Moderate Postoperative Pain Research Articles

Efficacy and Safety of Percutaneous Epiphysiodesis Operation around the Knee to Reduce Adult Height in Extremely Tall Adolescent Girls and Boys

Objective. The aim was to determine efficacy and safety of a surgical method to reduce adult height in extremely tall adolescents. Methods. Data for all girls (n = 12) and boys (n = 9) in our center subjected to bilateral percutaneous epiphysiodesis around the knee who had reached final height were included. Final height predictions were based on hand and wrist X-rays before surgery. Results. When compared to prediction, adult height was reduced by 4.1 ± 0.7 cm in treated girls (P < .001) and 6.4 ± 0.7 cm in treated boys (P < .001) corresponding to a 33.6 ± 3.4% and 33.6 ± 4.2% reduction of remaining growth, respectively. Besides mild to moderate postoperative pain reported in 9 operated individuals, no other side effects were reported. Postoperative X-rays confirmed growth plate closure and absence of leg angulations. Conclusions. Bilateral epiphysiodesis is an effective and safe method to reduce adult height in extremely tall girls and boys.

Single dose oral rofecoxib for acute postoperative pain in adults.

Editor's note: The anti-inflammatory drug rofecoxib (Vioxx) was withdrawn from the market at the end of September 2004 after it was shown that long-term use (greater than 18 months) could increase the risk of heart attack and stroke in a study of secondary prevention of adenoma recurrence. Further information is available at www.vioxx.com.Rofecoxib is a selective cyclooxygenase-2 (COX-2) inhibitor previously licensed for treating acute and chronic pain; it was associated with fewer gastrointestinal adverse events than conventional NSAIDs. An earlier Cochrane review (Barden 2005) showed that rofecoxib is at least as effective as conventional non-steroidal anti-inflammatory drugs (NSAIDs) for postoperative pain. To assess the analgesic efficacy and adverse effects of rofecoxib in single oral doses for moderate and severe postoperative pain. We searched Cochrane CENTRAL, MEDLINE, EMBASE and the Oxford Pain Relief Database for studies to June 2009. Randomised, double blind, placebo-controlled trials of single dose orally administered rofecoxib in adults with moderate to severe acute postoperative pain. Two review authors independently assessed trial quality and extracted data. Pain relief or pain intensity data were extracted and converted into the dichotomous outcome of number of participants with at least 50% pain relief over 4 to 6 hours, from which relative risk and number needed to treat to benefit (NNT) were calculated. Numbers of participants using rescue medication over specified time periods, and time to use of rescue medication, were sought as additional measures of efficacy. Information on adverse events and withdrawals was collected. Twenty new studies and seven from the earlier review met the inclusion criteria. Twenty-four studies were in dental surgery and three in other types of surgery. In total, 2636 participants were treated with rofecoxib 50 mg, 20 with rofecoxib 500 mg, and 1251 with placebo. The NNT for at least 50% pain relief over 4 to 6 hours with rofecoxib 50 mg was 2.2 (2.0 to 2.3) in all studies combined, 1.9 (1.8 to 2.0) in dental studies, and 6.8 (4.6 to 13) in other types of surgery. The median time to use of rescue medication was 14 hours for rofecoxib 50 mg and 2 hours for placebo. Significantly fewer participants used rescue medication following rofecoxib 50 mg than with placebo. Adverse events did not differ from placebo. Rofecoxib 50 mg (two to four times the standard daily dose for chronic pain) is an effective single dose oral analgesic for acute postoperative pain in adults, with a relatively long duration of action.

Single dose oral ibuprofen for acute postoperative pain in adults.

