Patient-controlled Analgesia Morphine Requirements Research Articles

Evaluation of Two Different Doses of Pre-Emptive Intravenous Magnesium Sulphate as Post- Operative Adjunct Analgesia after Gynaecological Surgery

This study compared the analgesic effects of pre-emptive intravenous magnesium sulphate of different dosages in patients undergoing lower abdominal gynaecological surgery. Fifty-six patients with Body Mass Index (BMI) <35 kg/m2 who underwent lower abdominal gynaecological surgery were randomly recruited into two groups. Group I received one ampoule (2.47 g) of magnesium sulphate and Group II received 50 mg/kg magnesium sulphate (based on body weight), pre-operatively. Pain score and patient controlled analgesia (PCA) morphine requirement were compared at 30 minutes, 12 hours and 24 hours post-operatively. The pain score was comparable at all intervals between the two groups (30 minutes, p = 0.450; 12 hours, p = 0.402; and 24 hours, p = 1.000). Post-operative PCA morphine requirement was not statistically significant between the two groups at 30 minutes, 12 hours, and 24 hours (2.7 vs 2.4 mg, p = 0.545; 12.5 vs 9.8 mg, p = 0.154; 7.7 vs 6.4 mg, p = 0.323). The side-effects of magnesium sulphate on blood pressure, heart rate and sedation were not statistically significant between the two groups. In conclusion, the analgesic effects of pre-emptively administered intravenous MgSO4 of 2.47 g (one ampule) was comparable to 50 mg/kg in patients with BMI less than 35 kg/m2 following lower abdominal gynaecological surgery under general anaesthesia with negligible side effects.

Is COMBIPECS the answer to perioperative analgesia for breast surgery? A double blinded randomized controlled trial.

Background and Aims:Pecs block and its variations provides perioperative analgesia, reduce PONV and other opioid related side effects. We hypothesized that COMIBPES block in addition to general anaesthesia will provide better postoperative analgesia when compared to general anaesthesia alone in breast cancer surgery patients.Methods:After obtaining permission from the institutional review board and registering the trial with Clinical Trials Registry of India (CTRI), we conducted a double blinded randomized controlled trial of 100 patients posted for elective breast surgery with axillary dissection. Patients were divided into two groups, P (Pecs block) and C (control). Intraoperative analgesia, postoperative analgesia, postoperative nausea vomiting (PONV) and shoulder mobility on first postoperative day (POD1) were noted. Primary outcomes were the pain scores measured by visual analog scale (VAS) and cumulative intravenous morphine consumption from patient controlled analgesia (PCA) pump at measurement intervals of 0, 1, 4, 8, 12 and 24 hours postoperatively.Results:Intraoperatively, Group P patients did not require any additional analgesia, whereas all the patients in Group C required additional intraoperative morphine (mean, SD: 5.12, 2.63 mg, compared to nil in group P, P< 0.01). COMBIPECS block group had lower pain scores and PCA morphine requirements, less PONV and better shoulder mobility on POD1.Conclusion:COMBIPECS block is a valuable addition to general anaesthesia for breast cancer surgery as it reduces pain and PONV while allowing better postoperative shoulder mobility.

Transitional Study of Patient-Controlled Analgesia Morphine With Ketorolac to Patient-Controlled Analgesia Morphine With Parecoxib Among Donors in Adult Living Donor Liver Transplantation: A Single-Center Experience

