Major Abdominal Gynaecological Surgery Research Articles

Postoperative analgesia after major abdominal gynaecological surgery using surgical transversus abdominis plane block

Postoperative analgesia after major abdominal gynaecological surgery using surgical transversus abdominis plane block

Postoperative Acute Kidney Injury in Geriatric Gynecologic Oncology Patients After Major Open Abdominal Surgery: A Retrospective Cohort Study

Introduction: This investigation’s purpose was to determine the incidence of acute kidney injury, the associated risk factors, and the 90-day outcomes and kidney function of geriatric patients who underwent major open abdominal gynecologic oncologic surgery. Materials and Method: This retrospective cohort study involved patients aged ≥ 65 years who underwent major open abdominal gynecologic oncologic surgery. Results: The postoperative incidence of acute kidney injury in gynecologic oncologic surgical procedures was 22.1%, with a transient nature observed in 72% of patients. The in-hospital mortality rate was 4 %. Kidney function on the 90th day after acute kidney injury development revealed that estimated glomerular filtration rate regressed by over 25% in 6 patients (24%). Acute kidney injury development was associated with surgical time, intraoperative bleeding volume, bowel procedures, the presence of ascites, intraoperative hypotension, vasopressor use, postoperative diuretic use, postoperative hypoalbuminemia, prolonged post-anesthesia care unit, and hospital stay (p < 0.05). A logistic regression analysis of the risk factors for acute kidney injury revealed that surgery duration was a significant one (p < 0.05). Conclusion: Postoperative acute kidney injury is an important postoperative complication associated with the development or progression of chronic kidney disease. This leads to a prolonged stay in the post-anesthesia care unit and in the hospital. Although acute kidney injury is frequently transient in geriatric patients following major open abdominal gynecologic oncologic surgery, developing preventive measures, encouraging team collaboration, and monitoring serum creatinine concentration in the early postoperative period are critical in complex surgical procedures. Keywords: Postoperative Complications; Acute Kidney Injury; Geriatrics.

Comparison of prophylactic dexamethasone, metoclopramide, and combination of dexamethasone and metoclopramide for prevention of post-operative nausea and vomiting for major gynaecological surgery in Hawassa university compressive specialized hospital, Ethiopia, 2019

BackgroundPostoperative nausea and vomiting is a common postoperative unpleasant and distressful experience among major abdominal gynecological surgery with incidences of up to 54% and 71% vomiting &nausea respectively. PONV is primarily occurs within 24 h can lead to significant morbidity, unexpected hospital admission of surgical outpatients by reducing patient comfort, delayed discharge from the hospital, and an increase in costs. ObjectiveTo compare the effectiveness of dexamethasone, metoclopramide and combination of them in prevention of post-operative nausea and vomiting in patients undergoing gynaecological surgery. MethodsInstitutional based Prospective randomized control trial study was conducted Hawassa comprehnsive specialized hospital from March 2018–February 2019. This study was conducted on female patient age 18–65 years. Data was collected by pretested and self-designed structured questionnaire and analysed by using computer software SPSS version 22.data were evaluated using one way ANOVA test. Categorical data was analysed with the Chi-Square test and P- Value of less than 0.05 was significantly associated with outcome variable. ResultTotal incidence of PONV during 4–12 h was 25% in the dexamethasone group, 53% in the metoclopramide group, 18.8% in the dexamethasone plus metoclopramide group (p = 0.007). There was significant difference in incidence of nausea at 4–12 h (p = 0.011) and 12–24 h (p = 0.043). The overall incidence of PONV was 31.3%, 65.6% &28.1%of dexamethasone, metoclopramide and combination of them respectively which was lower in dexamethasone & combination (p = 0.003). Total antiemetic drug over 24 h was significantly lower in the dexamethasone and combination groups than the metoclopramide groups which were, 28.1%, 25% and 62.5% respectively (p = 0.003). ConclusionsWe conclude that prophylactic Dexamethasone and Dexamethasone plus 10 mg Metoclopramide was found more effective in preventing PONV and decreasing the requirement of rescue antiemetic than Metoclopramide & comparable effectiveness between dexamethasone and combination in prophylaxis of PONV.

