Pain-free Period Research Articles

Interictal Burden of Cluster Headache

The aim of this study was to measure the interictal burden (IIB) associated with cluster headache (CH). CH is characterized by an alternation of excruciatingly painful attacks and pain-free periods. Absence of pain does not necessarily imply absence of symptoms, though. Some may persist or improve more slowly than pain; others may arise in between attacks. Participants filled out an online survey based on the EUROLIGHT questionnaire. Inclusion criteria were a reported diagnosis of CH and residency in a European country; exclusion criteria were refusal to give informed consent and to complete the questionnaire. Most of the burden was related to higher headache frequencies: ongoing symptoms despite pain freedom, impaired autonomy due to avoidance of triggers, reluctance to tell others about the disease, and the feeling of not being understood by family and friends, employers and colleagues. Irreversible, potentially accumulating burden may occur if headache frequency is high; examples are impairment of career options, relationships, and family planning issues. Worrying about future attacks and avoiding potential triggers occur independently from attack frequency and disease duration. There were no differences between the in-bout and the out-bout period among participants with episodic CH. Participants with chronic CH reported greater IIB. Even between attacks CH can have a huge and potentially irreversible impact on life. Different types of IIB were identified, all of which may contribute to the total burden of disease. As cumulative burden might be irreversible, prevention strategies need to be developed.

Prolonged functional impairments after whiplash injury

Thirty patients with whiplash injuries were examined 1 to 55 months after the accidents. Pain had appeared on the day of the accident in 24 (80%) of the patients and with different delays in the remainder. The mean pain intensity was 43 mm (SD 26) on a visual analogue scale (VAS). All patients had pain in the neck, 17-33% had headache and 6-17% had pain in various regions of the arms. Thirteen patients (43%) suffered from constant pain, while 17 (57%) had pain-free periods. Muscle tenderness was higher at all tested sites compared with controls. The tolerance level to pressure pain in the index finger as well as grip strength and neck mobility was reduced compared with controls. The whiplash patients showed poorer mental well-being compared with a reference group representing the general population and compared with a group of tension-type headache patients.

A case-control study of visually evoked postural responses in childhood with primary headaches

Disorientation, nausea, confusion, dizziness, and displacement are frequently complained by headache-suffering children. Anyhow, the cause of these symptoms is still unclear, and a dysfunction of vestibular pathways or their alteration due to central pain pathways hyper-activation, has been proposed. The aim of this study is to use posturography to explore the balance function of headache-suffering children during pain-free periods. Posturography was performed on 19 migraineurs, 11 tension-type headache sufferers, and 20 healthy controls. Posturographic measures were performed during headache-free periods under different conditions: with eyes opened, eyes closed, and during right and left optokinetic stimulation. The last 2 conditions were used to mimic unreliable visual signals that can confound vestibular system. During eyes-closed conditions, headache-suffering children displayed higher displacements than healthy controls, since statokinesiogram surface was higher in tension-type headache sufferers and migraineurs compared with controls (P value = 0.0095). Romberg's index, indicating the overall stability of the subject, was lower in healthy controls than in headache sufferers (P = 0.0139), thus suggesting a vestibular impairment in the seconds. Moreover, both during right and left optokinetic stimulation, the statokinesiogram length was higher in headache-suffering children (P < 0.0001). Thereafter, statokinesiogram surface was higher in migraineurs during right optokinetic stimulation (P = 0.0388) than in tension-type headache sufferers when stimulation was directed on the opposite side (P = 0.0249). These results suggest a central alteration of vestibular pathways in headache-suffering children, that makes balance function more dependent from visual inputs than healthy subjects, even in inter-ictal phases.

Recurrent low back pain patients demonstrate facilitated pronociceptive mechanisms when in pain, and impaired antinociceptive mechanisms with and without pain.