This review updates a 1999 Cochrane review showing that ibuprofen at various doses was effective in postoperative pain in single dose studies designed to demonstrate analgesic efficacy. New studies have since been published. Ibuprofen is one of the most widely used non-steroidal anti-inflammatory (NSAID) analgesics both by prescription and as an over-the-counter medicine. Ibuprofen is used for acute and chronic painful conditions. To assess analgesic efficacy of ibuprofen in single oral doses for moderate and severe postoperative pain in adults. We searched Cochrane CENTRAL, MEDLINE, EMBASE and the Oxford Pain Relief Database for studies to May 2009. Randomised, double blind, placebo-controlled trials of single dose orally administered ibuprofen (any formulation) in adults with moderate to severe acute postoperative pain. Two review authors independently assessed trial quality and extracted data. Pain relief or pain intensity data were extracted and converted into the dichotomous outcome of number of participants with at least 50% pain relief over 4 to 6 hours, from which relative risk and number-needed-to-treat-to-benefit (NNT) were calculated. Numbers of participants using rescue medication over specified time periods, and time to use of rescue medication, were sought as additional measures of efficacy. Information on adverse events and withdrawals were collected. Seventy-two studies compared ibuprofen and placebo (9186 participants). Studies were predominantly of high reporting quality, and the bulk of the information concerned ibuprofen 200 mg and 400 mg. For at least 50% pain relief compared with placebo the NNT for ibuprofen 200 mg (2690 participants) was 2.7 (2.5 to 3.0) and for ibuprofen 400 mg (6475 participants) it was 2.5 (2.4 to 2.6). The proportion with at least 50% pain relief was 46% with 200 mg and 54% with 400 mg. Remedication within 6 hours was less frequent with higher doses, with 48% remedicating with 200 mg and 42% with 400 mg. The median time to remedication was 4.7 hours with 200 mg and 5.4 hours with 400 mg. Sensitivity analysis indicated that pain model and ibuprofen formulation may both affect the result, with dental impaction models and soluble ibuprofen salts producing better efficacy estimates. Adverse events were uncommon, and not different from placebo. The very substantial amount of high quality evidence demonstrates that ibuprofen is an effective analgesic in treating postoperative pain. NNTs for 200 mg and 400 mg ibuprofen did not change significantly from the previous review even when a substantial amount of new information was added. New information is provided on remedication.

Monitoring electrical skin conductance: a tool for the assessment of postoperative pain in children?

Funding: Princess Margaret Hospital Foundation, Perth, AustraliaThe manuscript has been written and checked according to the STROBE consensus.Objectives: To test whether changes in electrical skin conductance are a suitable tool for the assessment of postoperative pain in paediatric patients.Design: Prospective, blinded observational study.Setting: Recovery room Department of Anaesthesia, Princess Margaret Hospital for Children, Australia.Participants: A total of 180 postoperative paediatric patients aged 1–16 years.Main Outcome Measures: Area under the curve (ROC) for the skin conductance parameter ‘number of fluctuation per second’ (NFSC) to distinguish between no or mild vs moderate or severe postoperative pain (obtained by standard pain scores).Results: Postoperative pain was assessed in 165 children (1–16 years) by standard validated clinical pain assessment tools (Revised Faces Scale, FLACC Scale, Visual Analogue Scale) at various time points during their stay in the recovery room. NFSC was recorded simultaneously. Fifteen patients were excluded due to technical problems with monitoring NFSC. The area under the Receiver Operating Characteristic (ROC) curve for predicting moderate to severe pain from NFSC was 0.82 (95% CI, 0.79–0.85). Over all age groups, a NFSC cut‐off value of 0.13 was found to distinguish between no or mild vs moderate or severe pain with a sensitivity of 90% and a specificity of 64% (positive predictive value 35%, negative predictive value 97%).Conclusion: NFSC accurately predicts moderate to severe pain in postoperative paediatric patients. In this group of patients, the measurement of NFSC may therefore be a useful addition to the presently used, clinical pain assessment tools.Trial Registration: Australian Clinical Trials Register (ACTRN12607000474459)

Factors associated with moderate and severe postoperative pain

Factors associated with moderate and severe postoperative pain

Single minimally invasive surgical technique with an enamel matrix derivative to treat multiple adjacent intra‐bony defects: clinical outcomes and patient morbidity

