Duration Of Postoperative Pain Relief Research Articles

Arthroscopic Debridement of Irreparable Massive Rotator Cuff Tears — A Comparison of Debridement Alone and Combined Procedure with Biceps Tenotomy

The goal of the study was to compare the results of arthroscopic debridement in massive, irreparable rotator cuff tears with and without tenotomy of the long head of the biceps (LHB). We evaluated 41 patients who were treated by a single surgeon for massive, irreparable rotator cuff tears either by arthroscopic debridement alone (24 patients) or with additional tenotomy of LHB (17 patients). The mean age was 67 years (range: 61 to 82 years) and the average follow-up was 31 months (range: 24 to 48 months). There was no significant difference between the two groups in age, gender, pain, function, and follow-up. All patients had significant disabling pain weakness preoperatively. Assessments were made using the Constant score. The average Constant score for the group without LHB tenotomy improved from a mean of 39 points (range: 19 to 54 points) preoperatively to a mean of 67 points (range: 41 to 87 points) and for the group with additional LHB tenotomy from a mean of 41 points (range: 16 to 54 points) preoperatively to a mean of 69 points (range: 49 to 87 points) at the time of follow-up. The radiological study showed no significant narrowing of the subacromial space. No statistical significance (P > .05) was found between the two groups. However, patients with additional LHB tenotomy had a longer duration of postoperative pain relief, but final pain score difference was not statistically significant. There was no complication related to the procedure. Arthroscopic débridement of massive, irreparable rotator cuff tears provides reliable expectation for improvement in function, decrease in pain, and improvement in shoulder scores for most patients. Additional LHB tenotomy did not significantly influence the postoperative results at the latest follow-up. In our series we noted no significant humeral head migration or developing rotator cuff arthropathy.

Buprenorphine added to the local anesthetic for brachial plexus block to provide postoperative analgesia in outpatients

Background and Objectives: Over the past 10 years, several studies have suggested that the addition of certain opiates to the local anesthetic used for brachial block may provide effective, long-lasting postoperative analgesia. One of these studies indicated that the agonist-antagonist, buprenorphine, added to bupivacaine provided a longer period of postoperative analgesia than the traditional opiates, but in this study, it is impossible to determine the relative contributions of the local anesthetic and the opiate to the postoperative analgesia because of the extremely long duration of the anesthesia provided by the local anesthetic, bupivacaine. By repeating the study using a local anesthetic of a shorter duration, the present study delineates more clearly the contribution of the buprenorphine to postoperative analgesia when added to a shorter-acting local anesthetic. Methods: Forty, healthy, consenting adult patients scheduled for upper extremity surgery were enrolled in the study. Premedication was provided by intravenous midazolam 2 mg/70 kg and anesthesia by a subclavian perivascular brachial plexus block. The patients were assigned randomly to 1 of 2 equal groups based on the agents used for the blocks. The patients in group I received 40 mL of a local anesthetic alone, while those in group II received the same local anesthetic plus buprenorphine 0.3 mg. The study was kept double-blind by having 1 anesthesiologist prepare the solutions, a second anesthesiologist perform the blocks, and a third anesthesiologist monitor the anesthesia and analgesia thereafter, up to and including the time of the first request for an analgesic medication. The data were reported as means (± SEM), and differences between groups were determined using repeated measures of analysis of variance (ANOVA) and χ2, followed by the Fisher exact test for post hoc comparison. A P value of less than .05 was considered to be statistically significant. Results: The mean duration of postoperative pain relief following the injection of the local anesthetic alone was 5.3 (± 0.15) hours as compared with 17.4 (± 1.26) hours when buprenorphine was added, a difference that was statistically (and clinically) significant (P < .0001). Conclusions: The addition of buprenorphine to the local anesthetic used for brachial plexus block in the present study provided a 3-fold increase in the duration of postoperative analgesia, with complete analgesia persisting 30 hours beyond the duration provided by the local anesthetic alone in 75% of the patients. This practice can be of particular benefit to patients undergoing ambulatory upper extremity surgery by providing prolonged analgesia after discharge from the hospital. Reg Anesh Pain Med 2001;26:352-356.