Low back pain (LBP) has been inconsistently associated with enhanced pronociceptive and impaired antinociceptive mechanisms. It remains unknown whether alterations are causal, consequential, or coincidental to pain presence. This study investigated pronociceptive and antinociceptive mechanisms in recurrent LBP (RLBP) patients across painful and pain-free periods, compared with age/sex-matched asymptomatic controls. During a painful episode (day 0) and when pain-free (day 28), 30 RLBP patients were assessed and compared with 30 controls over the same timeframe. Pressure pain thresholds were recorded bilaterally on the arm, back, and leg. Cuff algometry was used to assess cuff pressure pain detection threshold and cuff pain tolerance threshold on the lower legs, as well as temporal summation of pain (10 repeated painful cuff test stimuli on the dominant leg scored on a visual analogue scale) and conditioned pain modulation ([CPM]: cuff pain detection/tolerance threshold on dominant leg, before vs during painful cuff conditioning on the contralateral leg). Recurrent LBP patients displayed reduced pressure pain thresholds at the arm and back on day 0 compared with day 28 (P < 0.047) and with controls on day 0 (P < 0.049). Cuff pain detection threshold was reduced, and ratings of suprathreshold test stimuli were increased in RLBP patients on day 0 compared with day 28 (P < 0.02). Temporal summation of pain magnitude (increase in visual analogue scale scores) was enhanced in RLBP participants on day 0 compared with day 28 (P = 0.027) and with controls on day 0 (P = 0.039). Conditioned pain modulation magnitude (increased threshold during conditioning) was lower overall in RLBP participants than in controls (P = 0.021). Enhanced pronociceptive mechanisms were observed in RLBP patients. When pain-free, measures returned to similar levels as controls, except for CPM, which remained impaired.

Comparação do bloqueio do canal adutor para analgesia em cirurgia artroscópica com ropivacaína isolada e ropivacaína + clonidina

Background and objectivesInadequate pain relief after anterior cruciate ligament reconstruction affects mobility leading to development of adhesions, weakened ligament insertion and muscle atrophy. Adductor canal block for postoperative analgesia preserves quadriceps strength. The present study was conducted to compare pain free period in patients undergoing arthroscopic anterior cruciate ligament reconstruction, receiving ultrasound‐guided adductor canal block with ropivacaine alone and ropivacaine with clonidine. MethodsA prospective randomized double blinded study was conducted including sixty‐three adult, ASA class I, II patients undergoing anterior cruciate ligament reconstruction. They were randomized into three groups: Group S – control group received adductor canal block with 30mL saline, Group R – ropivacaine group received adductor canal block with 30mL of 0.375% ropivacaine and Group RC – clonidine group received adductor canal block with 30mL of 0.375% ropivacaine with clonidine 1μg.kg−1. The primary aim was to compare the pain free period in patients receiving adductor canal block with ropivacaine alone or ropivacine with clonidine. The secondary outcomes were pain score at rest and movement, total analgesic requirement, sedation score and postoperative nausea and vomiting. ResultsThe mean pain free periods were 20min, 384.76min and 558.09min for Group S, Group R and Group RC, respectively and this difference was statistically significant (p < 0.001). There was no significant difference between Group R and Group RC in terms of pain scores at rest and movement and total analgesic requirement. ConclusionAddition of clonidine to ropivacaine in USG guided adductor canal block led to significant prolongation of pain free period though pain score at rest and movement, and rescue analgesic requirement, did not differ.

Addition of intrathecal dexamethasone to bupivacaine for spinal anesthesia in cesarean section

