Need For Supplemental Analgesia Research Articles

Analgesia for the treatment of acute pancreatitis: a protocol for a systematic review and network meta-analysis

IntroductionGastrointestinal hospitalisations in the USA cause over US$130 billion in expenditures, and acute pancreatitis is a leading cause of these hospitalisations. Adequate pain control is one of the primary treatment...

The preventive effect of dexmedetomidine on anesthesia complications in strabismus surgery: a systematic review and meta-analysis

ObjectiveDexmedetomidine is a medication that has analgesic, sedative, and anti-anxiety properties. In the clinical, it is often used to prevent common complications associated with strabismus surgery, including postoperative delirium, postoperative nausea and vomiting, postoperative pain, and oculocardiac reflex. However, its effectiveness and side effects of the present studies are different. The sample sizes of the present studies on the prevention of complications of dexmedetomidine are small. Therefore, this study evaluates the efficacy of dexmedetomidine in preventing anesthesia-related complications in strabismus surgery through a systematic review and meta-analysis.MethodsLiterature was retrieved from 10 commonly used databases and randomized controlled trials published up to May 2022 were sought. The included studies compared the intervention effects of dexmedetomidine versus placebo on anesthesia-related complications in surgery. The occurrence rates of postoperative delirium, postoperative nausea and vomiting, postoperative pain, and oculocardiac reflex in patients undergoing strabismus surgery were evaluated. Statistical analyses and forest plots were generated using Review Manager and STATA software. Binary outcomes were measured using relative risk (RR) with a 95% confidence interval for each outcome. The Cochrane risk of bias tool was used to assess the bias and risk in the studies that met the inclusion criteria.ResultsA total of 13 articles were ultimately included in the analysis, comprising 1,018 patients who underwent strabismus surgery. The dexmedetomidine group, compared to the placebo group, demonstrated significant reductions in the incidence of postoperative delirium (RR = 0.73, P = 0.001), severe postoperative delirium (RR = 0.45, P = 0.005), postoperative nausea and vomiting (RR = 0.48, P < 0.0001), and the need for supplemental analgesia postoperatively (RR = 0.60, P = 0.004). Additionally, subgroup analysis revealed that intravenous administration of dexmedetomidine significantly reduced the incidence of oculocardiac reflex (RR = 0.50, P = 0.001). In contrast, intranasal administration of dexmedetomidine did not have a significant effect on the incidence of oculocardiac reflex (RR = 1.22, P = 0.15). There was a significant difference between the subgroups (P = 0.0005, I2 = 91.7%).ConclusionAmong patients undergoing strabismus surgery, the use of dexmedetomidine can alleviate postoperative delirium and reduce the incidence of postoperative nausea and vomiting, as well as postoperative pain. Moreover, intravenous administration of dexmedetomidine can lower the occurrence rate of the oculocardiac reflex.

Fixed Dose versus Height-Adjusted Conventional Dose of Intrathecal Hyperbaric Bupivacaine for Caesarean Delivery: A Prospective, Double-Blinded Randomised Trial.

The optimal intrathecal dose of local anaesthetic for caesarean section (CS) anaesthesia is still being debated. We performed a study to compare the effectiveness and safety of spinal anaesthesia with 12.5 mg of hyperbaric bupivacaine and a dosing regimen of conventional doses adjusted to parturient height. One hundred and forty parturients scheduled for elective CS were enrolled. The fixed-dose group (FD) received a spinal block with 12.5 mg of hyperbaric bupivacaine with fentanyl, whereas the adjusted-dose group (AD) received a height-adjusted dose of bupivacaine (9–13 mg) with fentanyl. Sensory block ≥ T5 dermatome within 10 min and no need for supplementary analgesia were set as the composite primary outcome (success). Rates of successful blocks and complications were compared. Complete data were available for 134 cases. Spinal anaesthesia was successful in 58 out of 67 patients in the FD group and 57 out of 67 in the AD group (p > 0.05). Eight spinals in each group failed to produce a block ≥ T5 in 10 min, and one patient in the FD group and two in the AD group required i.v. analgesics despite sensory block ≥ T5. No differences were noted in terms of hypotension, bradycardia and nausea between the FD and AD groups. Compared to the height-adjusted dose regimen based on conventional doses of hyperbaric bupivacaine, the fixed dose regimen of 12.5 mg was equally effective and did not increase the risk of spinal block-related complications.