This case cohort study was designed to evaluate the clinical performance and the intra-operative and post-operative morbidity of the "minimally invasive surgical technique" (MIST) associated with the application of an enamel matrix derivative (EMD) in the treatment of multiple deep intra-bony defects in a single surgical procedure. Forty-four deep intra-bony defects in 20 patients (>or=2 defects/patient) were surgically accessed with the MIST. This technique was designed to limit the mesio-distal flap extension and the apical flap reflection in order to reduce the surgical trauma and increase flap stability. The incision of the defect-associated papilla was performed according to the principles of the papilla preservation techniques. EMD was applied on the debrided and dried root surfaces. Stable primary closure of the flaps was obtained with modified internal mattress sutures. Surgery was performed with the aid of an operating microscope and microsurgical instruments. Clinical outcomes were collected at baseline and at 1 year. Intra-operative and post-operative morbidity was evaluated with questionnaires. The 1-year clinical attachment level (CAL) gain was 4.4+/-1.4 mm (p<0.0001 compared with baseline). Seventy-three per cent of defects showed CAL improvements >or=4 mm. This corresponded to an 83+/-20% resolution of the defect (15 defects were completely filled). Residual probing pocket depths (PDs) were 2.5+/-0.6 mm. A minimal increase of 0.2+/-0.6 mm in gingival recession between baseline and 1 year was recorded. Twelve patients reported a mild perception of the hardship of the surgical procedure. Primary closure was obtained and maintained in all treated sites over time. Only six subjects reported moderate post-operative pain that lasted for 21+/-5 h. These data indicate that a MIST in combination with EMD can be applied successfully for the treatment of multiple deep intra-bony defects in the same surgical procedure with excellent clinical outcomes and very limited patient morbidity.

Diclofenac Sodium Injection (Dyloject®)

*A new formulation of the nonselective NSAID diclofenac sodium suitable for intravenous bolus injection has been developed using hydroxypropyl beta-cyclodextrin as a solubility enhancer (HPbetaCD diclofenac). * HPbetaCD diclofenac intravenous bolus injection was shown to be bioequivalent to the existing parenteral formulation of diclofenac containing propylene glycol and benzyl alcohol as solubilizers (PG-BA diclofenac), which is relatively insoluble and requires slow intravenous infusion over 30 minutes. * Single-dose HPbetaCD diclofenac 3.75, 9.4, 18.75, 25, 37.5, 50 and 75 mg administered by intravenous bolus injection produced significantly greater responses than placebo for total pain relief (TOTPAR) over 6 hours or pain intensity at 4 hours in the treatment of moderate or severe postoperative dental pain in randomized, double-blind trials. HPbetaCD diclofenac 37.5 and 75 mg were similar in efficacy to intravenous bolus ketorolac 30 mg. * In a well controlled trial, single-dose HPbetaCD diclofenac 75 mg intravenous bolus injection was shown to be superior to PG-BA diclofenac 75 mg intravenous infusion with respect to TOTPAR over 4 hours, indicating faster onset of analgesia in the treatment of moderate or severe postoperative dental pain. Both HPbetaCD diclofenac and PG-BA diclofenac were superior to placebo. * HPbetaCD diclofenac was generally well tolerated during single-dose treatment of postoperative pain. The tolerability profile was similar to that of PG-BA diclofenac, but with a lower incidence of thrombophlebitis.

The Use of Brain Positron Emission Tomography to Identify Sites of Postoperative Pain Processing With and Without Epidural Analgesia

It is not known how different analgesic regimes affect the brain when reducing postoperative pain. We performed positron emission tomography (PET) scans on a 69-yr-old woman in the presence of moderate postoperative pain and then with epidural analgesia producing complete analgesia, during the first 2 days after total knee arthroplasty. Day 2 postsurgery PET scan data (no pain with epidural analgesia) were subtracted from Day 1 postsurgery PET scan data (time of moderate pain without epidural analgesia) to determine the brain regions activated. Postsurgical pain was associated with increased activity in the contralateral primary somatosensory cortex. Other brain regions showing increased postsurgical activity were the contralateral parietal cortex, bilateral pulvinar and ipsilateral medial dorsal nucleus of the thalamus, contralateral putamen, contralateral superior temporal gyrus, ipsilateral fusiform gyrus, ipsilateral posterior lobe, and contralateral anterior cerebellar lobe. This study demonstrates the feasibility of evaluating the central processing of acute postoperative pain using PET.