BackgroundIn this study, as our center transitions from using patient-controlled analgesia (PCA) morphine with intravenous (IV) ketorolac to PCA morphine with IV parecoxib, the two regimens are compared in terms of quality of pain control. MethodsPost-operative pain management sheets were collected retrospectively among the living donors of liver transplantation during this transitional period. Group parecoxib was given plain PCA morphine. A single dose of IV parecoxib 40 mg was given 30 minutes before the end of surgery. Group ketorolac was given PCA morphine pre-mixed ketorolac with a concentration of 1.87 mg/mL. Daily and total morphine consumption, Visual Analog Score (VAS), and number of rescue attempts made up to 3 post-operative days, together with satisfaction score and incidence of side effects of PCA usage, were analyzed and compared by means of the Mann-Whitney U test; a value of P < .05 was regarded as significant, and data are given as mean ± SD. ResultsFifty patients were analyzed; group 1 comprised 21 patients and group 2 comprised 29 patients. There was no difference between group 1 and group 2 in terms of daily VAS. PCA morphine requirements were significantly lower at day 2 and day 3 in group 1. However, the total overall morphine usage and satisfactory score was not statistically different (P = .863, P = .052). ConclusionsA single dose of IV parecoxib 40 mg can provide satisfactory pain control when paired with PCA morphine for donors undergoing living donor liver transplantation. The use of parecoxib in the multimodal analgesia regimen has similar efficacy, with possibly less morphine consumption, when compared with ketorolac.

The evaluation of efficacy and safety of paravertebral block for perioperative analgesia in patients undergoing laparoscopic cholecystectomy

Background:Paravertebral block is a popular regional anesthetic technique used for perioperative analgesia in multiple surgical procedures. There are very few randomized trials of its use in laparoscopic cholecystectomy in medical literature. This study was aimed at assessing its efficacy and opioid-sparing potential in this surgery.Methods:Fifty patients were included in this prospective randomized study and allocated to two groups: Group A (25 patients) receiving general anesthesia alone and Group B (25 patients) receiving nerve-stimulator–guided bilateral thoracic Paravertebral Block (PVB) at T6 level with 0.3 ml/kg of 0.25% bupivacaine prior to induction of general anesthesia. Intraoperative analgesia was supplemented with fentanyl (0.5 μg/kg) based on hemodynamic and clinical parameters. Postoperatively, patients in both the groups received Patient-Controlled Analgesia (PCA) morphine for the first 24 hours. The efficacy of PVB was assessed by comparing intraoperative fentanyl requirements, postoperative VAS scores at rest, and on coughing and PCA morphine consumption between the two groups.Results:Intraoperative supplemental fentanyl was significantly less in Group B compared to Group A (17.6 μg and 38.6 μg, respectively, P =0.001). PCA morphine requirement was significantly low in the PVB group at 2, 6, 12, and 24 hours postoperatively compared to that in Group A (4.4 mg vs 6.9 mg, 7.6 mg vs 14.2 mg, 11.6 mg vs 20.0 mg, 16.8 mg vs 27.2 mg, respectively; P <0.0001 at all intervals).Conclusion:Pre-induction PVB resulted in improved analgesia for 24 hours following laparoscopic cholecystectomy in this study, along with a significant reduction in perioperative opioid consumption and opioid-related side effects.

Dexmedetomidine Infusion During Laparoscopic Bariatric Surgery: The Effect on Recovery Outcome Variables

