/M=30/20). At baseline VAS, SF-MPQ, ODI scores were respectively 7.6±1.3, 22.49±9.96, 44.80±15.55 (mean and SD) in group A; VAS, SF-MPQ, ODI scores were respectively 6.7±1.6, 18.66±9.65, 39.04±16.06 (mean and SD) in group B. Mean differences between group A and group B in the changes of scores from baseline (T0) to end of study (T3) were -1.3 (VAS), -5.81 (SF-MPQ) and -17.05 (ODI). Mesotherapy induced significant reductions in pain severity and disability in both groups with better results in diclofenac-based treatment. This retrospective pilot study suggests the efficacy and safety of diclofenac mesotherapy for relieving pain and disability in patients affected by chronic nonspecific low back pain in a convenient sample but further studies will confirm these results. Diclofenac mesotherapy appears to be a viable treatment. to reduce pain and improve function in patients affected by chronic moderate-to-severe nonspecific low back pain.

Preemptive intrathecal administration of endomorphins relieves inflammatory pain in male mice via inhibition of p38 MAPK signaling and regulation of inflammatory cytokines

BackgroundPreemptive administration of analgesic drugs reduces perceived pain and prolongs duration of antinociceptive action. Whereas several lines of evidence suggest that endomorphins, the endogenous mu-opioid agonists, attenuate acute and chronic pain at the spinal level, their preemptive analgesic effects remain to be determined. In this study, we evaluated the anti-allodynic activities of endomorphins and explored their mechanisms of action after preemptive administration in a mouse model of inflammatory pain.MethodsThe anti-allodynic activities of preemptive intrathecal administration of endomorphin-1 and endomorphin-2 were investigated in complete Freund’s adjuvant (CFA)-induced inflammatory pain model and paw incision-induced postoperative pain model. The modulating effects of endomorphins on the expression of p38 mitogen-activated protein kinase (p38 MAPK) and inflammatory mediators in dorsal root ganglion (DRG) of CFA-treated mice were assayed by real-time reverse transcription-polymerase chain reaction (RT-PCR), Western blotting, or immunofluorescence staining.ResultsPreemptive intrathecal injection of endomorphins dose-dependently attenuated CFA-induced mechanical allodynia via the mu-opioid receptor and significantly reversed paw incision-induced allodynia. In addition, CFA-caused increase of phosphorylated p38 MAPK in DRG was dramatically reduced by preemptive administration of endomorphins. Repeated intrathecal application of the specific p38 MAPK inhibitor SB203580 reduced CFA-induced mechanical allodynia as well. Further RT-PCR assay showed that endomorphins regulated the mRNA expression of inflammatory cytokines in DRGs induced by peripheral inflammation.ConclusionsOur findings reveal a novel mechanism by which preemptive treatment of endomorphins attenuates inflammatory pain through regulating the production of inflammatory cytokines in DRG neurons via inhibition of p38 MAPK phosphorylation.

Pain and Administration of Pain Medication in the Elderly Population - A Goal Study in Finland

BACKGROUND: The aim of this population-based study was to examine older adults' self-reported SF-36 bodily pain domain (pain severity and pain-related interference) and pain-related factors. Administration of pain medication was under particular interest. METHODS: 1420 seniors aged 62-86 years self-reported SF-36 bodily pain during the past month. Four pain groups were formed based on these reports (group I [0-47.5, moderate to very severe pain intensity and interference], group II [55-70], group III [77.5-90], group IV [100, no pain at all]). Additional questionnaire-provided data regarding education, wealth, life habits and morbidity, as well as clinical and blood sample data were considered. Data regarding administration of pain medication during the previous and following 6 months were retrieved from the Finnish Social Insurance Institution. RESULTS: The overall pain prevalence was 78% (SF-36 bodily pain < 100). Prevalence of cohabiting and socioeconomic status decreased with increasing SF-36 bodily pain. Obesity and morbidity increased with pain. 84% of seniors had used some prescribed pain medication. 77% had used NSAIDs (percentage decreasing linearly from 91% in group I to 70% in group IV, p < 0.001). Opioids were used in all pain groups. INTERPRETATION: Low socio-economic status, obesity and morbidity were found to associate with pain. The majority of seniors had experienced pain despite the ample administration of analgesic drugs. NSAID: administration was remarkable in all pain groups. Increasing attention should be paid to pain management in the elderly considering especially the non-pharmacological modalities. FUNDING STATEMENT: No funding was applied or received for the study. DECLARATION OF INTERESTS: The authors report that there were no conflicts of interest. ETHICS APPROVAL STATEMENT: The approval for the study was given by the Regional Ethics Committee of Tampere University Hospital. All participants gave their written informed consent prior to data collection.