Minimally invasive surgical technique and enamel matrix derivative in intra‐bony defects. I: clinical outcomes and morbidity

This case cohort study was designed to evaluate the clinical performance and the intra-operative and post-operative morbidity of the minimally invasive surgical technique (MIST) associated with the application of an enamel matrix derivative (EMD) in the treatment of isolated deep intra-bony defects. Forty deep isolated intra-bony defects in 40 patients were surgically accessed with the MIST. This technique was designed to limit the mesio-distal flap extension and the corono-apical flap reflection in order to reduce the surgical trauma and increase flap stability. The incision of the defect-associated papilla was performed according to the principles of the papilla preservation techniques. EMD was applied on the debrided and dried root surfaces. Stable primary closure of the flaps was obtained with modified internal mattress sutures. Surgery was performed with the aid of an operating microscope and microsurgical instruments. Clinical outcomes were collected at baseline and at 1 year. Intra-operative and post-operative morbidity was evaluated with questionnaires. The 1-year clinical attachment gain was 4.9+/-1.7 mm (p<0.0001 compared with baseline). This corresponded to a 77.6+/-21.9% resolution of the defect. Residual probing pocket depths were 3+/-0.6 mm. A minimal increase of 0.4+/-0.7 mm in gingival recession between baseline and 1 year was recorded. No patients experienced intra-operative pain, while only 14 reported a very moderate perception of the hardship of the surgical procedure [7+/-12 visual-analogue scale (VAS) units, on average]. Primary closure was obtained in all treated sites. At the 1-week follow-up visit, 38 sites (95%) were still closed. Only 12 subjects reported moderate post-operative pain (VAS 19+/-10) that lasted for 26+/-17 h. These data indicate that the minimally invasive surgical technique, in combination with EMD, can be successfully applied in the treatment of isolated deep intra-bony defects, resulting in excellent clinical outcomes with very limited intra- and post-operative morbidity.

Synergistic interaction between dexamethasone and tramadol in a murine model of acute visceral pain

Tramadol is effective in the management of mild to moderate postoperative pain, but its administration is associated with nausea and vomiting. Patients treated with tramadol, often receive dexamethasone as antiemetic. The aim of our investigation was to assess if the two drugs interact in a murine model of acute visceral pain. Using the acetic acid writhing test in mice, we assessed the antinociceptive effects of tramadol and dexamethasone (a glucocorticoid with antiemetic effect) administrated individually and in a 1 : 1 fixed ratio combination. Tramadol and dexamethasone induced a dose-dependent inhibition of the writhing response when administered individually, with ED(50) values of 2.9 [2.09-4.31, 95% confidence limit (CL)] mg/kg, and 0.13 (0.05-0.29, 95% CL) mg/kg, respectively. The ED(50) of the combination was 0.13 (0.01-0.29, 95% CL) mg/kg; the isobolographic and interaction index analysis revealed a synergistic interaction. The results suggest that the combination of tramadol and dexamethasone could be beneficial in the management of postoperative pain in humans.

Nimesulide in the Treatment of Postoperative Pain: A Double-blind, Comparative Study in Patients Undergoing Arthroscopic Knee Surgery

To evaluate the efficacy and tolerability of nimesulide in the relief of postoperative pain after orthopedic surgery compared with naproxen and placebo. In this multicenter, double-blind, double-dummy, randomized, parallel group study, 94 patients with at least moderate postoperative pain after arthroscopy and meniscectomy were randomized to receive nimesulide 100 mg b.i.d., naproxen 500 mg b.i.d., or placebo for a maximum of 3 days. Nimesulide was significantly more effective than placebo for the treatment of postoperative pain, as measured by the primary efficacy variable of summed pain intensity difference within 6 hours after first treatment (10.91 vs. 6.29). Furthermore, nimesulide also provided significantly better pain relief than naproxen on this parameter. Overall, nimesulide demonstrated superior analgesic activity compared with naproxen and placebo for the majority of secondary efficacy variables. All 3 treatments were well tolerated, with a lower number of patients reporting adverse events in the nimesulide group. Nimesulide recipients reported no gastrointestinal disorders. This study demonstrates that nimesulide is an effective, fast-acting and well-tolerated oral anti-inflammatory drug with a distinct analgesic activity after out-patient orthopedic surgery.