Effects Of Mouth Dissolving Mosapride Tablets (Mdmts) On Gut Recovery After Major Abdominal Gynecological Surgery (Mags)

Aim. To access whether receiving mouth dissolving mosaperide tablets (MDMTs) in immediate postoperative period in addition to routine care accelerates the recovery of upper and lower gastrointestinal function after major abdominal gynecological surgery (MAGS).Patients & Methods: A randomized controlled study was conducted from December 2014 to December 2015. Patients scheduled to undergo abdominal hysterectomy were assigned to receive MDMTs beside routine care immediately postoperatively or routine care alone after surgery. patient's postoperative charts were reviewed to establish incidence of postoperative nausea, vomiting, use of analgesics, use of antiemetics, cases developing postoperative ileus (P01) (nausea, vomiting, distention, absence of bowel sounds) and its degree mild (resolved spontaneously on basic support), moderate (required nasogastric tube insertion beside basic support), severe (POI that resist management lines including antiemetic and persist for > 2 days), time to discharge and time from end of surgery to first postoperative hearing intestinal sounds, toleration of fluids intake, toleration to solid foods intake, passage of flatus, as well as first defecation.Results: A total of 120 patients were randomly assigned to receive MDMTs (n=60, 2 were excluded, 58 were available for intension to treat analysis) or routine postoperative care alone (n =60, 4 were excluded, 56 were available for intension to treat analysis). The mean time to first hunger, toleration of liquids and solids, bowel movement, flatus as well as first defecation were significantly shorter in participants whom assigned to receive MDMTs (P = 0002, P = 0.027, P < 0.0001, P = 0.0001, P < 0.000, P = 0.0006 respectively). Participants assigned to receiving MDMTs than routine care experienced significant postoperative nausea (P = 0.004) vomiting (P = 0.005) and mild and moderate POI (P = 0.008, P = 0.02 respectively). MDMTs intake was well tolerated and well accepted by patients and no intervention — related side effects were observed.Conclusion: Receiving MDMTs after MAGS accelerates the time of gut recovery, shortened the length of hospital stay as well as reduce the incidence of POI. This simple, inexpensive and well tolerated treatment could be added to routine postoperative care of major gynecological abdominal surgery patients.

Comparison of postoperative pain outcomes after vertical or Pfannenstiel incision for major gynecologic surgery

ABSTRACTObjective: The Pfannenstiel incision is commonly used for gynecologic surgery. It is not known if this incision is associated with less postoperative pain compared to a vertical midline incision. Therefore, as part of a study to evaluate the postoperative analgesic effects and dose response of intravenous adenosine in patients undergoing open abdominal gynecologic surgery, this manuscript compares postoperative pain and analgesic consumption in patients who had a midline vertical incision or a Pfannenstiel incision.Research design and methods: This is a secondary analysis of data from a primary study investigating the dose response of IV adenosine for postoperative analgesia. Women scheduled for elective major gynecologic surgery under general anesthesia were enrolled and randomly assigned to receive one of four doses of intraoperative adenosine infusion (25, 50, 100, or 200 µg/kg/min) or matching placebo (normal saline). The anesthetic technique was standardized and adjusted based on hemodynamic and depth of anesthesia (bispectral index) values. Postoperative analgesia was provided with a standardized morphine patient controlled analgesia protocol which included rescue ketorolac, as needed. Comparative outcome analysis of the midline and Pfannenstiel skin incisions with regards to analgesic consumption and pain scores was performed and presented in this manuscript.Results: A total of 165 patients were identified; 105 women had a Pfannenstiel incision and 60 had the lower midline abdominal incision. There were no differences between the midline and Pfannenstiel groups with respect to intraoperative fentanyl, postoperative pain scores [worst pain scores 0–24 h (mean ± SD) 8.2 ± 2.1 vs. 8.2 ± 1.9), p = 0.352], cumulative opioid consumption [0–24 h morphine equivalents (mean ± SD) 63 ± 27 vs. 72 ± 43 mg, p = 0.496], or need for rescue ketorolac. While the duration of surgery was longer in patients who had a vertical incision (p = 0.02), there was no difference between the groups in the duration of postanesthesia care unit (44 ± 53 vs. 30 ± 45 min, p = 0.093) or hospital stays (74 ± 27 vs. 67 ± 20 h, p = 0.254).Conclusions: There was no significant difference in postoperative pain and opioid consumption in patients undergoing major abdominal gynecologic surgery performed with either a midline or Pfannenstiel incision. However, it is important to note that since this a secondary analysis of data from a primary study investigating the dose response of IV adenosine, the patients were not prospectively randomized into the two incision types.