Fascia-iliaca compartment block vs intra-articular hip injection for preoperative pain management in intracapsular hip fractures: A blind, randomized, controlled trial

BackgroundThe aim of this study was to compare the fascia-iliaca compartment block and the intra-articular hip injection in terms of pain management and the need for additional systemic analgesia in the preoperative phase of intracapsular hip fractures. MethodsPatients >65 years old with an intracapsular hip fracture were randomized in this prospective, blind, controlled, parallel trial in a Level-I trauma center. Patients were randomly assigned to receive either the fascia-iliaca compartment block (cohort FICB) or the intra-articular hip injection (cohort IAHI) upon admission to the emergency department. The primary outcome was pain relief at 20 min, 12 h, 24 h and 48 h after the regional anesthesia, both at rest and during internal rotation of the fractured limb. The Numeric Rating Scale was used. Residual pain was managed with the same protocol in all patients. Additional analgesic drug administration during the 48 h from admission was recorded. ResultsA total of 120 patients with comparable baseline characteristics were analyzed in this study: the FICB group consisted of 70 subjects, while the IAHI group consisted of 50 subjects.Pain was significantly lower in the IAHI group during movement of the fractured limb at 20 min (p < 0.05), 12 h (p < 0.05), 24 h (p < 0.05) and 48 h (p < 0.05).In the FICB cohort 72.9% of patients needed to take oxycodone, in contrast to 28.6% of the IAHI cohort (p < 0.05). In the FICB cohort 14.09 ± 11.57 mg of oxycodone was administered, while in the IAHI cohort 4.38 ± 7.63 mg (p < 0.05). No adverse events related to either technique were recorded. ConclusionsIntra-articular hip injection provides better pre-operatory pain management in elder patients with intracapsular hip fractures compared to the fascia-iliaca compartment block. It also reduced the need for supplementary systemic analgesia. Level of EvidenceTherapeutic Level I.

Acute myocardial infarction secondary to blunt chest trauma in motorcycle accident: A rare combination where percutaneous coronary intervention and intravascular imaging optimization are needed

Blunt chest trauma is a common occurrence in vehicle accident. Cardiac injuries following nonpenetrating thoracic trauma have been reported. ST-elevation myocardial infarction (STEMI) due to coronary artery involvement is a rare but extremely serious condition for the high risk of undetected diagnosis. Blunt thoracic trauma may obscure typical chest pain associated with cardiac ischemia especially in patients with high tolerance of pain or secondary administration of analgesic drugs. We report two consecutive cases of young adults admitted to our emergency department after motorcycle accident and concomitant anterior STEMI due to occlusion of left anterior descending artery. In both cases primary percutaneous coronary intervention with a second generation drug eluting stent implantation was successfully performed. Imaging with intravascular ultrasound and optical coherence tomography showed the mechanisms of coronary occlusion, allowing an optimal stent implantation and avoiding procedural complications in this complex setting.

Potamotrygon motoro stingray venom induces both neurogenic and inflammatory pain behavior in rodents