Background: Post-caesarean section pain is an important issue in obstetrics. Several studies have shown the importance of adequate postoperative analgesia on mobilization, rehabilitation and decreasing the length of hospital stay. Large amounts of opioid analgesic drugs are often required in the management of intense post-operative pain. However, this option is associated with many side effects.Objective: The aim of the study was to assess the efficacy of adding dexamethasone to bupivacaine for spinal anesthesia in prolonging the duration and anesthetic effect in women undergoing cesarean section.Patients and Methods: Populations of the study were comprised of 100 pregnant full term female planed for cesarean section. All patients had cesarean section under spinal anesthesia. Pain was assessed using 10 cm visual analogue scale (VAS) after 0, 15, 30 min and 2, 4, 6 hours post-operatively and until the mother asked for an analgesic. The duration of sensory block as well as postoperative analgesia were calculated.The study population had been randomized into 2 groups: The 1st group C (n=50 women) included 50 women receiving intrathecal dexamethasone added to bupivacaine. The 2nd group B (n=50 women) included 50 women receiving placebo which was added to intrathecal bupivacaine.Results: This study has shown that the addition of intrathecal dexamethasone to bupivacaine significantly improved the duration of sensory block in spinal anesthesia as the duration of sensory block in the study group was 122 + 7.9 minutes while in the control group it was 91.8 + 10.8 minutes and p 6 and the first analgesic dose prescription in the case group was significantly longer than that in the control group (P<0.001) as the pain free period in the study group was 434.3 + 43.8 minutes while in the control group it was 215.3 + 40.3minutes. Also, the motor block duration in the study group was significantly prolonged when compared with control group (p<0.01).There was no difference in onset time between the two groups and the addition of dexamethasone cause no complications.Conclusion: This study has shown that the addition of intrathecal dexamethasone to bupivacaine significantly improved the duration of sensory block in spinal anesthesia without any changes in onset time and complications, and has increased the pain free period statistically.Recommendations: Further studies are needed to evaluate the optimal dose of dexamethasone to be used in spinal anesthesia.

Pentazocine, a Kappa-Opioid Agonist, Is Better Than Diclofenac for Analgesia in Acute Pancreatitis: A Randomized Controlled Trial.

The ideal analgesic is not known for patients with acute pancreatitis (AP). Concerns have been raised about serious adverse effects of opioid analgesics increasing the severity of AP. We hypothesized that nonsteroidal anti-inflammatory drugs might be better analgesics because of their anti-inflammatory effect. Our objective was to compare pentazocine, an opioid, and diclofenac, a nonsteroidal anti-inflammatory drug, for adequate analgesia in patients with AP. In a double-blind randomized controlled trial, patients with AP were randomized to either intravenous diclofenac 75 mg or pentazocine 30 mg. Fentanyl was given as a rescue analgesic through a patient-controlled analgesia pump. Primary outcome was pain relief measured objectively by the dose of fentanyl required as the rescue analgesic, pain-free period, and numbers of effective and ineffective demands of fentanyl. Secondary outcome was adverse events. Fifty patients were randomized, 24 to the pentazocine group and 26 to the diclofenac group. Baseline characteristics were comparable between the groups. Pentazocine was found to be better than diclofenac in terms of significantly lower dose of the rescue analgesic (fentanyl) required (126 μg (interquartile range (IQR) 65-218 μg) vs 225.5 μg (IQR 133-427 μg); P = 0.028) and longer pain-free period (31.1 ± 8.2 vs 27.9 ± 6.6 hours, P = 0.047). The number of effective and ineffective demands was lower in the pentazocine group compared with the diclofenac group (11.5 (IQR 8-15) vs 16 (IQR 13-20), P = 0.098) although not statistically significant. Adverse events were similar between the groups. Pentazocine, a kappa-opioid receptor agonist, was significantly better than diclofenac for pain relief in AP (Trial registration number: CTRI/2016/09/007326).

Increased QT and P-wave dispersion during attack-free period in pediatric patients with migraine attacks.

Migraine is a common neurovascular disease characterised with recurrent attacks by pain-free periods. It has been suggested that both sympathetic and parasympathetic dysfunctions play a role in its pathophysiology. The aim of our study was to investigate the ECG changes during attack-free period in children with migraine, in terms of QTc interval, QTc, and P-wave dispersion to evaluate the autonomic nervous system disturbance. Sixty children who were diagnosed with migraine were included as patient group and 50 healthy, age- and body mass index-matched children who were examined for innocent murmur were included as control group. The patients' routine ECG records were screened from the outpatient clinic files. The durations of P-wave, QT, and QTc intervals and dispersion values and heart rates (beats/minute) were compared between the patient and control groups. P maximum and P dispersion were significantly higher, and P minimum was significantly lower in the migraine group compared with the control group. QT-QTc maximum and QT-QTc dispersion were significantly higher and QT-QTc minimum was significantly lower in the migraine group compared with the control group. According to our findings, although migraine patients were asymptomatic and no arrhythmia was detected in the surface ECG, sympathovagal balance in the sympathetic system, which may be disrupted in favour of the sympathetic system, should continue even in the attack-free period, and we should be careful in terms of serious arrhythmias that may develop in these patients.