Early Oral Intake After Intra-abdominal Gynecological Oncology Surgery

To explore and evaluate the safety and efficacy of early oral intake following major abdominal gynecological oncology surgery. During an 11-month period, 60 gynecological oncology patients undergoing major intra-abdominal surgery were enrolled in a randomized controlled clinical trial of semiliquid diet (experimental group) compared with clear feeds (control group) 6 hours after operation. Patients were evaluated for nausea, vomiting, bowel sound, passage of flatus, body weight difference before and after operation, urine acetone, fasting blood sugar, and prealbumin level, and need for nasogastric tube decompression. There were significantly higher incidences of nausea, shorter time of regular diet resumption, and higher level of prealbumin on postoperative day 7 in patients from the experimental group than those from the control group (P < .05). No significant differences were found in vomiting, the time to development of bowel sound and passage of flatus, body weight difference before and after operation, urine acetone and fasting blood sugar on postoperative day 1, and prealbumin level on postoperative day 2 between the 2 groups. Early oral intake with semiliquid diet 6 hours after major intra-abdominal gynecological oncology surgery is safe and well tolerated.

Review: early feeding after major gynaecological surgery is safe except for an increase in nausea

K Charoenkwan Dr K Charoenkwan, Chiang Mai University, Chiang Mai, Thailand; kicharoe@mail.med.cmu.ac.th In women having major abdominal gynaecological surgery, does early initiation of oral intake of food and fluids increase...

Locked out and still knocking: predictors of excessive demands for postoperative intravenous patient-controlled analgesia

Psychosocial factors governing the use of postoperative, intravenous patient-controlled analgesia (PCA) have received little attention in spite of the fact that PCA is the most common modality for managing pain after surgery. The motivation behind requests for analgesia during lockout periods is not known. Unrelieved pain and need for pain medication are obvious reasons but other factors may be involved. The aim of the present study was to predict PCA lockout interval demands based on preoperative psychosocial factors. Approximately one week before major abdominal gynecologic surgery, 117 women completed the impact of events scale (IES) measuring intrusive thoughts and avoidant behaviours. Pain was measured by visual analogue scale at three, six, 12, 24 and 48 hr after surgery. Measures of anxiety and negative affect were obtained 24 and 48 hr after surgery. Cumulative morphine consumption and every PCA demand (drug delivered and not delivered) were downloaded from the PCA pump. Multiple regression analyses revealed that preoperative intrusive thoughts and avoidant behaviours about the upcoming surgery positively predicted PCA lockout interval demands after controlling for postoperative pain, morphine consumption, anxiety, and negative affect (R2 = 0.45; P < 0.0001). Path analysis showed a direct pathway from preoperative IES scores to lockout interval demands (beta = 0.23, P = 0.002) which was not associated with untreated pain, anxiety, or negative affect. Excessive demands for postoperative intravenous- PCA morphine during lockout intervals appear to reflect, in part, poor preoperative adaptation to surgery involving intrusive thoughts and avoidant behaviours about the upcoming surgery.

Evaluation of the Effect of Perioperative Rofecoxib Treatment on Pain Control and Clinical Outcomes in Patients Recovering From Gynecologic Abdominal Surgery: A Randomized, Double-Blind, Placebo-Controlled Clinical Study

In this randomized, placebo-controlled, double-blind study, the efficacy and safety of rofecoxib 50 mg was evaluated in patients undergoing major abdominal gynecologic surgery. Patients were randomized to receive rofecoxib 50 mg (n = 81) or placebo (n = 83) approximately 2 hours before total abdominal hysterectomy or myomectomy and once daily over the ensuing 4 days. Clinical measurements included average daily opioid use over the 5-day period (primary endpoint), pain intensity on movement, and opioid-related side effects. Patients receiving rofecoxib required 32% less (P = .001) intravenous and oral opioids to relieve their postoperative pain from days 1 to 5 (primary endpoint), used 21% less (P = .011) on day 1, and 42% less (P < .001) from days 2 to 5. The rofecoxib group experienced less pain upon movement (P < .001), less sedation (P = .007), and a 24% reduction in the rate of antiemetic intake (P = .037) over the first 72 hours postsurgery. Earlier mean times to first flatus (-10.1 hours, P = .001), first bowel movement (-14.1 hours, P = .037), and time to hospital discharge (-10.9 hours; 95% confidence interval, -17.1 to -4.7) occurred in the rofecoxib group. There were no significant intergroup differences in blood loss, wound healing, or overall adverse experiences. Compared with placebo, perioperative administration of rofecoxib 50 mg provided significant opioid sparing, significantly better pain control, improved clinical outcomes, and was well tolerated.