Intra-Articular Morphine 5 mg After Knee Arthroscopy Does Not Produce Significant Pain Relief When Administered to Patients With Moderate to Severe Pain via an Intra-Articular Catheter

Intra-articular (IA) morphine for postoperative analgesia after knee arthroscopy is controversial. The IA catheter technique for test drug administration allows baseline pain assessment before inclusion. Results from one such randomized controlled trial (RCT) in patients with moderate to severe pain have shown equal effects of IA saline with or without morphine 2 mg. However, the IA catheter technique may have an unintended placebo effect. The aims of this placebo-controlled RCT were (1) to compare the analgesic effect of IA saline 1 mL (placebo) with morphine 5 mg given through an IA catheter and (2) to analyze the impact on pain of immediate or delayed removal of the IA catheter. Sixty patients operated under general anesthesia had an IA catheter inserted at the end of arthroscopy. Patients who reported moderate or severe postoperative pain during the following hour were randomized to IA saline 1 mL (placebo) or IA morphine 5 mg and to immediate or delayed removal of IA catheter. Forty of 60 patients (67%) developed moderate to severe pain within 1 hour. In addition, 5 patients experienced intolerable pain and were excluded. Significantly more women (24/26) than men (26/39) reported at least moderate pain (P = .018) during the first hour after surgery. There were no differences between IA morphine 5 mg and placebo in pain intensity or pain relief at any time during the 48-hour observation period. There was no detectable effect on pain intensity of early compared with late removal of the IA catheter. IA morphine 5 mg does not produce clinically significant pain relief in patients with moderate or severe pain after knee arthroscopy.

ANALGESIA

Pain following tonsillectomy in childrenis a significant problem that tends to be underestimated. Nonsteroidal anti-inflammatory drugs are effective in themanagement of mild to moderate post-operative pain in children. They can decrease or even eliminate the need foropioid analgesia, thus reducing the opioid-induced side effects. In this study, I used paracetamol alone and acombination of paracetamol with either mefenamic acid or ibuprofen and examined the analgesia produced by all thesethree regimens by using Wong and Baker facial pain scale. Patients and method: The study comprised of three groupsA, B, and C (50 patients in each group selected by non probability convenient method and randomly divided). Analgesiawas achieved in group A with paracetamol 20mg/kg, with paracetamol 20mg/kg plus mefenamic acid 10mg/kg in groupB and paracetamol 20mg/kg plus ibuprofen 5mg/kg in group C orally in syrup form. Post-operative pain was assessedby Wong &amp; Baker faces pain scale at recovery, 4, 8, 12 and 24 hours. Supplementary analgesia was given with oralmefenamic acid (10 mg/kg) in-group B and ibuprofen (5mg/kg) in-group C; otherwise regular oral paracetamol (20mg/kg-6 hourly) was given routinely in all three-study groups post-operatively. Results: Pain score was significantlyhigher in paracetamol group as compared to mefenamic acid or ibuprofen groups (P&lt;0.05), however there was nosignificant difference in pain scores between mefenamic acid and ibuprofen groups. Conclusion: Although there is stillneed for improving analgesia for tonsillectomy pain in children but I can acclaim that a combination of mefenamic acidor ibuprofen with paracetamol is still the most useful, cheap and safe strategy in children, which avoids all opioids sideeffects.

The Exploration of the Establishment of Cutpoints to Categorize the Severity of Acute Postoperative Pain

Although several studies have established different cutpoints (CPs) for mild, moderate, and severe pain for a variety of chronic pain conditions, only one study by Mendoza and colleagues reported on CPs for acute postoperative pain that were derived using ratings of worst pain. The purpose of this study was to explore the establishment of the optimal CPs for mild, moderate, and severe postoperative pain using ratings of average and worst pain and to determine if these CPs distinguished among the pain severity groups on several outcomes. The study is a reanalysis of data from patients who underwent hip and knee replacement surgery. Using the methodology described by Serlin et al, a series of CP derivations were performed based on both single item scores for pain intensity and mean scores for pain intensity. One-way analyses of variance, chi analyses, or Kruskal-Wallis tests were conducted to determine if the optimal CPs for pain severity distinguished among the 3 pain severity groups on several outcomes. CPs 3,5 were found using a mean score based on patients' ratings of average and worst pain on the third postoperative day. Findings suggest that mean pain scores of >3 have a significant effect on general activity, mood, walking ability, and sleep. Possible explanations for the differences in the CPs found in this study compared with the results by Mendoza and colleagues are discussed. The findings warrant replication in other samples of postoperative patients.