Are peripheral nerve blocks effective in pain control of pediatric orthopedic tumor surgery?

This study aims to evaluate the efficacy of ultrasound (US)-guided peripheral nerve blocks in postoperative analgesia after pediatric orthopedic tumor surgery. This retrospective study included 108 children (64 boys, 44 girls, mean age 10.23 years; range, 2 to 18 years) who were performed orthopedic tumor surgery under general anesthesia. The children were divided into two groups as those who were performed nerve block for postoperative pain control (group 1, n=54) and those who were performed intravenous analgesic (group 2, n=54). In group 1, nerve blocks were performed with bupivacaine 0.25%. In group 2, intraoperative acetaminophen 15 mg/kg was performed intravenously. Postoperative visual analog scale (VAS) scores, time to pain onset, nausea, vomiting, total analgesic consumption in 24 hours, and complications were recorded at first, second, sixth and 24th hours. Visual analog scale scores were higher in group 2 than group 1 at first, second, and sixth hours, but were not different at 24th hour. Mean time to pain onset was 10.2 hours in group 1 and 1.8 hours in group 2 (p<0.05). Mean time to pain onset and VAS values at first, second, sixth and 24th hours did not differ between nerve block types. Nausea and vomiting rates were not different between groups 1 and 2 (18.51% and 16.66%, respectively; p=0.4). Total analgesic consumption in 24 hours was higher in group 2 compared to group 1 (1.7 and 0.07 mg/kg, respectively; p<0.05). Pain-free periods extending up to 10 hours provided by US-guided peripheral nerve blocks may help recovery while reducing postoperative analgesic use and their side effects.

A Study to Evaluate the Effects of Intrathecal Nalbuphine Hydrochloride with Bupivacaine and Bupivacaine Alone on Post-Operative Analgesia in Lower Abdominal Surgeries

Background: A pain-free and stress-free post-operative period helps in early mobilization and recovery, thereby reducing morbidity and mortality. Accomplishing the subarachnoid block with local anaesthetic alone has a drawback of analgesia of shorter duration in postoperative period. Addition of opioids to local anaesthetic solution used for conduct of&nbsp; has subarachnoid block been found safe, devoid of any nerve toxicity and in addition it increases the quality as well as the duration of the block. Nalbuphine is a semisynthetic opioid having agonist and antagonist effects on opioid receptors and devoid of other opioid like side effects. Aim: The purpose of our study was to establish the effectiveness of intrathecal nalbuphine as an adjuvant and also the efficacy of nalbuphine for post-operative analgesia and its side effects if any. &nbsp;Subjects and Methods: The study conducted on 60 patients of ASA grade I and II, age group between 18-60 years, scheduled for elective lower abdominal, perineal and lower limb surgeries. Patients were randomised into two equal groups of 30 each, group I (Nalbuphine group) received 3cc of hyperbaric bupivacaine 0.5% + 0.8 cc injection nalbuphine preservative free (0.8mg) intrathecally, Group II(controlled group) received 3cc of hyperbaric bupivacaine 0.5% + 0.8 cc of injection normal saline intrathecally. Statistical analysis was done using appropriate tests. Results: The mean time of post-operative analgesia in nalbuphine group (Group-I) was found to be highly significant (P&lt;0.001) than control group (Group-II), no patient developed any side effects in our study. Conclusion: Nalbuphine hydrochloride&nbsp; provides better quality of blockade as well as prolongs the post-operative analgesia when used as adjuvant with bupivacaine in spinal anesthesia.