A Comparative Study of Postoperative Early Ambulation with Intrathecal Morphine by 27-gauge Whitacre Needle and Bed Rest without Morphine by 25-gauge Quincke Needle

Background : Early ambulation after anorectal surgery may be possible by relieving pain with intrathecal morphine and decreasing headache and backache with a much thinner and pencil-point needle. The difference in urinary peak flow rate in upright posture compared with recumbent position was reported to be highly significant, although acute urinary retention induced by intrathecal morphine may be decreased by early ambulation. Methods : Eighty patients due for anorectal surgery were selected to receive spinal anesthesia. Subjects in group A (n =40) received 0.5% tetracaine 5―6 mg through a 25-gauge Quinke needle while group B (n =40) received 0.5% tetracaine 5 ― 6 mg and intrathecal morphine 0.2 mg through a 27-gauge Whitacre needle. Postoperatively, group A received 24 hours bed rest and group B was recommended to walk as soon as possible. The duration of pain relief, onset time to ambulation, headache, backache, urinary retention and nausea were observed in both groups. Results : The average onset time of early ambulation and duration of postoperative pain relief in group B was 3.6 ± 1.0 and 15.1 ± 3.5 hours respectively. The incidence of postpinal headache and backache was 2.5 and 5.0% in group B respectively and decreased significantly in comparison with group A (20.0 and 22.5%) respectively (P < 0.05). However, the incidence of postoperative nausea was 35.0% in group B and increased in comparison with group A (12.5%) (P < 0.05). Group B yielded a relatively lower urinary retention rate (40.0%) than group A (52.5%), but the difference did not reach statistical significance. Conclusions : Intrathecal morphine infused by a 27-gauge Whitacre needle provided postoperative pain relief with early ambulation, and decreased headache and backache, but we suggest that there is a need to select another drug or method instead of intrathecal morphine to decrease the incidence of urinary retention and nausea. (Korean J Anesthesiol 2000; 38: 810 ~ 816)

A Double-Blind Comparison of Ropivacaine, Bupivacaine, and Mepivacaine During Sciatic and Femoral Nerve Blockade

A Double-Blind Comparison of Ropivacaine, Bupivacaine, and Mepivacaine During Sciatic and Femoral Nerve Blockade

Intercostal nerve block for lumpectomy: Superior postoperative pain relief with bupivacaine

Study Objectives: To investigate whether equipotent doses of lidocaine and bupivacaine were equally effective for intercostal nerve blockade (ICNB) and whether a lower amount of lidocaine would be comparably effective. To see whether plasma levels of lidocaine with and without epinephrine and of plain bupivacaine would reach toxic ranges. Finally, to evaluate the duration of postoperative analgesia following general anesthesia and regional anesthesia with two different local anesthetics. Design: Randomized, double-blind study, with control group administered general anesthesia. Setting: Gynecologic operating room of a university hospital. Patients: 48 adult ASA physical status I and II otherwise healthy patients undergoing lumpectomy. Interventions: 36 patients received ICNB of T 3−T 6 unilaterally using either 4 ml/segment of 1.5% lidocaine with epinephrine 3.75 μg/ml (n = 10, Group A), 4 ml/segment of 2% lidocaine with epinephrine 5 μg/ml (n = 13, Group B), or 4 ml/segment of plain 0.5 % bupivacaine (n = 13, Group C). The control group consisted of 12 patients (Group D) who received a general anesthetic using propofol, alfentanil, and nitrous oxide in oxygen for induction and maintenance of anesthesia. Measurements and Main Results: In all three ICNB groups, the highest plasma concentrations were reached after 5 to 10 minutes following ICNB—i.e., a lidocaine plasma level of 2.77 ± 0.5 μg/ml (mean ± SEM) in Group A, a lidocaine plasma level of 2.78 ± 0.2μg/ml in Group B, and a bupivacaine plasma level of 1.44 ± 0.2 μg/ml in Group C. There were no significant differences in plasma levels between 1.5% lidocaine and 2% lidocaine. For the first 90 minutes after surgery, higher postoperative pain scores were found in the control group than in the ICNB groups. Notably longer-lasting postoperative pain relief was achieved with plain bupivacaine. The number of women requiring postoperative analgesic medication, the time of first request, and the total amount of analgesic drugs administered during the 24 hours postoperatively were significantly lower in the regional anesthesia groups than in the general anesthesia group ( p < 0.05). Conclusions: ICNB is an alternative to general anesthesia for female breast surgery. Both lidocaine with epinephrine and plain bupivacaine in the doses used did not raise venous plasma concentrations to levels considered potentially toxic. With. respect to duration of postoperative pain relief and analgesic drug request, the local anesthetics (in particular, bupivacaine) were found to be superior to general anesthesia.