Patient satisfaction with intravenous regional anaesthesia or an axillary block for minor ambulatory hand surgery: A randomised controlled study.

Intravenous regional anesthesia (IVRA) and the axillary brachial plexus block are popular alternatives to general anaesthesia in ambulatory hand surgery. Although both have proven their effectiveness, patients' preferences have never been evaluated. We investigated patient satisfaction with both techniques and hypothesised that satisfaction after IVRA is noninferior compared with axillary brachial plexus block. A prospective, randomised controlled trial. Ambulatory surgical day care centre, University Hospitals of Leuven, Belgium, from September 2016 to November 2017. One hundred and twenty adults undergoing minor ambulatory hand surgery were included in this study. Patients received either IVRA with 300 mg lidocaine or an axillary block with 280 mg mepivacaine. The primary endpoint was the evaluation of patient satisfaction using the 'Evaluation du Vécu de l'Anésthesie Locoregional' (EVAN-LR) questionnaire. Secondary outcomes included different procedural times, block quality, tourniquet discomfort, the incidence of block failure and postoperative nausea and vomiting (PONV), the severity of postoperative pain and the need for postoperative analgesics during the first 24 h. Noninferiority of IVRA was shown for the median [IQR] total score on the EVAN-LR questionnaire, IVRA-group: 92 [87 to 96] vs. axillary brachial plexus block-group: 91[87 to 97]; Hodges--Lehmann estimator (95% confidence interval (CI)] for the shift: -0.25 (-2.60 to 2.20). Induction of anaesthesia and time to discharge, requiring partial recovery of the motor block, were significantly longer in the axillary brachial plexus block group. The IVRA-group had a lower block quality, a higher incidence of tourniquet-discomfort and higher median intra-operative and postoperative pain scores on day 0; 0 [0 to 2] vs. 0 [0 to 0] and 0.8 [0 to 1.8] vs. 0 [0 to 0.25], respectively, but no increase in the need for supplementary analgesics or conversion rate to general anaesthesia. IVRA and axillary brachial plexus block result in comparably high patient satisfaction in ambulatory hand surgery. EudraCT 2016-002325-11.

Evaluation of the Efficacy of Prolonged Pregabalin Administration Before and After Surgery in Patients Undergoing Arthroscopic Anterior Cruciate Ligament Repair: A Prospective, Randomized, Double-blind Study.

Reconstruction of the knee ligament causes postoperative pain and delayed rehabilitation. The primary objective of this study was to evaluate the effect of a prolonged preoperative and postoperative pregabalin use for arthroscopic anterior cruciate ligament repair. Group 1 (N=25) patients received pregabalin 75 mg/d, and group 2 (N=25) received placebo, 7 days before and 7 days after surgery. Spinal anesthesia was performed using 0.5% hyperbaric bupivacaine (15 mg). The following were evaluated: pain intensity immediately after the surgery, and 12 hours, 24 hours, 1 week, 2 weeks, 1 month, and 2 months after the surgery using a Numerical Rating Scale; dose of postoperative supplementary analgesic for 2 months; time to first analgesic requirement; and side effects during 2 months. For supplementation, the participants received 1 g dipyrone; if there was no pain control, 100 mg ketoprofen was administered; if there was no effect, 100 mg tramadol was administered; and if there was no pain control, 5 mg intravenous morphine was administered until pain control. There was no difference between the groups with regard to pain intensity (P=0.077). In the pregabalin group, morphine consumption was lower at 12 hours (P=0.039) and 24 hours (P=0.044) after surgery, and the consumption of tramadol and ketoprofen was lower 24 hours after surgery. There was no significant difference in the incidence of nausea and vomiting. Dizziness was higher in the pregabalin group (group 1=12 patients; group 2=3 patients; P=0.005). A prolonged preoperative and postoperative pregabalin prescription for anterior cruciate ligament repair decreased the need for supplementary analgesics during the first 24 postoperative hours but increased dizziness.