Effectiveness of Mixture of Xylocaine, Bupivacaine and Buprenorphine for Lumbar Blockade by Epidural Approach

Background: Pain is one of the most compelling experience for human beings. Pain is the most difficult one to define and assess, as it is a purely subjective sensation experienced only by the sufferer. Present study was done in which Buprenorphine was given epidurally along with Bupivacaine and Xylocaine as a single shot technique to evaluate its potency, duration of analgesia and other side effects. Subjects and Methods: Fifty adult patients of ASA risk I/II undergoing lower abdominal surgery, lower limb - orthopaedic surgery, surgery involving perineal region and gynaecological procedures were selected for our study. The patients were divided into two groups consisting of 25 patients each. In group I, patients were given Inj. Bupivacaine 0.5% 20 cc + xylacaine in lumbar epidural space. In group II, patients were given Bupivacaine 0.5% 20 cc + xylacaine 0.5% 20 cc mixed with Inj. Buprenorphine 0.2 mg (2 ml) in same syringe in lumbar epidural space. Duration of total analgesia was measured with help of pain scorre, which were measured throughout operative period and in postoperative period. All the statistical tests will be performed in SPSS version 15 software. Results: In study group majority patients complain of pain at around 16 to 20 hours. Most of the patients in group-I are in 0-4 hours and in group – II are 20-24 hours. Maximum respiratory depression was around 12% (2/min). It was observed that hypotension was seen in 4 cases and bradycardia in 4 cases – intraoperatively and postoperatively no patient had bradycardia or hypotension in study group. Conclusion: Buprenorphine if given epidurally along with local anesthetic solution for various surgical procedures can provide excellent pain free period lasting up to 24 hours without any disturbances to normal physiology life and notable side effects.

Comparison of adductor canal block for analgesia in arthroscopic surgery with ropivacaine alone and ropivacaine and clonidine

Background and objectivesInadequate pain relief after anterior cruciate ligament reconstruction affects mobility leading to development of adhesions, weakened ligament insertion and muscle atrophy. Adductor canal block for postoperative analgesia preserves quadriceps strength. The present study was conducted to compare pain free period in patients undergoing arthroscopic anterior cruciate ligament reconstruction, receiving ultrasound-guided adductor canal block with ropivacaine alone and ropivacaine with clonidine. MethodsA prospective randomized double blinded study was conducted including sixty-three adult, ASA class I, II patients undergoing anterior cruciate ligament reconstruction. They were randomized into three groups: Group S – control group received adductor canal block with 30mL saline, Group R – ropivacaine group received adductor canal block with 30mL of 0.375% ropivacaine and Group RC – clonidine group received adductor canal block with 30mL of 0.375% ropivacaine with clonidine 1μg.kg−1. The primary aim was to compare the pain free period in patients receiving adductor canal block with ropivacaine alone or ropivacine with clonidine. The secondary outcomes were pain score at rest and movement, total analgesic requirement, sedation score and postoperative nausea and vomiting. ResultsThe mean pain free periods were 20min, 384.76min and 558.09min for Group S, Group R and Group RC, respectively and this difference was statistically significant (p < 0.001). There was no significant difference between Group R and Group RC in terms of pain scores at rest and movement and total analgesic requirement. ConclusionAddition of clonidine to ropivacaine in USG guided adductor canal block led to significant prolongation of pain free period though pain score at rest and movement, and rescue analgesic requirement, did not differ.

Comparison of levobupivacaine alone versus levobupivacaine with ketamine in subcutaneous infiltration for postoperative analgesia in lower segment cesarean section

Context: Local anesthetic wound infiltration is employed as a part of multimodal analgesia to reduce opiate consumption and pain after lower segment cesarean section (LSCS). Additional blockade of pain pathway at spinal level by ketamine prolongs the duration of analgesia. Aims: To compare analgesic efficacy of subcutaneous wound infiltration of levobupivacaine or levobupivacaine plus ketamine following LSCS. Material and Methods: Randomized double blind study was conducted on 60 parturients undergoing LSCS under spinal anesthesia. Group A received surgical wound infiltration with 0.5% levobupivacaine 2 mg/kg body weight and Group B parturients were infiltrated with 0.5% levobupivacaine plus ketamine 1 mg/kg body weight diluted with normal saline. Postoperative pain scores, time to first rescue analgesia (FRA), hemodynamic parameters, and total opioid analgesic consumption were assessed. Results: Pain free period and time to FRA was 1.5 hours later in group B, which also had reduced mean VAS scores. In addition, the overall pain scores and total opioid consumption were significantly less (P = 0.003) in Group B. Only 50% in Group B and 97% parturients in Group A needed rescue analgesia. Patient satisfaction score was statistically superior in Group B (P = 0.009). Incidence of nausea and vomiting was comparable between the groups (P = 0.554). Conclusions: Addition of ketamine to levobupivacaine for surgical wound infiltration prolongs the analgesia duration, improves patient satisfaction, and decreases 24-hour opioid consumption.