Dexmedetomidine (Dex), an alpha(2) agonist, has well-known anesthetic and analgesic-sparing effects. We designed this prospective, randomized, double-blind, and placebo-controlled dose-ranging study to evaluate the effect of Dex on both early and late recovery after laparoscopic bariatric surgery. Eighty consenting ASA II-III morbidly obese patients were randomly assigned to 1 of 4 treatment groups: (1) control group received a saline infusion during surgery, (2) Dex 0.2 group received an infusion of 0.2 microg x kg(-1) x h(-1) IV, (3) Dex 0.4 group received an infusion of 0.4 microg x kg(-1) x h(-1) IV, and (4) Dex 0.8 group received an infusion of 0.8 microg x kg(-1) x h(-1) IV. Mean arterial blood pressure values were maintained within +/-25% of the preinduction baseline values by varying the inspired desflurane concentration. Perioperative hemodynamic variables, postoperative pain scores, and the need for "rescue" analgesics and antiemetics were recorded at specific intervals. Follow-up evaluations were performed on postoperative days (PODs) 1, 2, and 7 to assess severity of pain, analgesic requirements, patient satisfaction with pain management, quality of recovery, as well as resumption of dietary intake and recovery of bowel function. Dex infusion, 0.2, 0.4, and 0.8 microg x kg(-1) x h(-1), reduced the average end-tidal desflurane concentration by 19, 20, and 22%, respectively. However, it failed to facilitate a significantly faster emergence from anesthesia. Although the intraoperative hemodynamic values were similar in the four groups, arterial blood pressure values were significantly reduced in the Dex 0.2, 0.4, and 0.8 groups compared with the control group on admission to the postanesthesia care unit (PACU) (P < 0.05). The length of the PACU stay was significantly reduced in the Dex groups (81 +/- 31 to 87 +/- 24 vs 104 +/- 33 min in the control group, P < 0.05). The amount of rescue fentanyl administered in the PACU was significantly less in the Dex 0.2, 0.4, and 0.8 groups versus control group (113 +/- 85, 108 +/- 67, and 120 +/- 78 vs 187 +/- 99 microg, respectively, P < 0.05). The percentage of patients requiring antiemetic therapy was also reduced in the Dex groups (30, 30, and 10% vs 70% in the control group). However, the patient-controlled analgesia morphine requirements on PODs 1 and 2 were not different among the four groups. Pain scores in the PACU, and on PODs 1, 2, and 7, in the three Dex groups were not different from the control group. Finally, quality of recovery scores and times to recovery of bowel function and hospital discharge did not differ among the four groups. Adjunctive use of an intraoperative Dex infusion (0.2-0.8 microg x kg(-1) x h(-1)) decreased fentanyl use, antiemetic therapy, and the length of stay in the PACU. However, it failed to facilitate late recovery (e.g., bowel function) or improve the patients' overall quality of recovery. When used during bariatric surgery, a Dex infusion rate of 0.2 microg x kg(-1) x h(-1) is recommended to minimize the risk of adverse cardiovascular side effects.

The Short-Lasting Analgesia and Long-Term Antihyperalgesic Effect of Intrathecal Clonidine in Patients Undergoing Colonic Surgery

In this study, we investigated the antihyperalgesic effect of clonidine after surgery. Sixty patients undergoing right colic resection were studied. Patients were randomized to receive prior to general anesthesia a 2-mL intrathecal (IT) injection of 300 microg of clonidine or saline, or 10 mg of bupivacaine. General anesthesia was achieved using a target concentration propofol infusion and monitored using bispectral index. Postoperative analgesia was provided by morphine IV given through a patient-controlled analgesia device. Postoperative analgesia was assessed by morphine requirements and visual analog scale pain scores at rest, cough, and movement during the first 72 h. Mechanical hyperalgesia was measured by von Frey filaments. Patients were questioned regarding residual pain at 2 wk,1, 6, and 12 mo. The patient-controlled analgesia morphine requirements were significantly smaller in the IT clonidine group (31.5 +/- 12 versus 91 +/- 25.5 and 43 +/- 15 mg, respectively, in groups clonidine, saline, and bupivacaine: P < 0.05 at 72 postoperative hours). The area of hyperalgesia at 72 h was 3 +/- 5 cm(2) in the clonidine group versus 90 +/- 30 and 35 +/- 20 cm(2) in the saline and bupivacaine groups (P < 0.05). At 6 mo, fewer patients in the clonidine group experienced residual pain than in the saline group (0 of 20 versus 6 of 20, P < 0.05). We conclude that both intraoperative spinal clonidine and bupivacaine improve immediate postoperative analgesia. IT clonidine was, however, more potent than IT bupivacaine to reduce postoperative secondary hyperalgesia. Spinal clonidine contributes to the reduction of secondary hyperalgesia in patients recovering from abdominal surgery.

Combination Spinal Analgesic Chemotherapy: A Systematic Review

Combination Spinal Analgesic Chemotherapy: A Systematic Review

Combination spinal analgesic chemotherapy: a systematic review.

Combination spinal analgesic chemotherapy: a systematic review.