Freshwater stingray accidents cause an immediate, intense, and unrelieved pain which is followed by edema, erythema and necrosis formation. Treatment for stingray envenomation is based on administration of analgesic, antipyretic and anti-inflammatory drugs. Concerning pain control, it is prescribed to immerse punctured limb on hot water to alleviate pain. There are no studies demonstrating specific targets on which stingray venom acts to promote pain. Therefore, the aim of this work was to investigate some mechanisms of Potamotrygon motoro venom (PmV) that contribute to nociception induction. Evaluating spontaneous pain behavior in mice injected i.pl. with PmV, it was seen that PmV induced both neurogenic and inflammatory pain. PmV also induced hyperalgesia in both mice and rats, evaluated through electronic von Frey and rat paw pressure test, respectively. Partial inhibition of hyperalgesia was observed in mice treated with cromolyn or promethazine, which indicated that mast cell and histamine via H1 receptor participate in the inflammatory pain. To search for some targets involved in PmVinduced hyperalgesia, the participation of TRPV1, calcium channels, neurokinins, CGRP, and norepinephrine, was evaluated in rats. It was seen that PmV-induced hyperalgesia occurs with the participation of neurokinins, mainly via NK1 receptor, CGRP, and calcium influx, through both P/Q and L-type voltage-dependent calcium channels, besides TRPV1 activation. The data presented herein indicate that PmV causes hyperalgesia in rodents which is dependent on the participation of several neuroinflammatory mediators.

Closed-loop Administration of General Anaesthesia: From Sensor to Medical Device

AbstractClosed-loop administration devices for general anaesthesia have become a common subject of clinical research over the last decade and appear more and more acceptable in clinical practice. They encompass various therapeutic needs of the anesthetized patient, e. g. fluid administration, hypnotic and analgesic drug administration, myorelaxation. Multiple clinical trials involving closed-loop devices have underscored their safety, but data concerning their clinical benefit to the patient are still lacking. As the marketing of various devices increases, clinicians need to understand how comparisons between these devices can be made: the measure of performance error and wobble are technical but have also a clinical meaning, to which clinical outcomes can be added, such as drug consumption and maintenance of hemodynamic parameters (e. g. heart rate and blood pressure) within predefined ranges. Clinicians using closed-loop devices need especially to understand how various physiological signals lead to specific drug adaptations, which means that they switch from decision making to supervision of general anaesthesia.

Postoperative analgesia following elective abdominal surgery: a prospective observational study

Background: Laparotomy forms an important subset of general surgical operations. This study aimed at collecting the baseline information on postoperative analgesia, to detect deficiencies in current management of postoperative pain and to aid as a reference for future endeavours aimed at improving pain management following abdominal surgeries.Methods: It was conducted as a prospective descriptive study in patients undergoing elective laparotomies in the Department of General Surgery of a tertiary care institute, for two years. The patterns of prescription and administration of analgesic drugs for postoperative pain after abdominal surgery, incidence and severity of postoperative pain, adverse effects of drugs and patient satisfaction were assessed.Results: A total of 289 elective laparotomies were performed. Combinations of Non-steroidal anti-inflammatory drugs (NSAID) with opioids, epidural analgesia (EA) with supplemental intramuscular ketorolac and PCEA (Patient controlled EA) provided effective pain relief with high satisfaction score (3/4) and were associated with low sedation (1/3) and the least side effects. Patients receiving NSAIDs had higher pain score with lesser satisfaction score and lower sedation score. IV-PCA with morphine provided effective pain relief with high satisfaction score (3/4), with least side effects, but patients had high sedation score (2/3). Around 55 (55/289; 19.03%) patients experienced postoperative nausea and vomiting, which responded to antiemetic treatment.Conclusions: A combination of NSAIDs with opioids provided effective pain relief, high satisfaction with less sedation and least side effects. Epidural analgesia with supplemental intramuscular ketorolac and PCEA also provided effective pain relief with high satisfaction and less sedation with least side effects.

Analgesia Nociception Index for perioperative analgesia monitoring in spinal surgery

The Analgesia Nociception Index is an index used to measure the levels of pain, sympathetic system activity and heart rate variability during general anesthesia. In our study, Analgesia Nociception Index monitoring in two groups who had undergone spinal stabilization surgery and were administered propofol-remifentanil (Total Intravenous Anesthesia) and sevoflurane-remifentanyl anesthesia was compared regarding its significance for prediction of postoperative early pain. BIS and Analgesia Nociception Index monitoring were conducted in the patients together with standard monitoring. During induction, fentanyl 2μg.kg-1, propofol 2.5mg.kg-1 and rocuronium 0.6mg.kg-1 were administered. During maintenance, 1.0 MAC sevoflurane+remifentanil 0.05-0.3μg.kg-1.min-1 and propofol 50-150μg.kg-1.min+remifentanil 0.05-0.3μg.kg-1.min-1 were administered in Group S and Group T, respectively. Hemodynamic parameters, BIS and Analgesia Nociception Index values were recorded during surgery and 30min postoperatively. Postoperative visual analog scale (VAS) values at 30minutes were recorded. While no difference was found between mean Analgesia Nociception Index at all times of measurement in both groups, Analgesia Nociception Index measurements after administration of perioperative analgesic drug were recorded to be significantly higher compared to baseline values in both groups. There was correlation between mean values of Analgesia Nociception Index and VAS after anesthesia. Analgesia Nociception Index is a valuable parameter for monitoring of perioperative and postoperative analgesia. In spine surgery, similar analgesia can be provided in both Total Intravenous Anesthesia with remifentanil and sevoflurane administration. Analgesia Nociception Index is efficient for prediction of the need for analgesia during the early postoperative period, and therefore is the provision of patient comfort.