Laparoscopic Hemi-Hysterectomy-Retrospective Study of Case Series of over 9 Years

Background: Word hemi-hysterectomy and removal of rudimentary functional horn may be used interchangeably in published data. The same term may be used when a non-obstructive hemi-uterus is removed when there is an associated pathology. The article tries to standardise classification of Mullerian dysgenesis where this procedure is required according to ESHRE ESGE classification, preoperative diagnosis and discuss the operative details. Objective: The objective was to study the demographic profile, symptoms, association of endometriosis, variation in the anatomy, accuracy of preoperative diagnosis, to classify according to ESHRE ESGE classification and to standardize the laparoscopic surgical steps of hemi-hysterectomy. Study Design: This is a retrospective case series of cases of Mullerian dysgenesis with obstructive hemi-uterus or non-obstructive hemi-uterus with pathology treated by laparoscopic hemi-hysterectomy. (Canadian task force classification III). Methods: Data from hospital electronic records of all cases tagged with word laparoscopic hemi-hysterectomy were collected for 9 years from Jan 2009 to Dec 2018. Results: Total 19 patients of hemi-hysterectomy were analysed. Pre-operative diagnosis was made in 100% of patients. 100% patients with obstructive horn had dysmenorrhoea. ESHRE ESGE class U4aC3V0 was more frequently seen followed by U5aC4V4 and U3bC3V2 as obstructive and U4bC3V0, as non-obstructive. Associated endometriosis along with other pathology was seen in 74% of the patients. 3 patients with HWWS had ipsilateral renal agenesis. Laparoscopic hemi-hysterectomy was offered to all such patients. The operative steps & variants were studied. Post-operative outcome was uneventful in all. Conclusion: An experienced surgeon should deal with these problems of Mullerian dysgenesis discussed in this study. The other variants diagnosed also must be treated by an experienced surgeon only. Laparoscopic hemi-hysterectomy is almost the most standard surgical method to treat pelvic pain in cases with rudimentary non-communicating horns or in cases of non-obstructive horns with other associated pathologies. Post-operative recovery is uneventful, and all patients reported pain free periods as well as they are free of chronic pain which they had before surgery.

Pain control for laparoscopic hysterectomy with magnesium versus nalbuphine added to intraperitoneal bupivacaine: a randomized double-blinded study

Background Pain control for laparoscopic hysterectomy carries some concerns. Intraperitoneal bupivacaine either alone or with additives has been studied with favorable results. However, adding nalbuphine has not been sufficiently examined. This study aimed to compare between the addition of magnesium sulfate (MgSO4) or nalbuphine to bupivacaine regarding efficacy and drawbacks. Patients and methods A total of 80 female patients of American Society of Anesthesiologists I–II scheduled for laparoscopic hysterectomy in Ain Shams University hospitals were randomly distributed into two groups: group bupivacaine magnesium (BM) (n=40), in which patients received 30 ml of intraperitoneal bupivacaine 0.25% plus 30 mg/kg MgSO4, and group bupivacaine nalbuphine (BN) (n=40), in which patients received 30 ml of intraperitoneal bupivacaine 0.25% plus 5-mg nalbuphine at the end of operation. A standard general anesthesia technique was used in all patients. Visual analog scale, total intravenous diclofenac consumption, the time for first analgesia requirement, incidence of adverse effects, and patient satisfaction in the first 24 h postoperatively were recorded in both groups. Results BN group experienced prolonged postoperative pain-free period. Total diclofenac consumption and pain scores were significantly less in BN group as compared with BM group. Regarding the adverse effects, there was insignificant difference between both groups for incidence of shoulder pain; however, BN group experienced more postoperative nausea and vomiting. Other adverse events were not reported. Patient satisfaction was significantly higher in BN group when compared with BM group. Conclusion This study showed that addition of nalbuphine to bupivacaine for intraperitoneal instillation gave better postoperative pain control when compared with adding MgSO4 to bupivacaine.