Ultrasound-guided popliteal sciatic nerve block: an effective alternative technique to control ischaemic severe rest pain during endovascular treatment of critical limb ischaemia.

PurposeThere are challenges with pain management related to a severely ischaemic limb. Although opioid-based treatment has been the cornerstone of pain relief, the use of these drugs should be limited because of their side effects in such vulnerable patients. We evaluated the utility and efficiency of sciatic nerve block as an alternative method to relieve severe rest pain during endovascular treatment of critical limb ischaemia.Material and methodsWe retrospectively investigated 10 patients who received ultrasound-guided popliteal sciatic nerve block for the relief of severe rest pain during endovascular treatment of critical limb ischaemia. The degree of pain relief was evaluated by using subjective criteria, from no relief of pain (= 1) to complete relief of pain (= 4). Details of endovascular treatment, time to perform the block, amount of local anaesthetics, duration of the block, need for supplemental analgesia, patient and operator satisfaction, and complications were recorded.ResultsAll blocks were technically successful, and all of the patients had complete resolution of the pain within five minutes. The degree of pain relief was 3 in two patients and 4 in eight patients. All patients were satisfied with the block anaesthesia, and no patient required additional analgesia during this period. Operator satisfaction was very good in all cases. Complications secondary to block did not occur in any patient.ConclusionsUltrasound-guided popliteal sciatic nerve block provides effective pain control, which results in excellent patient and operator satisfaction during endovascular treatment of critical limb ischaemia with severe rest pain.

Levobupivacaine Thermogel for Long-acting Analgesia.

The adequate management of analgesia, by pharmacological methods or not, is a great challenge. Local anesthetics are used for pain relief, mainly by parenteral, intramuscular, catheter, and other routes of administration. The use of in situ forming systems becomes an alternative for the control of pain. The present research investigates development of thermogels containing poloxamer and levobupivacaine. All formulations were prepared by the cold method; the compatibilities of the excipients were evaluated by DSC, rheology and viscosities, transition temperature, syringeability, release kinetics, and permeation. The compatibility of the tested excipients with the drug was initially observed; all formulations had a viscosity increase at 37°C. Different delivery rates were observed in both the release and permeation studies. The developed systems maintained the in vitro release of the drug for a long period, likely decreasing side effects in vivo and avoiding the need for supplementary analgesia by other routes.

Sublingual sufentanil tablet system Zalviso\xae for postoperative analgesia after knee replacement in fast track surgery: a pilot observational study