Preoperative coping strategies and distress predict postoperative pain and morphine consumption in women undergoing abdominal gynecologic surgery

Objectives The aim of the present study was to predict postoperative pain and morphine consumption based on preoperative psychosocial factors. Methods One hundred and twenty-two women completed measures of distress and coping 1 week before major abdominal gynecological surgery by laparotomy. Forty-eight hours after surgery, measures of pain and negative affect (NA) were completed, and morphine consumption was recorded from a patient-controlled analgesia pump. Four weeks after surgery, measures of pain and NA were completed. Results Multivariate analyses revealed that preoperative self-distraction coping ( P=.039) positively predicted postoperative pain levels in the hospital, after accounting for the effects of age, concurrent NA, and morphine consumption. Emotional support ( P=.031) and religious-based coping ( P=.036) positively predicted morphine consumption in the hospital, after accounting for the effects of age, concurrent NA, and pain levels. Preoperative distress ( P<.04 to .008) and behavioral disengagement ( P=.034), emotional support ( P=.049), and religious-based coping ( P=.001) positively predicted pain levels 4 weeks after surgery, after accounting for the effects of age and concurrent NA. Conclusion The results suggest that preoperative psychosocial factors are associated with postoperative pain and morphine consumption.

Early postoperative feeding and abdominal gynaecological surgery

Since the 1990s, the traditional postoperative feeding protocol has been challenged for patients who have undergone major abdominal gynaecological surgery, and value of extended delays in commencing oral intake has been questioned. This review aims to determine whether early rather than delayed postoperative feeding following major abdominal gynaecological surgery has an impact upon recovery as measured by length of hospital stay. The Cochrane Library, Embase, CINAHL and Medline were searched for randomized controlled trials (RCTs) which compared early postoperative oral intake with delayed (traditional) postoperative oral intake for patients who had undergone major abdominal gynaecological surgery. Three RCTs were identified and available for consideration. Although study quality was variable, they suggest that early postoperative feeding appears to be safe and well tolerated after most abdominal gynaecological surgery and leads to a considerable reduction in hospital stay of approximately one day. However, patients' preference and costs remain unclear. Therefore, further well-designed studies are needed to identify the comprehensive effectiveness of early postoperative feeding protocol.

Patient-controlled thoracic epidural infusion with ropivacaine 0.375% provides comparable pain relief as bupivacaine 0.125% plus sufentanil after major abdominal gynecologic tumor surgery

Background and Objectives: We tested the hypothesis that an opioid-free local anesthetic alone is able to provide comparable analgesia to the opioid supplemented epidural application of local anesthetics using thoracic epidural catheters after major abdominal surgery. Methods: In a prospective, randomized, and double-blind study, we have compared the analgesic efficacy and side effects of ropivacaine 0.375% (group R) versus bupivacaine 0.125% in combination with sufentanil 0.5 μg/mL−1 (group B/S) via a thoracic epidural catheter for a duration of 96 hours after major abdominal surgery in 30 gynecologic tumor patients. Piritramide was given for breakthrough pain. Assessments were performed every 12 hours after start of the epidural infusion using continuous (first 24 hours) and patient-controlled epidural analgesia (PCEA) (24 to 96 hours). Results: No differences were seen in demographic and perioperative data. Dynamic pain scores (visual analog scale [VAS] values) were comparable between groups during mobilization (group R v group B/S: 24 hours: 40 ± 30 v 36 ± 14, P = .9; 48 hours: 46 ± 33 v 42 ± 25, P = .93; 72 hours: 42 ± 24 v 48 ± 26, P = .78; 96 hours: 42 ± 25 v 29 ± 28, P = .49) and on coughing during the whole study period. Hemodynamics, intensity of motor block (Bromage scale), and side effects like nausea, vomiting, pruritus, and bladder disfunction also did not differ between groups. Conclusion: The present study shows that thoracic epidural infusion of ropivacaine 0.375% provides comparable pain relief and incidence of side effects after major abdominal gynecologic surgery as bupivacaine 0.125% in combination with 0.5 μg/mL−1 sufentanil and may therefore represent an alternative in epidural pain management. Reg Anesth Pain Med 2002;27:367-373.