Rofecoxib 50 mg and valdecoxib 20 or 40 mg in adults and adolescents with postoperative pain after third molar extraction: Results of two randomized, double-blind, placebo-controlled, single-dose studies

Objective: These studies assessed the comparative efficacy of rofecoxib and valdecoxib in the treatment of acute postoperative dental pain. Methods: Two randomized, double-blind, placebocontrolled, single-dose studies were conducted in patients undergoing extraction of ≥2 third molars, with ≥1 mandibular impaction, who experienced moderate or severe pain after extraction. In study 1, patients were randomized in a 4:4:1 ratio to receive rofecoxib 50 mg, valdecoxib 20 mg, or placebo. In study 2, which was an exploratory study, patients were randomized in a 2:2:1 ratio to receive reofecoxib 50 mg, valdecoxib 40 mg, or palcebo. The primary efficacy end point was total pain relief at 12 hours (TOPAR12) for rofecoxib compared with valdecoxib 20 mg (study 1) or valdecoxib 40 mg (study 2). Tolerability was assessed based on clinical adverse experiences (AEs) and vital signs. These studies were performed before both agents were withdrawn from the market. Results: In study 1, 200 patients were randomized to receive rofecoxib 50 mg, 201 to valdecoxib 20 mg, and 49 to placebo. In study 2, 51 patients were randomized to receive rofecoxib 50 mg, 50 to valdecoxib 40 mg, and 24 to placebo. The majority of patients in both studies were female (∼54%) and white (∼66%), with a mean age of ∼22 years and a mean weight of ∼75 kg. Most (∼58%) patients reported experiencing moderate postoperative pain. In study 1, mean TOPAR12 scores were 30.7 for rofecoxib 50 mg, 28.9 for valdecoxib 20 mg, and 5.5 for placebo; in study 2, TOPAR12 scores were 27.0 for rofecoxib 50 mg, 28.6 for valdecoxib 40 mg, and 6.9 for placebo. In both studies, the active treatments were comparable in terms of the primary end point and were statistically superior to placebo ( P<0.001). In study 1, rofecoxib was associated with a longer median time to use of rescue medication compared with valdecoxib 20 mg (>24 hours vs 23 hours 58 minutes; P=0.010) and a significantly smaller proportion of patients using rescue medication over 24 hours (35.0% vs 50.2%; P<0.001). In study 2, there were no significant differences in the median time to use of rescue medication or the proportion of patients using rescue medication between active treatments. There were no significant differences in total pain relief at 4 or 8 hours, patients' global assessment, onset of analgesia, or EAs between active treatments in either study. The incidence of clinical AEs in study 1 was similar for rofecoxib 50 mg, valdecoxib 20 mg, and placebo (39.5%, 36.8%, and 49.0%, respectively). In study 2, AEs occurred significantly less frequently with rofecoxib 50 mg compared with placebo (35.3% vs 70.8%, respectively; P<0.01); there was no significant difference between the rate of AEs with valdecoxib 40 mg (50.0%) and placebo. Conclusions: Rofecoxib 50 mg had comparable analgesic efficacy to valdecoxib 20 and 40 mg in these patients with pain after dental surgery. All active treatments were well tolerated.

A prospective randomised single blinded study comparing harmonic scalpel tonsillectomy with bipolar tonsillectomy