BackgroundCurrently many TKA protocols rely on multimodal analgesic protocols with patient-controlled analgesia systems that administer opioids through a patient controlled IV infusion pump, in addition to concomitant peripheral nerve blocks and local anesthetics. Although effective, PCA IV opioids do not provide optimal results with fast track rehabilitation protocols.MethodsThe present is a retrospective study comparing the novel sublingual sufentanil PCA system (SSTS) to our standard of care foreseeing continuous femoral nerve block (cFNB) within a multimodal analgesic in a TKA fast-track protocol. The study evaluated 95 patients on SSTS (SSTS group) and 87 on cFNB (cFNB/control group) and collected data on numeric rating scores for pain from day 1–3 after surgery (T1, T2, T3), both at rest (NRS) and during movement (mNRS), patient’s ability to walk, need for supplementary analgesia (rescue dose), occurrence of adverse effects, length of hospital stay, and usability rating for SSTS by both patients and hospital staff.ResultsNRS at rest was lower in the cFNB than in the SSTS group for all 3 days after surgery, whereas mNRS scores were lower in the SSTS group at all time points measured. Adverse effects were significantly fewer among patients of the SSTS group (6% patients) than those of the cFNB (74% patients) (p < 0.001). Rescue doses were needed by 5% of SSTS patients vs 60% of cFNB. The fewer adverse events and lower pain scores for the SSTS group were associated to a notably better ability to ambulate, with all patients (100%) of the SSTS group being able to stand and walk for 10 m from T1 on; patients in the cFNB group showed a slower recovery with only 40% being able to stand and walk on T1, 70% on T2 and 85% on T3. All patients of the SSTS group had a length of stay of 4 days (day of surgery plus 3 after) as foreseen by the fast track protocol, in comparison only 36% of cFNB. Lastly, patient and nursing staff judged SSTS easy to use.ConclusionOur experience suggests that SSTS is a valuable strategy for routine postoperative analgesia following TKA in the context of a multimodal analgesic approach within the fast-track setting.

Effect of Dexmedetomidine as an Adjuvant to Ropivacaine in Ilioinguinal-Iliohypogastric Nerve Blocks for Inguinal Hernia Repair in Pediatric Patients: A Randomized, Double-Blind, Control Trial.

Background:Bulk of published data support the efficacy of dexmedetomidine for prolongation of peripheral nerve block; but most of the studies are in adults. Ample data regarding use of dexmedetomidine in setting of paediatric peripheral nerve blocks is scarce.Aim and Objective:To determine whether adding dexmedetomidine to ropivacaine in ilioinguinal-iliohypogastric nerve block prolongs postoperative analgesia in children undergoing inguinal hernia repair.Material and Methods:Sixty children of American Society of Anesthesiologist (ASA) grade I – II aged between 2-11 years scheduled for elective hernitomy were randomly allocated to receive an ultrasound guided ilioinguinal-iliohypogastric nerve block (IINB) with 0.2 ml/kg dose of plain ropivacaine 0.2% (group R; n = 30) or ropivacaine 0.2% with adjunct dexmedetomidine 1 μg/kg (group RD; n = 30). Time to first post-operative need for supplemental analgesia triggered by pain score ≥4 according to Children's and infants postoperative pain scale (CHIPPS scale) was the primary end point of study. Number of analgesic doses during first 24 hours; intraoperative hemodynamic changes; sedation; postoperative adverse effects were noted.Results:The mean duration of analgesia was significantly prolonged in group RD (970.23 ± 46.71minutes) as compared to group R (419.56 ± 60.6 minutes). Children in group RD had significantly lower CHIPPS score, and less number of rescue analgesic requirements during first 24 hours postoperatively. No adverse effects were recorded in any group.Conclusion:The present study concluded that combined use of ropivacaine and dexmedetomidine in IINB provided profound prolongation of post operative analgesia in children following inguinal hernia repair.

Hyperbaric vs. isobaric bupivacaine for spinal anaesthesia for elective caesarean section: a Cochrane systematic review.

Both isobaric and hyperbaric bupivacaine have been used for spinal anaesthesia for elective caesarean section, but it is not clear if one is better than the other. The primary objective of this systematic review was to determine the effectiveness and safety of hyperbaric bupivacaine compared with isobaric bupivacaine administered during spinal anaesthesia for elective caesarean section. We included 10 studies with 614 subjects in the analysis. There was no evidence of differences either in the risk of conversion to general anaesthesia, with a relative risk (95%CI) of 0.33 (0.09-1.17) (very low quality of evidence), or in the need for supplemental analgesia, the relative risk (95%CI) being 0.61 (0.26-1.41) (very low quality of evidence). There was also no evidence of a difference in the use of ephedrine, the amount of ephedrine used, nausea and vomiting, or headache. Hyperbaric bupivacaine took less time to reach a sensory block height of T4, with a mean difference (95%CI) of -1.06 min (-1.80 to -0.31). Due to the rarity of some outcomes, dose variability, use of adjuvant drugs and spinal technique used, future clinical trials should look into using adequate sample size to investigate the primary outcome of the need for supplemental analgesia.