Clonidine premedication reduces maternal requirement for intravenous morphine after cesarean delivery without affecting newborn's outcome

Background and Objectives: The α 2-agonist clonidine has several benefits for patients undergoing surgery. During and after elective cesarean delivery (C-section), we assessed the condition of parturient and neonate when one half of the parturients were pretreated with oral clonidine. Methods: Forty-six consenting parturients were studied in a randomized, double-blinded manner. Preanesthetic medication was atropine and famotidine with or without clonidine 4 μg/kg. After baseline measurements in parturients and fetuses, combined spinal and epidural anesthesia was established (1.6 mL of 0.5% tetracaine diluted with 10% dextrose in water). C-section was performed while breathing oxygen spontaneously (3 L/min) through a facemask. After delivery, neonates were assessed at 1 and 5 minutes, and the condition of mother and neonate was observed for 48 hours. Results: Parturients receiving clonidine showed no hemodynamic instability during and after C-section, and while their visual analog scale (VAS) scores, verbal descriptive scale (VDS) scores, and sedation scores did not differ from those without clonidine, they needed significantly less patient-controlled analgesia (PCA) morphine for postoperative pain for the first 2 days ( P < .01). Fetal heart rate, umbilical artery and vein pH and gas tensions, and the Apgar-scores of the newborns showed no intergroup differences. No neonatal depression or bradycardia was observed for 48 hours after delivery. Conclusion: The present results indicate that oral clonidine reduces the PCA morphine requirement after C-section without compromising the condition of the fetus or newborn. Further study including larger number of patients would be needed before we conclude that oral clonidine for parturients is safe for their newborns. Reg Anesth Pain Med 2001;26:461-467.

Preoperative Small-Dose Ketamine Has No Preemptive Analgesic Effect in Patients Undergoing Total Mastectomy

We evaluated the preemptive analgesic effect of a small dose of ketamine given before or immediately after surgery in a randomized, double-blinded study performed in 128 women undergoing total mastectomy. Group 1 patients received ketamine 0.15 mg/kg as a 5-mL IV injection 5 min before surgery and isotonic saline 5 mL IV at the time of skin closure. Group 2 received 5 mL IV of isotonic saline, then 0.15 mg/kg IV ketamine. A standard general anesthesia procedure including sufentanil was used. In the recovery room, patient-controlled analgesia IV morphine was used for postoperative analgesia. Postoperative pain was assessed by measuring morphine consumption and visual analog scale pain scores. No significant intergroup differences were seen in the pain scores. Patient-controlled analgesia morphine consumption was lower during the first 2 h after surgery in patients given ketamine at the time of skin closure. No patient complained of hallucinations or nightmares. The incidence of adverse effects was not different between the two groups. In conclusion, administering ketamine at the end of surgery is more effective in reducing morphine consumption than it is when given before surgery. Implications: We administered the same small dose of ketamine before or after surgery. The preoperative administration of 0.15 mg/kg ketamine in patients undergoing total mastectomy did not elicit a preemptive analgesic effect. Ketamine given at closure reduced the patient-controlled analgesia morphine requirement in the first 2 h after surgery. (Anesth Analg 1999;89:444-7)

Addition of morphine to intra-articular bupivacaine does not improve analgesia following knee joint replacement

In an effort to further decrease postoperative opioid requirements and improve analgesia in patients undergoing elective knee joint replacement, a study was made of the effectiveness of adding morphine to an intra-articular bupivacaine injection given immediately following surgery. In random, double-blind fashion, 75 patients received a 31-mL intra-articular injection consisting of either 30 mL 0.5% bupivacaine with 1:200,000 epinephrine and 1 mL normal saline (group BUP), 30 mL 0.5% bupivacaine with 1:200,000 epinephrine and 1 mg (1 mL) preservative-free morphine (group BUP-MORPH), or 30 mL normal saline with 1:200,000 epinephrine and 1 mg preservative-free morphine (group MORPH). Postoperative analgesia was supplied by patient controlled analgesia (PCA) with morphine. Patients were assessed at 1, 2, 4, and 24 hours for pain (visual analog and verbal rating scales), morphine utilization, and side effects. Knee range of motion was measured before operation and at hospital discharge. There was no difference among the three groups in PCA morphine requirements, pain scores by either scale, range of motion, or incidence of side effects, including somnolence, urinary retention, nausea and vomiting, and pruritus. The addition of 1 mg morphine to an intra-articular injection of 30 mL 0.5% bupivacaine with 1:200,000 epinephrine given at wound closure does not improve analgesia in patients undergoing elective knee joint replacement.