To compare the differences in pain, analgesic use and bleeding in children after tonsillectomy using either a harmonic scalpel or a bipolar diathermy surgical technique. Children 6-15 years presenting for tonsillectomy were randomised to either a harmonic scalpel or bipolar diathermy surgical technique. Post-operative pain scores (VAS, 0-10) were recorded within 30 min of surgery and again at the 4h hospital discharge. A subsequent telephone interview daily for 7 days and then every second day until day 13 was used to monitor pain scores, analgesic use and tonsil bed bleeding. There were 204 children studied. The response rate over the first 7 days was 93% for the children in the harmonic scalpel group and 87% for the bipolar group. Children experienced moderate post-operative pain for the first 6 days, after which pain declined from 4-7 to reach a score of 1-2 by day 11. Children undergoing harmonic scalpel tonsillectomy (n=103) reported higher mean pain scores than those who underwent bipolar diathermy (n=101) for current pain (4.7 versus 4.2, p=0.002), worst pain of the day (6.9 versus 6.2, p<0.001) and pain on swallowing (5.9 versus 5.2, p<0.001) over the first 6 post-operative days. Analgesic use (acetaminophen, ibuprofen) was similar in both groups. Hospital readmission for bleeding in children who underwent harmonic scalpel was similar to those who underwent bipolar diathermy tonsillectomy (9% versus 11%) as was bleeding requiring surgical re-exploration (4% versus 2%). Tonsillectomy was associated with considerable pain for the first 6 post-operative days. Children undergoing harmonic scalpel tonsillectomy had a slight increase in pain compared to the bipolar diathermy group during this time. Both methods of tonsillectomy are effective and safe.

Optimizing Patient Selection and Outcomes with Total Hip Resurfacing

Short-term failures of total hip resurfacing have been related to specific characteristics of the proximal femur. A radiographic arthritic hip grading scale was used to assess four characteristics of the proximal femur: bone density, shape, biomechanics, and focal bone defects. Hips with no unfavorable characteristics were Grade A, hips with one unfavorable characteristic were Grade B, hips with two unfavorable characteristics were Grade C, hips with three unfavorable characteristics were Grade D, and hips with four unfavorable characteristics were Grade F. One hundred forty-seven consecutive hips were treated with metal-on-metal resurfacing by a single surgeon. There were no femoral neck fractures. Of the 91 hips eligible for a minimum 2 year followup, 90% were Grades A or B, 10% were Grade C, and none were Grades D or F. With a minimum 2-year followup, arthritic hip grading was associated with preoperative Harris hip score, occurrence of mild to moderate postoperative pain, preoperative and postoperative range of motion, preoperative and postoperative hip center of rotation, preoperative and postoperative horizontal femoral offset, preoperative and postoperative limb length discrepancy, and acetabular radiolucencies. Hips with a lesser degree of secondary arthritic changes have a higher arthritic hip grade and better outcomes with total hip resurfacing. Relatively strict selection criteria for resurfacing were associated with a low occurrence of short-term failures. Prognostic study, Level II (retrospective study). See the Guidelines for Authors for a complete description of levels of evidence.

Efficacy Of Phenytoin Sodium In The Management Of Post Operative Pain

Postoperative pain in three groups of Nigerian patients, comprising 15 cases each of minor, intermediate and major surgical operations, was treated with phenytoin sodium, dihydrocodeine and paracetamol respectively. The aim of the study was to determine the efficacy of phenytoin sodium as a postoperative analgesic agent. Analgesia was assessed using the results of verbal rating scale scores namely, PID (pain intensity difference), SPID (sum of pain intensity difference) and TOTPAR (total pain relief) and a modified global rating scale. The results showed phenytoin sodium to be superior to paracetamol in the treatment of all grades of postoperative pain. It was equipotent to dihydrocodeine in mild and moderate pain, while dihydrocodeine was superior in severe pain. It is concluded that Phenytoin sodium is an efficacious analgesic agent in mild to moderate postoperative pain. Key words: Pain; Analgesia; Postoperative Nigerian Journal of Physiological Sciences Vol.18(1-2) 2003: 72-76

Analgesic effects of intranasal butorphanol tartrate administered via a unit-dose device in the dental impaction pain model: A randomized, double-blind, placebo-controlled, parallel-group study