A randomized controlled trial of early versus “traditional” postoperative oral intake after major abdominal gynecologic surgery

Objective: The purpose of this study was to compare early oral intake and the traditional timing of feeding after major gynecologic surgery and the effects on the length of hospital stay. Study Design: Gynecologic oncology and urogynecology patients who underwent major abdominal gynecologic surgery were prospectively randomized to 1 of 2 groups. The traditional feeding group (group A, 49 patients) received nothing by mouth until documentation of bowel function. They were then advanced slowly to solid diet. The patients allocated to the early feeding regimen (group B, 47 patients) began clear fluids on the first postoperative day. Once 500 mL of clear fluid was tolerated, they received a regular diet. The groups were compared with regard to length of hospital stay, postoperative day that solids were tolerated, and the incidence of adverse effects. Statistical analyses were performed with the χ2 test, the Fisher exact test, the Student t test, and analysis of variance. Results: The demographic characteristics of the 2 groups were similar. There was a statistically significant reduction in the length of hospital stay for those patients on the early feeding regimen. The median length of stay for group A was 6.0 days and for group B was 4.0 days (P =.0001). There was no difference in the incidence of emesis, ileus, or other postoperative complications between the 2 groups. Conclusion: Early postoperative dietary advancement after major abdominal gynecologic surgery results in a decreased length of hospital stay and appears to be safe, with no increased adverse effects. (Am J Obstet Gynecol 2002;186:861-5.)

Early postoperative feeding after major gynecologic surgery: Evidence-based scientific medicine

Postoperative gastrointestinal care after major gynecologic surgery has evolved considerably over the last decade. According to evidence-based scientific medicine, the following conclusions can be drawn: (1) Postoperative colonic stasis occurs after major abdominal surgery and persists for approximately 3 days (classes I and IIA). (2) Elective postoperative nasogastric decompression after major abdominal surgery is unnecessary (class I). (3) Early feeding after major gynecologic surgery results in emesis but does not increase the incidence of aspiration pneumonia, dehiscence, or intestinal leaks and decreases hospital stay (class I). (4) Slow advancement of postoperative diet after major gynecologic surgery is probably unnecessary (class III). (5) After major abdominal gynecologic surgery, there appear to be minimal medical benefits (decreased infection rate) of early postoperative feeding (class III). (6) After radical hysterectomy, postoperative bowel stimulation decreases length of hospital stay (class IIA). (Am J Obstet Gynecol 2001;185:1-4.)

Comparison of continuous and intermittent administration of extradural bupivacaine for analgesia after lower abdominal surgery

We have compared intermittent bolus and continuous infusion of extradural local anaesthetic for pain relief in a randomized, double-blind study of 48 patients who underwent major abdominal gynaecological surgery. Each patient received 5 ml of 0.375% bupivacaine hourly, either as a bolus over 5 min or as a constant infusion. Patients who received the intermittent administration technique maintained a more extensive sensory block, reported marginally better analgesia and had a lower requirement for rescue medication. The intermittent bolus technique was not associated with an increase in side effects.

A Prospective Controlled Trial of Early Postoperative Oral Intake Following Major Abdominal Gynecologic Surgery

Objective.The objective was to determine whether, when compared with traditional dietary advancement, early oral intake following major gynecologic surgery leads to a reduction in the length of hospitalization. Methods.Patients undergoing major abdominal gynecologic surgery were invited to participate in this study. After informed consent was obtained, they were randomized to one of two groups. The control group (group 1) was treated traditionally. Oral intake was initiated only after documentation of bowel function, which was defined by two of the following three criteria: (1) bowel sounds; (2) flatus or bowel movement; and (3) subjective hunger. Those assigned to the study group (group 2) were given a clear liquid diet on postoperative day 1. Once 500 cc was tolerated, a regular diet was given. Patients were evaluated on a daily basis for bowel sounds, flatus, bowel movement, hunger, nausea, vomiting, and need for nasogastric tube decompression. The groups were compared with regard to length of hospital stay, length of postoperative ileus, and incidence of adverse effects including nausea, vomiting, and postoperative complications. Statistical analyses were performed with the Student tand χ 2tests. Results.The demographic characteristics of the control ( N= 47) and study groups ( N= 49) were similar, with no significant differences in underlying medical conditions, prior abdominal surgery, or diagnosis of a malignancy. The groups did not vary statistically in the number of subjects who required postoperative antiemetics or postoperative biscodyl suppository. There was a statistically significant reduction in the length of hospitalization for those patients on the early feeding regimen. The average length of stay for group 1 was 4.02 days ± 0.30 (SEM), while that for group 2 was 3.12 days ± 0.16 ( P= 0.008). While there was a significantly higher incidence of emesis in the study population, this was not associated with any untoward outcome, and this group actually tolerated a solid diet nearly one full day earlier (2.72 days ± 0.14 vs 1.88 days ± 0.14, P< 0.0001). Conclusions.Early postoperative oral intake results in a decreased length of hospitalization and is well tolerated when compared with traditional dietary management in patients undergoing abdominal surgery on a university gynecologic oncology service.