Age is the best predictor of postoperative morphine requirements

The dose of opioid prescribed for postoperative pain relief has traditionally been based on the weight of the patient. Although a reduction in dose is often suggested for elderly patients over 70 years of age, age-related alterations to dose are generally not considered for younger patients. The records of 1010 patients, under 70 years old, prescribed morphine via patient-controlled analgesia (PCA) after major operations were examined to see what factors might best predict the amount of morphine used in the first 24 h after surgery. Factors included were age, sex, weight, operative site, verbal numeric pain score (at rest and on movement) and a nausea/vomiting score. In a subgroup of 78 of these patients, the effects of intraoperative and recovery room doses of opioid (‘clinical’ loading dose) were analysed. Although the interpatient variability in PCA morphine doses was large (differences of up to 10-fold in each age group), the best predictor of PCA morphine requirement in the first 24 h after surgery (the amount required in the 24 h after the initial loading dose) was the age of the patient. An estimate of these requirements for patients over the age of 20 years can be obtained from the formula: average first 24 h morphine requirement (mg) = 100 − age. PCA allows patients the flexibility to titrate their own opioid dose; if conventional analgesic regimens are to become more effective, they too need to allow for the wide interpatient variation in dose requirements. Although previous studies have noted a correlation between patient age and the amount of opioid needed, this study quantifies this correlation and provides guidelines for opioid dosing. Prescriptions for conventional analgesic regimens should include a dose range centred on values obtained from the above formula to allow for the large interpatient variation in each age group. While initial morphine dose should be guided by patient age and not weight, subsequent doses must still be titrated according to effect.

Therapeutic Suggestion Has No Effect on Postoperative Morphine Requirements

This study was designed to confirm the effect of therapeutic intraoperative auditory suggestion on recovery from anesthesia, to establish the effect of preoperative suggestion, and to assess implicit memory for intraoperative information using an indirect memory task. Sixty consenting unpremedicated patients scheduled for elective gynecologic surgery were randomly divided into three equal groups: Group 1 received a tape of therapeutic suggestions preoperatively, and the story of Robinson Crusoe intraoperatively; Group 2 heard the story of Peter Pan preoperatively and therapeutic suggestions intraoperatively; Group 3 heard the Crusoe story preoperatively and the Peter Pan story intraoperatively. A standardized anesthetic technique was used with fentanyl, propofol, isoflurane, and nitrous oxide. After surgery, all patients received patient-controlled analgesia (PCA) with a standardized regimen. In the 24 h postsurgery, morphine use was recorded every 6 h and at 24 h an indirect memory test (free association) was used to test for memory of the stories. Anxiety scores were measured before surgery and at 6 and 24 h postsurgery. There were no significant differences between groups for postoperative morphine use, pain or nausea scores, anxiety scores, or days spent in hospital after surgery. Seven of 20 patients who heard the Pan story intraoperative gave a positive association with the word "Hook," whereas 2 of 20 who did not hear the story gave such an association. Indirect memory for the Pan story was established using confidence interval (CI) analysis. (The 95% CI for difference in proportion did not include zero). No indirect memory for the Crusoe story could be demonstrated. This study did not confirm previous work which suggested that positive therapeutic auditory suggestions, played intraoperatively, reduced PCA morphine requirements. In contrast, a positive implicit memory effect was found for a story presented intraoperatively.

Postoperative analgesia with transdermal fentanyl following lower abdominal surgery

In a randomised, placebo-controlled, double-blind study involving 81 patients undergoing total abdominal hysterectomy, the postoperative analgesia provided by transdermal fentanyl given at 25, 50, or 75 micrograms.h-1 for 72 h was compared with a placebo group. The efficacy of the Transdermal Therapeutic System was related to the rate of fentanyl delivery, higher rates being associated with significantly lower visual analogue pain scores (24, 20, 17 and 13, for placebo, 25, 50 and 75 micrograms.h-1 respectively) and reduced patient controlled analgesia morphine requirements (44, 38, 33 and 31 mg respectively). Patients' overall sedation scores were not increased by transdermal fentanyl, but respiratory rates decreased with higher transdermal fentanyl dosage.