Background: Butorphanol tartrate (BT) nasal spray is currently marketed as a multidose spray pump product. However, access to excessive amounts of drug in a single bottle (up to 15 doses) creates the potential for misuse, diversion, and abuse. Objective: This study evaluated the efficacy and tolerability of a sterile, unpreserved BT nasal spray administered via a unit-dose device in the treatment of moderate to severe pain after dental impaction surgery. Methods: This was a single-site, single-dose, randomized, double-blind, placebo-controlled, parallel-group pilot study of unit-dose BT nasal spray 1 and 2 mg compared with vehicle in patients who received standard anesthesia and underwent surgery to remove impacted third molars. When patients reported experiencing moderate or severe postoperative pain, they were assigned to receive the respective treatments in a 2:2:1 ratio. Patients rated pain intensity and pain relief and performed other assessments of analgesic efficacy before dosing and at 0.25, 0.5, 0.75, 1, 1.25, 1.5, 1.75, 2, 3, 4, and 6 hours after receipt of study medication. They could request rescue medication from 1 hour after the administration of nasal spray. The primary efficacy variables were summed pain intensity difference (SPID) at 2, 4, and 6 hours after administration of study medication and total pain relief at 6 hours (TOTPAR-6). Vital signs, pulse oximetry, and adverse events were monitored on the same schedule as pain assessments. Results: Thirty men and 30 women were enrolled (mean [SD] age, 22.5 [3.8] years; mean body weight, 168 [41.3] lb) and completed the trial. Pain relief was recorded in most patients within 15 minutes of receiving active treatment. A dose response was observed in SPID scores, with the 2-mg dose of BT providing the greatest response compared with placebo ( P < 0.05). Overall, 52 (86.7%) patients requested rescue medication: 22 of 24 (91.7%) in the 1-mg group, 19 of 24 (79.2%) in the 2-mg group, and 11 of 12 (91.7%) in the placebo group. The time to use of rescue medication occurred a median of 75 to 110 minutes after nasal spray dosing. The analysis of TOTPAR-6 showed no significant differences overall or in pairwise comparisons. On the global assessment, 58.3% of patients in each of the active-treatment groups and 83.3% of patients in the placebo group evaluated the study drug as “poor.” The unit-dose BT nasal spray was well tolerated, with central nervous system adverse effects being most common in the active-treatment groups compared with placebo ( P = 0.029). Dizziness occurred in 11 (45.8%) patients who received BT 1 mg, 14 (58.3%) who received BT 2 mg, and 4 (33.3%) who received placebo; for headache, the corresponding numbers were 11 (45.8%), 7 (29.2%), and 2 (16.7%). There were no significant changes from baseline in vital signs, pulse oximetry, reported nasal irritation, or pathology (eg, irritation, epistaxis, ulceration). Conclusions: In this small pilot study, sterile BT nasal spray administered via a unit-dose device provided effective postsurgical analgesia in approximately half of patients who had undergone surgery to remove impacted third molars. The results are similar to those of previous studies of BT nasal spray administered via multidose pump for postsurgical analgesia in the dental impaction pain model. The outcomes of this study are limited to the population studied.

Risk factors for bacterial catheter colonization in regional anaesthesia

BackgroundAlthough several potential risk factors have been discussed, risk factors associated with bacterial colonization or even infection of catheters used for regional anaesthesia are not very well investigated.MethodsIn this prospective observational trial, 198 catheters at several anatomical sites where placed using a standardized technique. The site of insertion was then monitored daily for signs of infection (secretion at the insertion site, redness, swelling, or local pain). The catheters were removed when clinically indicated (no or moderate postoperative pain) or when signs of potential infection occurred. After sterile removal they were prospectively analyzed for colonization, defined as > 15 colony forming units.Results33 (16.7%) of all catheters were colonized, and 18 (9.1%) of these with additional signs of local inflammation. Two of these patients required antibiotic treatment due to superficial infections. Stepwise logistic regression analysis was used to identify factors associated with catheter colonization. Out of 26 potential factors, three came out as statistically significant. Catheter placement in the groin (odds-ratio and 95%-confidence interval: 3.4; 1.5–7.8), and repeated changing of the catheter dressing (odds-ratio: 2.1; 1.4–3.3 per removal) increased the risk for colonization, whereas systemic antibiotics administered postoperatively decreased it (odds ratio: 0.41; 0.12–1.0).ConclusionColonization of peripheral and epidural nerve catheter can only in part be predicted at the time of catheter insertion since two out of three relevant variables that significantly influence the risk can only be recorded postoperatively. Catheter localisation in the groin, removal of the dressing and omission of postoperative antibiotics were associated with, but were not necessarily causal for bacterial colonization. These factors might help to identify patients who are at increased risk for catheter colonization.