Intervertebral epidural anaesthesia in paediatric surgery: success rate and adverse effects in 650 consecutive procedures

The success rate and occurrence of adverse effects are reported in a retrospective study of 650 (99 sacral, 468 lumbar, 76 thoracic and seven cervical) paediatric epidurals performed, mostly (91%) under light general anaesthesia, by several anaesthetists. Seventeen‐gauge Tuohy and 20‐gauge (Potts‐Cournand® and Tuohy) needles were used. Anaesthetic solutions used were 1% lignocaine, 0.5% bupivacaine and a mixture of equal volumes of 0.5% bupivacaine with either 1% lignocaine or 1% etidocaine, all containing 1:200 000 adrenaline. The epidural space was identified by loss‐of‐resistance technique (LORT) with normal saline, air or CO2. Up to five attempts were occasionally necessary. LORT using fluid resulted in more subarachnoidal penetrations than the LORT using air (P &lt; 0.05) which was easy and reliable but produced patchy anaesthesia (‘painful gaps') in 4.2% of patients. CO2‐LORT was as easy and reliable as air‐LORT and did not result in painful gaps. Lateral and mid‐line insertion routes were equally suitable whatever the level of approach. Twenty‐gauge needles, especially Tuohy needles, resulted in significantly less dural punctures in young children. The spread of the local anaesthetic correlated with the volume injected and the height of the epidural approach. Epidural anaesthesia had little haemodynamic effects. Administration of epidural morphine improved the duration of postoperative pain relief but undesirable effects occurred in up to 50% of patients. Low doses of naloxone (2–5 μg?kg−1.h−1) counteracted most adverse effects, avoiding urinary retention and delayed apnoea. Anaesthetists and residents without experience in paediatric anaesthesia had a good success rate in performing the techniques (under supervision of an experienced anaesthetist). At the same time, experience in regional anaesthesia would significantly boost the confidence of the anaesthetist in managing such cases. The authors recommend using CO2 instead of air in the LORT.

Timing of caudal block placement in relation to surgery does not affect duration of postoperative analgesia in paediatric ambulatory patients

The purpose of this study was to determine if the timing of caudal block placement in relation to surgery affected either the duration of postoperative pain relief or the discharge time in children undergoing brief ambulatory surgical procedures. Forty ASA physical status I or II children ages 18 mo to 11 yr were randomly assigned to one of two groups. Group 1 patients received a caudal block with 0.5 ml.kg-1 of bupivacaine 0.25 per cent following the induction of anaesthesia but before the onset of surgery. Group 2 patients received a similar block at the completion of surgery but before emergence from general anaesthesia. An experienced observer, who was not aware of the timing of block placement, observed all patients from arrival to the post-anaesthetic recovery room until discharge from the ambulatory surgery unit. Pain was assessed at five-minute intervals using an Objective Pain Scale. No statistically significant differences were noted between Group 1 and Group 2 patients with regard to their postoperative pain/discomfort scores, the need for postoperative narcotic analgesia, or the time required for either group to meet standard discharge criteria. It is concluded that the duration of postoperative analgesia is not impaired by placing the caudal block prior to the start of a brief surgical procedure.

Penile Block via the Subpubic Space in 100 Children

A technique for blocking the dorsal nerves of the penis was designed after reevaluation of the gross anatomy of the subpubic space and penis in children. The technique consists of inserting a short bevel needle in the two compartments of the subpubic space, where the nerves run before entering the base of the penis, and of injecting a small volume (0.1 mL/kg of body weight) of local anesthetic. This two-puncture procedure was prospectively evaluated in 100 children undergoing surgery of the penis under light general anesthesia. The local anesthetic was a solution of 1% lidocaine (Group A) or 0.5% bupivacaine (Group B). The technique did not require any special skill and was successful in all patients. In four cases, the block needle was withdrawn and reinserted due to venous blood reflux. No complications occurred and anesthesia was satisfactory for completion of surgery. The duration of postoperative pain relief was significantly longer in patients given bupivacaine than in those given lidocaine. It is concluded that the subpubic approach to the dorsal nerves of the penis is easy, safe, and reliable, and that 0.5% plain bupivacaine provides long-lasting postoperative pain relief.

Pharmacodynamics and pharmacokinetics of methadone during the perioperative period.

The duration of postoperative pain relief was assessed in 23 general surgical or orthopedic patients administered 20 mg methadone as an iv bolus following induction of anesthesia. Nine patients (39%) were pain-free and required no additional analgesia for the control of their postoperative pain (Gro