Intraperitoneal instillation of lornoxicam–levobupivacaine versus tramadol–levobupivacaine in patients undergoing laparoscopic cholecystectomy under general anesthesia

Background Intraperitoneal local anesthetic administration is used for reducing postoperative pain after laparoscopic surgery, this study aimed to compare intraperitoneal instillation of lornoxicam–levobupivacaine versus tramadol–levobupivacaine on the quality of postoperative analgesia for elective laparoscopic cholecystectomy. Patients and methods After ethical approval, 90 (30/group) patients scheduled for elective laparoscopic cholecystectomy were randomly allocated to receive intraperitoneal instillation of either 25 ml of normal saline for patients in group S, 20 ml of levobupivacaine 0.5% combined with 5 ml of lornoxicam (16 mg) for patients in group L or to receive 20 ml of levobupivacaine 0.5% combined with 5 ml of tramadol (100 mg) for patients in group T. Postoperative pain-free period, visual analog pain scores, pulmonary functions and cumulative fentanyl consumption were recorded. Results Postoperative pain-free period showed significantly longer duration in group L and group T in comparison to group S with 6.86 h in group L and 6.90 h in group T versus 1.33 h in group S at 95% confidence interval, also total fentanyl consumption decreased in group L and group T in comparison to group S. Pulmonary functions were decreased in all groups but with less decrease in group L and group T in comparison to group S. Conclusion Addition of either lornoxicam or tramadol provided safe, effective, less affection of pulmonary functions and good quality of analgesia when added to levobupivacaine without any significant differences between both groups for intraperitoneal administration.

Dexmedetomidine versus fentanyl added to bupivacaine for epidural analgesia in combination with general anesthesia for elective lumbar disc operations: A prospective, randomized double-blinded study.

Background:The literature on drugs used for combined general anesthesia and epidural analgesia (CGE) in lumbar operations is scarce. The purpose of the study was to compare the addition of either dexmedetomidine or fentanyl to bupivacaine for epidural analgesia in combination with general anesthesia with regard to efficacy and adverse events in such operations.Materials and Methods:This prospective, randomized, double-blinded study was conducted on 80 patients who were scheduled for an elective lumbar disc operation, age 20–65 years, of either sex and American Society of Anesthesiologists physical status I or II. They were randomly allocated into one of the two groups – group bupivacaine-dexmedetomidine (BD) (n = 40): patients who received CGE with 15 mL of bupivacaine 0.20% plus 50 μg of dexmedetomidine and group bupivacaine-fentanyl (BF) (n = 40): patients who received CGE with 15 mL of bupivacaine 0.20% plus 50 μg fentanyl. The primary outcome was time to first analgesic requirement, whereas the secondary outcomes were the total opioid consumption and pain scores during the first 24 h. The incidence of adverse postoperative (PO) effects related to the study drugs, such as sedation, nausea and vomiting, pruritus, shivering, and respiratory depression, was also documented.Results:Patients in the BD group experienced a significantly prolonged pain-free period, lower total opioid consumption, and lower pain scores than patients in the BF group (P < 0.001). Patients in the BD group showed a significantly lower intraoperative heart rate and mean blood pressure (P < 0.001). Regarding adverse events, there were greater PO sedation scores (P < 0.001) and less frequent episodes of PO nausea and vomiting in the BD group. In addition, patients in the BD group showed less pruritis and shivering. There were no reported cases of respiratory depression in either group.Conclusion:CGE with bupivacaine plus dexmedetomidine provided better PO pain control than bupivacaine plus fentanyl, with fewer adverse events overall.