Histological analysis of tonsillectomies: relationship with surgical technique, post-operative pain and haemorrhage.

There is no consensus on the optimal technique to decrease post-tonsillectomy morbidity. Histopathological analysis can estimate collateral tissue damage. This study compared histological findings for tonsils removed by cold or electrocautery dissection and their relationship with post-operative complications. Two adult out-patient groups were included in the study: 37 who underwent cold dissection and 37 who underwent electrocautery dissection. Histological analysis was used to assess tissue damage. Tissue damage was significantly higher in the electrocautery dissection group (p = 0.002), as were the number of emergency department visits (p = 0.01) and the need for supplemental analgesia (p = 0.013). Patients in the cold dissection group experienced less pain (p = 0.001) and fewer secondary haemorrhage episodes. Cold dissection produces less tissue damage, which is associated with lower incidence of complications. This study suggests that cold dissection is the technique of choice for tonsillectomy.

Perioperative low-dose ketamine improves postoperative analgesia following Cesarean delivery with general anesthesia

Objective: In this study, the effect of perioperative uses of low dose ketamine on post-operative wound pain and analgesic consumption in patients undergoing elective Cesarean section was evaluated.Methods: In randomized, double blind clinical trial, 52 women with American Society of Anesthesiologists (ASA) class I-II identification undergoing elective Cesarean section in general anesthesia were enrolled. In the ketamine group (group K), a ketamine bolus of 0.5 mg kg−1 IV was administered at the time of induction of general anesthesia. After induction, a ketamine infusion of 0.25 mg kg−1 h−1 was started and discontinued at the end of surgery. Patients allocated to the control group (group C) were given identical volumes of saline. The cumulative dose of morphine consumption after surgery was measured as the primary outcome of this study. Secondary outcomes were pain control assessed by numeric rating scale (NRS) and need for rescue analgesia and incidence of side effects.Results: The mean 24-h morphine consumption was lower in group K (p = 0,001). At 15 min postoperatively, NRS values were lower in group K than group C (p = 0,001). There was no difference among groups regarding the need for supplemental analgesia (rescue diclofenac doses) (p > 0.05).Conclusions: Perioperative uses of low dose ketamine decreased post-operative opioid requirements, which was observed long after the normal expected duration of ketamine.

Single-Dose Intra-Articular Bupivacaine Versus Morphine After Arthroscopic Knee Surgery

This meta-analysis compared the earliest clinical effects of intra-articular bupivacaine and morphine for pain management following arthroscopic knee surgery. A comprehensive literature search was conducted using MEDLINE (1966 to 2013), the Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and Google Scholar databases for identification of randomized-controlled trials that compared IA bupivacaine and morphine for postoperative pain. The relative risk, weighted mean difference (WMD), and their corresponding 95% confidence intervals (CI) were calculated using RevMan statistical software. Bupivacaine and morphine group had similar acute postoperative pain scores (WMD: 0.07; 95% CI, -0.18 to 0.32; P=0.60); number of patients requiring supplementary analgesia (relative risk: 0.74; 95% CI, 0.42 to 1.31; P=0.30) for the trials in this meta-analysis (n=13); and side effects (relative risk: 0.63; 95% CI, 0.39 to 1.02, P=0.06). Even though, the time to first analgesic request resulted in a significant difference (WMD: 66.59; 95% CI, 11.75 to 122.14, P=0.02), this result was not supported by the sensitivity analysis. On the basis of the currently available literature, this study failed to demonstrate a significant difference between single-dose intra-articular bupivacaine and morphine at the end of the arthroscopic knee surgery in terms of pain relief, need for supplementary analgesics, times interval before the first request for additional analgesic, and short-term side effects. Level II-meta-analysis of Level I and II studies.