Epidural bupivacaine/sufentanil therapy for postoperative pain control in patients tolerant to opioid and unresponsive to epidural bupivacaine/morphine.

Opioids are thought to have equal analgesic effects when equivalent doses are used. However, sufentanil may achieve maximum effect while occupying fewer spinal opioid receptors (higher intrinsic efficacy). Therefore, sufentanil may be more effective than morphine when administered intraspinally in opioid-tolerant patients. This study evaluated 20 chronic cancer pain patients who underwent abdominal surgery for tumor resection. All patients used large doses of morphine (> 250 mg/day-1) preoperatively for 3 months or longer. Intraoperatively, patients received combined general-epidural anesthesia with 0.5% bupivacaine and 0.02% morphine at 8 ml/h-1. Postoperative continuous epidural analgesia with 0.1% bupivacaine and 0.02% morphine at 5 ml/h-1 plus intravenous patient-controlled analgesia morphine (3 mg every 6 min) was given. Epidural infusions were increased every 30 min by 1 ml/h-1 to achieve a dynamic (during coughing) visual analog pain score (VAPS) of less than 5/10. If the desired VAPS was not achieved after 6 h or the epidural morphine infusion was increased to 2 mg/h-1, 50 micrograms of sufentanil in 10 ml of normal saline was given as an epidural bolus dose. The epidural infusion then was switched to 0.0002% sufentanil (2 micrograms/ml-1) and 0.1% bupivacaine (1 mg/ml-1) at 7 ml/h-1. Further titration to maintain a dynamic VAPS of less than 5/10 occurred every 4 h. Mean preoperative daily oral morphine use was 380 +/- 97 mg (range 290-490) for 4 +/- 1 months. Before the switch to sufentanil, patients had received a mean maximum morphine dose of 8.8 +/- 0.2 mg intraoperatively plus 9.0 +/- 1.2 mg during 4.2 +/- 0.3 h postoperatively (1.8 +/- 0.4 mg/h-1), at which point VAPS ranged between 7-10/10. All patients experienced adequate analgesia within 1 h of starting sufentanil therapy. The mean sufentanil dose during the first 4 h of treatment was 17 +/- 0.2 micrograms/h-1. At this time, VAPS ranged from 0-3/10. Satisfactory analgesia was achieved with sufentanil at a lower than a calculated equally potent dose of morphine (23 micrograms/h-1 vs. 17 micrograms/h-1, P < 0.01). Intravenous patient-controlled analgesia morphine requirements were also lower (7.8 mg/h-1 vs. 2.0 mg/h-1, P < 0.01). Length of morphine and sufentanil therapies were 5 +/- 3 h and 10 +/- 2 days, respectively. No patient experienced signs or symptoms of opioid withdrawal. These results suggest that sufentanil can be used successfully in opioid-tolerant patients who do not experience adequate pain control in the early postoperative period despite a large dose of epidural morphine. Moreover, sufentanil should be considered an effective alternative therapy for postoperative pain control in chronic opioid users using high doses of oral opioids before surgical intervention.

Continuous Interpleural Infusion of Bupivacaine for Postoperative Analgesia After Surgery With Flank Incisions