Pain level after ACL reconstruction: A comparative study between free quadriceps tendon and hamstring tendons autografts

ObjectiveThe objective of this study was to compare the pain levels and analgesic consumption after single bundle ACL reconstruction with free quadriceps tendon autograft versus hamstring tendon autograft. Patients and methodsA total of 48 patients scheduled for anatomic single-bundle ACL reconstruction were randomized into two groups: the free quadriceps tendon autograft group (24 patients) and the hamstring tendons autograft group (24 patients). A basic multimodal analgesic postoperative program was used for all patients and rescue analgesia was provided with tramadol, at pain scores over 30 on the Visual Analog Scale. The time to the first rescue analgesic, the number of doses of tramadol and pain scores were recorded. The results within the same group were compared with the Wilcoxon signed test. ResultsSupplementary analgesic drug administration proved significantly higher in the group of subjects with hamstring grafts, with a median (interquartile range) of 1 (1.3) dose, compared to the group of subjects treated with a quadriceps graft, median = 0.5 (0.1.25) (p = 0.009). A significantly higher number of subjects with a quadriceps graft did not require any supplementary analgesic drug (50%) as compared with subjects with hamstring graft (13%; Z-statistics = 3.01, p = 0.002). The percentage of subjects who required a supplementary analgesic drug was 38% higher in the HT group compared with the FQT group. ConclusionThe use of the free quadriceps tendon autograft for ACL reconstruction leads to less pain and analgesic consumption in the immediate postoperative period compared with the use of hamstrings autograft. Level of EvidenceLevel I Therapeutic study

A description of pharmacological analgesia administration by public sector advanced life support paramedics in the City of Cape Town.

IntroductionEmergency Medical Services are ideally placed to provide relief of acute pain and discomfort. The objectives of this study were to describe pre-hospital pain management practices by Emergency Medical Services in the Western Cape, South Africa.MethodsA retrospective, descriptive survey was undertaken of analgesic drug administration by advanced life support paramedics. Patient care records generated in the City of Cape Town during an 11-month period containing administrations of morphine, ketamine, nitrates and 50% nitrous oxide/oxygen were randomly sampled. Variables studied were drug dose, dose frequency, and route of administration, patient age, gender, disorder and call type as well as qualification and experience level of the provider.ResultsA total of 530 patient care records were included (n = 530). Morphine was administered in 371 (70%, 95% CI 66–74) cases, nitrates in 197 (37%, 95% CI 33–41) and ketamine in 9 (1.7%, 95% CI 1–3) cases. A total of 5 mg or less of morphine was administered in 278 (75%, 95% CI 70–79) cases, with the median dose being 4 mg (IQR 3–6). Single doses were administered to 268 (72.2%, 95% CI 67–77) morphine administrations, five (56%, 95% CI 21–86) ketamine administrations and 161 (82%, 95% CI 76–87) of nitrate administrations. Chest pain was the reason for pain management in 226 (43%) cases. Advanced Life Support Providers had a median experience level of two years (IQR 2–4).DiscussionPre-hospital acute pain management in the Western Cape does not appear to conform to best practice as Advanced Life Support providers in the Western Cape use low doses of morphine. Chest pain is an important reason for drug administration in acute pre-hospital pain. Multimodal analgesia is not a feature of care in this pre-hospital service. The development of a Clinical Practice Guideline for and training in pre-hospital pain should be viewed as imperative.