Omuz cerrahisi olgularında postoperatif analjezik tüketimine cinsiyetin etkisi

Aim. Postoperative pain is a major problem in patients who have undergone surgery of the shoulder joint. We retrospectively evaluated 26 patients in whom a subacromial catheter had been placed for postoperative pain management following shoulder surgery. Method. Infusion of local anesthetics and/or opioids through a subacromial catheter, placed at the end of the procedure, was started after surgery. This catheter was kept in place for 24 hours. The patients’ pain was evaluated by using a visual analog scale (VAS). Patients with a VAS score greater than 7 were given meperidine, 0.5 mg/kg i.v., those with a score of 5-7 received tenoxicam, 20 mg i.v., and patients who continued to have a score of >5 at the end of 30 minutes were given paracetamol, 1 g i.v. as an additional analgesic injection. Results. None of the patients had a need for meperidine after 24 hours of surveillance. Seven patients with a VAS score of 5-7 were given tenoxicam, while seven patients, all female, who had continuing pain, received paracetamol. Conclusion. A subacromial catheter, which does not cause adverse effects or complications, is easy to apply and allows effective analgesia, can be used with confidence in the postoperative pain management of patients undergoing shoulder surgery. The need for supplementary analgesia in women only is significant, indicating the role of the patient’s sex in pain perception.

Opioids for acute pancreatitis pain

Acute pancreatitis is an acute inflammatory process of the pancreas that may also involve adjacent tissues and/or remote organ systems. Abdominal pain is the main symptom and is usually accompanied by nausea, vomiting and fever. Opoids are commonly used to manage pain in acute pancreatitis but there are still some uncertainties about their clinical effectiveness and safety. To assess the effectiveness and safety of opioids for treating acute pancreatitis pain. The search strategy included the Cochrane Upper Gastrointestinal and Pancreatic Diseases Review Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2013, Issue 6), MEDLINE (from 1950 to June 2013) and EMBASE (from 1980 to June 2013). There were no restrictions by language or publication status. We considered randomised clinical trials (RCTs) assessing the effectiveness of any opioid drug used for treating acute pancreatitis pain. Two review authors independently selected studies, assessed risks of bias and extracted data. We estimated risk ratios (RRs) for dichotomous data and calculated a 95% confidence interval (CI) for each RR. We performed an intention-to-treat (ITT) analysis. We undertook meta-analysis for some outcomes. We included five RCTs with a total of 227 participants (age range 23 to 76 years; 65% men) with acute pancreatitis pain. The opioids assessed were intravenous and intramuscular buprenorphine, intramuscular pethidine, intravenous pentazocine, transdermal fentanyl and subcutaneous morphine.One RCT, comparing subcutaneous morphine with intravenous metamizole reported non-significant reduction in the number of participants with improvements in pain intensity (primary outcome) (RR 0.50, 95% CI 0.19 to 1.33). Three studies compared analgesia using opioids with non-opioid treatments. After excluding one study that used opioids through continuous intravenous infusion, there was a decrease in the number of patients requiring supplementary analgesia (RR 0.53, 95% CI 0.30 to 0.93). In a single study, there were no differences in the number of patients requiring supplementary analgesia between buprenorphine and pethidine (RR 0.82, 95% CI 0.61 to 1.10).Pancreatitis complications were not associated with a significant difference between the drugs tested. No clinically serious or life-threatening adverse events occurred related to treatment. No differences for this outcome were found between opioid and non-opioid treatments, or for type of adverse event (nausea-vomiting and somnolence-sedation). One death in the procaine group was reported across all the trials.One RCT comparing pethidine with intramuscular buprenorphine reported non-significant differences of supplementary analgesic, adverse events or deaths. One RCT comparing fentanyl with placebo found no difference in adverse events.The findings of this review are limited by the lack of information to allow full appraisal of the risk of bias, the measurement of relevant outcomes and the small numbers of participants and events covered by the trials. Opioids may be an appropriate choice in the treatment of acute pancreatitis pain. Compared with other analgesic options, opioids may decrease the need for supplementary analgesia. There is currently no difference in the risk of pancreatitis complications or clinically serious adverse events between opioids and other analgesia options.Future research should focus on the design of trials with larger samples and the measurement of relevant outcomes for decision-making, such as the number of participants showing reductions in pain intensity. The reporting of these RCTs should also be improved to allow users of the medical literature to appraise their results accurately. Large longitudinal studies are also needed to establish the risk of pancreatitis complications and adverse events related to drugs.