Effect of Intravenous Dexmedetomidine During General Anesthesia on Acute Postoperative Pain in Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Dexmedetomidine has been shown to have an analgesic effect. However, no consensus was reached in previous studies. Electronic databases such as PubMed, Embase, and Cochrane Central were searched for relevant randomized controlled trials. The relative risk and weighted mean difference (WMD) were used to analyze the outcomes. Random-effects model was used for meta-analysis. Compared with the normal saline group, patients using DEX showed a significantly decreased pain intensity within 6 hours [WMD=-0.93; 95% confidence interval (CI), -1.34 to -0.53) and at 24 hours after surgery (WMD=-0.47; 95% CI, -0.83 to -0.11). DEX usage significantly reduced the cumulative opioids consumption at 24 hours after surgery (WMD=-6.76; 95% CI, -10.16 to -3.35), decreased the rescue opioids consumption in postanesthesia care unit (WMD=-3.11; 95% CI, -5.20 to -1.03), reduced the risk of rescue analgesics (relative risk=0.49; 95% CI, 0.33-0.71), and the interval to first rescue analgesia was prolonged (WMD=34.93; 95% CI, 20.27-49.59). Intravenous DEX effectively relieved the pain intensity, extended the pain-free period, and decreased the consumption of opioids during postoperative recovery of adults in general anesthesia.

Origin and characteristics of haematogenous periprosthetic joint infection

ObjectivesRecognition of infectious origin of haematogenous periprosthetic joint infections (PJI) is crucial. We investigated the primary focus and characteristics of haematogenous PJI. MethodsConsecutive patients who presented with haematogenous PJI between 01/2010 and 01/2018 were retrospectively analysed. Haematogenous PJI was defined by diagnosis of infection ≥1 month after surgery, acute manifestation after a pain-free period and positive blood or prosthetic-site culture and/or evidence of distant infectious focus consistent with the pathogen. Fisher's exact, Student's t and Mann–Whitney U tests were used, as appropriate. ResultsA total of 106 episodes of PJI were included, involving 59 knee, 45 hip, one shoulder and one elbow prostheses. The median time from last surgery until haematogenous PJI was 47 months (range, 1–417 months). The pathogen was identified in 105 episodes (99%), including Staphylococcus aureus (n = 43), streptococci (n = 32), enterococci (n = 13), Gram-negative bacteria (n = 9) and coagulase-negative staphylococci (n = 8). Gram-negative bacteria were significantly more often found in hip joints than in knee joints. Blood cultures grew the pathogen in 43 of 70 episodes (61%). The primary infectious focus was identified in 72 episodes (68%) and included infections of intravascular devices or heart valves (22 episodes), skin and soft tissue (16 episodes), the oral cavity (12 episodes), urogenital (12 episodes) or gastrointestinal tract (seven episodes) and other sites (three episodes). ConclusionsIn acute PJI manifesting after a pain-free period, the haematogenous infection route should be considered and the primary infectious focus should be actively searched for. The cardiovascular system, skin and soft tissue, oral cavity, urogenital and gastrointestinal tracts were common origins of haematogenous PJI.

Postural instability during attacks of migraine without aura.

Migraine has long been associated with unsteadiness and dizziness but postural control has not been studied in the ictal state. Here, the stability of upright stance during migraine attacks was measured. Static balance was assessed prospectively in migraine patients (n=30) during quiet stance for 40s on a posturographic force platform. Recordings were performed both ictally and in the pain-free interval. Subjects were assessed under four different conditions yielding different visual and proprioceptive feedback environments. Both ictal and interictal data were compared with age-matched healthy controls (n=30). Postural instability increased significantly under all experimental conditions during migraine attacks. Whilst standing on a foam pad with eyes closed, median sway area was 353mm2 in control subjects, 318mm2 in migraineurs in the pain-free period and 618mm2 in the ictal state. However, Romberg and vestibular Romberg quotients were not altered during migraine attacks. Spectral analyses of postural sway also showed similar profiles in migraineurs and controls. The severity of headache was inversely correlated to Romberg quotients. The demonstrated pattern of balance disorder during migraine attacks suggests a transient cerebellar dysfunction. Our findings also indicate that intense headache induces a re-weighting of sensory processing toward less dependence on visual and proprioceptive information.