Postoperative Epidural Fentanyl Infusion—is the Addition of 0.1% Bupivacaine of Benefit?

A randomised, double-blind controlled clinical trial was conducted in 90 women scheduled for major abdominal gynaecological oncology surgery to determine the effect of adding 0.1% plain bupivacaine to a thoracic epidural fentanyl infusion. Following combined epidural and general anaesthesia, patients were randomised to receive epidural fentanyl 10 μg/ml, with (group FB) or without (group F) bupivacaine. After an initial 50 μg bolus of fentanyl, infusion rate was adjusted according to need between 2 and 10 ml/hr for 48 hours. The two groups (n = 40) were similar with regard to age, weight and preoperative status. Analgesia both at rest and with movement were significantly better in group FB (P &lt;0.0001) during the first 24 hours postoperatively, the greatest difference occurring in the 4 to 16 hour period. There was no significant difference between groups from 24 to 48 hours postoperatively. Fentanyl utilisation was significantly lower in group FB (median 41 versus 53 μg/hr, P &lt;0.001), although clinically the fentanyl dose-sparing effect of bupivacaine was small and did not reduce opioid-induced side-effects. There was no significant difference between groups with respect to side-effects or lower limb weakness, although fewer patients in group FB could be mobilised on the morning of the first postoperative day (P &lt;0.01). Nevertherless, all study patients were ambulant by the same afternoon. We concluded that, in this patient population, the addition of 0.1% bupivacaine to a thoracic epidural fentanyl infusion was beneficial in the early postoperative period.

Comparison of extradural and intravenous diamorphine as a supplement to extradural bupivacaine

The influence of route of administration (extradural as compared with intravenous) of diamorphine 0.5 mg/hour as a supplement to extradural bupivacaine (0.125% at 15 ml/hour) was investigated in two groups of 20 patients who underwent major abdominal gynaecological surgery. Significantly more patients in the intravenous group withdrew because of inadequate analgesia (p less than 0.05). Those in the extradural group were significantly more drowsy throughout the study (p less than 0.01), but no major side effects were encountered.

POSTOPERATIVE ANALGESIA BY CONTINUOUS EXTRADURAL INFUSION OF BUPIVACAINE AND DIAMORPHINE

Three solutions administered by continuous extradural infusion for postoperative analgesia were compared in a randomized, double-blind manner. All patients underwent major abdominal gynaecological surgery and received 0.125% bupivacaine in 0.9% saline, diamorphine in 0.9% saline (0.5 mg in 15 ml) or diamorphine mixed with 0.125% bupivacaine (0.5 mg in 15 ml), at a rate of 15 ml h-1. The bupivacaine-diamorphine mixture provided significantly superior analgesia compared with either bupivacaine or diamorphine alone. No major side effects were encountered.

Epidural meptazinol for pain relief after lower abdominal surgery.

A preliminary investigation is reported into the use of epidural meptazinol for pain relief in 20 patients after major lower abdominal (gynaecological) surgery. Analgesia was rapid in onset (15 minutes), had a median duration of 124 minutes (interquartile range 85-212 minutes) after a single dose of 30 mg and a median duration of 122.5 minutes (interquartile range 70-127 minutes) after a single dose of 60 mg. Overall pain relief, as judged by the patients themselves, was satisfactory in 19 out of the 20 cases. At 30 minutes and 45 minutes pain relief was significantly better with the 60 mg than the 30 mg dose (p less than 0.02). No drug-related adverse effects were observed during the study.