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

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

Tramadol and levobupivacaine wound infiltration at Cesarean delivery for postoperative analgesia

The aim of the present study was to investigate whether levobupivacaine and tramadol wound infiltration decreases postoperative pain following Cesarean section and reduces the need for analgesics in the immediate post-delivery period. Ninety patients (aged 18-40years) scheduled for elective Cesarean section under general anesthesia were randomly allocated to one of the three groups: the placebo group (group P) received 20mL local wound infiltration with 0.9% saline solution; the levobupivacaine group (group L) received 20mL local wound infiltration with levobupivacaine 0.25%; and the tramadol group (group T) received 20mL local wound infiltration with 1.5mg/kg tramadol within 0.9% saline solution. Following the closure of the uterine incision and the rectus fascia, 20mL solution was infiltrated subcutaneously along the skin wound edges. The primary outcome was 24-h tramadol consumption. Secondary outcomes were recorded VAS scores, diclofenac requirement, fever, vomiting, and wound infection. At 15min postoperatively, VAS values were lower in groups T and L than group P (P=0.0001). The mean 24-h tramadol consumption was lowest in group T (P=0.0001) and it was lower in the group L compared to group P (P=0.007) (401.6, 483.3, and 557.5mg for T, L, and P groups, respectively). There was no difference among groups regarding the need for supplemental analgesia (rescue diclofenac doses) (P>0.05). We conclude that wound infiltration with tramadol and levobupivacaine in patients having Cesarean section under general anesthesia may be a good choice for postoperative analgesia.

Study of equivalence: spinal bupivacaine 15 mg versus bupivacaine 12 mg with fentanyl 15 μg for cesarean delivery

Background A safe and effective intrathecal dose of bupivacaine alone for cesarean delivery has not yet been established. This study tested the hypothesis that an intrathecal dose of hyperbaric bupivacaine 15 mg would produce equivalent spinal anesthesia for cesarean delivery as the combination of hyperbaric bupivacaine 12 mg and fentanyl 15 μg. Methods This was a single center, double-blind, randomized clinical trial of equivalence. One hundred and thirty-eight healthy parturients scheduled for elective cesarean delivery were randomized to receive either intrathecal hyperbaric bupivacaine 15 mg (Group B) or hyperbaric bupivacaine 12 mg with fentanyl 15 μg (Group BF). Parturients where asked to describe their degree of sensation during surgery using a four-point scale 20 min after spinal injection. Secondary outcomes included the incidence of maternal side effects, maternal hemodynamics and the need for supplemental analgesia. Results There was no difference in the quality of anesthesia between the two groups. Sixty-eight of 69 and 69/69 patients in Group B and Group BF, respectively had anesthesia classified as successful (RR = 1.01; 95% CI 0.85, 1.22). The only two secondary outcomes that were different between the groups were the largest change in mean arterial pressure (decrease of 40 mmHg and 34 mmHg for Group B and Group BF, respectively; P = 0.004) and the incidence of nausea (59% and 35% for Group B and Group BF, respectively; P = 0.006). Conclusion There was no difference in the degree of sensation at 20 min between Group B and Group BF. The only significant differences between the two techniques were a higher incidence of nausea and decrease in maternal blood pressure in Group B.