Postoperative analgesia, as assessed by visual analogue scale scores (0-10) and patient-controlled analgesia morphine requirements, pulmonary function (forced vital capacity and forced expiratory volume in 1 s), and plasma bupivacaine concentrations were studied in patients receiving interpleural blockade with bupivacaine after surgery with a flank incision. Two groups of 10 patients received either 0.5% or 0.25% bupivacaine, both with epinephrine (5 micrograms/mL). Pain relief was initiated when patients had visual analogue scale scores greater than or equal to 4. Patients received 21 mL of bupivacaine 0.25% or 0.5% in a double-blind fashion. One hour later, a continuous infusion of 5 mL/h of the study solution was started. At the same time, patient-controlled analgesia became accessible to the patients. The onset time of pain relief and the area under the visual analogue scale score-time curves over the first 8 h were similar in both groups. Patient-controlled analgesia morphine use was also similar in the 0.25% (21.3 +/- 14.6 mg) and 0.5% (21.0 +/- 16.0 mg) groups (mean +/- SD). In both groups, forced vital capacity and forced expiratory volume in 1 s improved significantly within 60 min (P less than 0.05). Peak plasma concentrations (Cmax) and the area under the plasma concentration-time curve (AUC) over 24 h were higher (P less than 0.001) in the 0.5% group (Cmax, 1.47 +/- 0.37 micrograms/mL; AUC, 1511 +/- 323 micrograms.mL-1.min) than those in the 0.25% group (Cmax, 0.55 +/- 0.22 micrograms/mL; AUC, 680 +/- 118 micrograms.mL-1.min) (mean +/- SD).(ABSTRACT TRUNCATED AT 250 WORDS)

The efficacy of intramuscular ketorolac in combination with intravenous PCA morphine for postoperative pain relief

Study Objective: To examine the efficacy of intramuscular (IM) ketorolac used in combination with intravenous (IV) patient-controlled analgesia (PCA) morphine for postoperative pain relief following intra-abdominal gynecologic surgery. Design: Randomized, double-blind, placebo-controlled study. Setting: Patient care unit at a university medical center. Patients: Thirty-five healthy women undergoing intra-abdominal gynecologic surgery who requested postoperative PCA. Interventions: Postoperatively, all patients received IV PCA morphine, with the PCA device programmed to deliver a maximum of 1 mg every 6 minutes (maximum of 30 mg over 4 hours). In addition, patients received one of three regimens: (1) IM saline every 6 hours; (2) IM ketorolac 30 mg while in the postanesthesia care unit (PACU), followed by 15 mg every 6 hours; or (3) IM ketorolac 60 mg while in the PACU, followed by 30 mg every 6 hours. Measurements and Main Results: Patients were assessed al regular intervals. Visual analog scale (VAS) scores were used to assess analgesia and patient satisfaction with therapy. Data on morphine usage were obtained from the PCA device, and the frequency and severity of adverse effects were assessed for the presence or absence of side effects. Cumulative morphine dosages were lower ( p < 0.05) in both ketorolac groups at 12, 18, and 24 hours. VAS scores and the frequency of side effects did not differ significantly among groups. Conclusions: IM ketorolac significantly decreased PCA morphine requirements. The analgesic effects of the two drugs appear to be additive.

Does Epidural Administration of Butorphanol Offer Any Clinical Advantage over the Intravenous Route? A Double-blind, Placebo-controlled Trial

The differential effects of intravenous versus epidural administration of short-acting, lipid-soluble opioids is controversial. This study was undertaken to compare these two routes of administration using the mixed agonist-antagonist opioid, butorphanol. Forty-five women undergoing elective cesarean delivery at term under epidural lidocaine anesthesia were randomized to receive a single bolus of either epidural or intravenous butorphanol 2 mg or saline control for postoperative analgesia. At precisely 60 min after the last dose of epidural local anesthetic, all patients received a simultaneous epidural and intravenous injection in a randomized, double-blinded fashion. The intravenous group received butorphanol intravenous and saline epidurally; the epidural group received saline intravenous and butorphanol epidurally; and a control group received saline via both routes. When additional analgesia was requested, all patients received patient-controlled analgesia (PCA) with intravenous morphine (2-mg demand dose, 7-min lockout interval). Analgesia was quantitated using a visual analogue scale and subsequent PCA morphine requirements. The interval from study drug injection until first request for PCA use was equivalent for the intravenous and epidural groups (89 +/- 9 and 83 +/- 8 min, respectively) and significantly longer than in control group (39 +/- 4 min, P less than 0.001, intravenous and epidural vs. control). Analgesia was equivalent in the intravenous and epidural groups at all observation points, and pain scores were significantly lower than control for the first 120 min after study drug injection.(ABSTRACT TRUNCATED AT 250 WORDS)