Ketamine as an adjunct to fentanyl improves postoperative analgesia and hastens discharge in children following tonsillectomy – a prospective, double‐blinded, randomized study

To evaluate the effect of ketamine, as an adjunct to fentanyl, on postoperative analgesia and duration of Postoperative Care Unit (PACU) stay, in children undergoing tonsillectomy. Ketamine, as an N-methyl-d-aspartate antagonist, has been recognized to have an opioid sparing effect. In addition, it does not depress respiration or affect airway tone. Hence, addition of ketamine could be potentially beneficial in children undergoing tonsillectomy, due to the high incidence of sleep apnea in these patients. In a double blinded, randomized trial, 60 ASA status I and II children between 2 and 7 years of age, scheduled to undergo elective tonsillectomy were recruited. They were randomly assigned to one of four groups to receive fentanyl 1 mcg·kg(-1) (F1 group), fentanyl 2 mcg·kg(-1) (F2 group), ketamine 0.5 mg·kg(-1) (K group), or fentanyl 1 mcg·kg(-1) plus ketamine 0.5 mg·kg(-1) (FK group) pre-incision. Postoperative pain was scored on arrival to the PACU and at 30, 60, and 90 min thereafter. Any incidence of nausea/vomiting and time to discharge from the PACU were also recorded. Important predictors found for postoperative pain on arrival to the recovery room are the group (P = 0.02) and duration of surgery (P = 0.02). Least square means and standard errors of pain scores on PACU arrival were 4.87±0.69, 3.04±0.68, 2.10±0.68 and 2.03±0.69 for F1, F2, K and FK groups, respectively. On group-wise comparison adjusted for surgical time, significant difference was detected between F1 and K (P = 0.02), and F1 and FK (P = 0.0048) groups. Marginal significance was detected in duration of PACU stay among groups (P = 0.08); F2 and FK group had a shorter PACU stay than F1 (P = 0.05 and 0.04 respectively). No significant difference was detected in the need for supplemental analgesia. We conclude that the administration of ketamine 0.5 mg·kg(-1) with 1 mcg·kg(-1) fentanyl in children undergoing tonsillectomy may improve postoperative pain control without delaying home discharge.

Predictive Risk Factors for Pain During Extracorporeal Shockwave Lithotripsy

Extracorporeal shockwave lithotripsy (SWL) is a noninvasive but painful procedure. The aim of this study was to identify predictive risk factors for pain during SWL. Two hundred twenty-two SWL treatments with the Lithostar lithotripter (Siemens) were included in a monocentric study. Patient and stone characteristics were prospectively collected in a database, and a standardized pain control protocol was administered 1 hour before treatment: paracetamol, nefopam, ketoprofen, and alprazolam. Subjective pain level was assessed with visual analog scale (VAS, 0-10). If VAS was >or=3, tramadol was added. If VAS was still >or=3, shockwave intensity was decreased or treatment was interrupted. The efficacy on stone fragmentation was evaluated 1 month after treatment. The need for adjuvant analgesia was compared with patient and stone characteristics to find out predictive risk factors for pain. The average subjective pain was 3.1. The need for supplementary analgesia was more frequent in women (p = 0.035), younger patients (p < 0.001), anxious and depressed patients (p = 0.018), in patients with previous SWL (p = 0.0185), in patients with a rib projected stone (p < 0.001), in patients with renal stones (p = 0.0535), and finally in patients with homogeneous stones (p = 0.02). Multivariate analysis revealed two independent risk factors for pain: young age (odds ratio = 5; p < 0.001) and rib projected stone (odds ratio = 5.23; p < 0.001). Stone fragmentation was worse in patients with an adjuvant analgesia requirement (p = 0.0311). Predictive risk factors for pain during SWL treatments were found: young age, rib projected stones, anxious and depressed patients, previous SWL treatment, and homogeneous stones. A higher analgesic requirement is necessary for these preselected patients to perform SWL and optimize its efficacy.