Regular Paracetamol Research Articles

Comparison of the Efficacy of Oral Oxycodone and Oral Codeine in the Treatment of Post-Craniotomy Pain—A Randomized, Double-Blind Trial

Background: Post-craniotomy pain has been reported to be moderate to severe. Management of post-craniotomy pain is often inadequate, yet limited by the side effects of opioids. We aim to find out the efficacy of oral oxycodone as compared to oral codeine for the treatment of post-craniotomy pain in our institution. Methods: A randomized, double-blinded controlled trial was used to evaluate the efficacy of oral oxycodone versus oral codeine. 40 patients were randomized to the control group of codeine (n = 20) or the experimental group receiving oxycodone (n = 20) in addition to regular oral paracetamol for both groups of patients. Results: There was no difference in the visual analogue scale scores at 24 hours (2.78 versus 1.85, p = 0.11) or side effects in the oxycodone group compared with the codeine group. Conclusions: Oral oxycodone had similar efficacy as oral codeine in the management of post-craniotomy pain.

Hysterectomy and Adenextomy via transvaginal natural orifice transluminal endoscopic surgery (vNOTES): A UK perspective with a case series of 33 patients

Objective: To evaluate operative outcomes of hysterectomy +/- adnexectomy by Trans-vaginal Natural Orifice Endoscopic Surgery (vNOTES) in a case series of 33 patients. Study Design: It was a prospective case series study carried out in Darent Valley and Benenden Hospital, to our knowledge, the first units in the United Kingdom to have undertaken VNOTE Hysterectomy.We collected data on a private shared drive noting patient demographics, indications for surgery, operation outcomes and patient follow-up details. Results and Conclusions: Between January and December 2018, 33 patients underwent surgery between two units. Indications for surgery included dysfunctional uterine bleeding, endometrial hyperplasia, pelvic pain, post-menopausal bleeding, prophylactic surgery in BRCA positive patients and one grade 1 stage 1 endometrial cancer in whom laparoscopic hysterectomy was technically difficult and complicated by previous midline laparotomy. Ages ranged from 35 to 75 and BMI from 20-53.Mean operation time was 68.5 min and mean blood loss intraoperatively was 269mls. 15.2% (n = 5) had a blood loss equal or more than 500 mls. There were no intraoperative complications and no conversions to open surgery.The median visual analogue pain score at 6 h post operatively and at discharge was 0. All patients received regular Paracetamol and Ibuprofen and opiate based analgesics were only used on an as required basis.Postoperative complication which included failed trial without catheter, urinary tract infection and urinary dysfunction were reported by four women (12.4%).Only 2 patients re-presented to hospital over a 30-day period and neither required inpatient management.Hysterectomy by vNOTES has advantages over traditional laparoscopic and vaginal hysterectomy that include reduced requirement for intra-abdominal insufflation and head down, absence of trocar related injuries and easier operative access in patients with morbid obesity, or previous abdominal surgery such as midline laparotomy or mesh hernia repair. In addition, both tubes and ovaries can be removed easily due to easier access and visibility and there is no requirement for vaginal descent in order to do so.Plans for a comparative study between laparoscopic hysterectomy and vNOTES hysterectomy are underway.

Paracetamol is ineffective for acute low back pain even for patients who comply with treatment: complier average causal effect analysis of a randomized controlled trial

In 2014, the Paracetamol for Acute Low Back Pain (PACE) trial demonstrated that paracetamol had no effect compared with placebo in acute low back pain (LBP). However, noncompliance was a potential limitation of this trial. The aim of this study was to investigate the efficacy of paracetamol in acute LBP among compliers. Using individual participant data from the PACE trial (ACTN12609000966291), complier average causal effect (CACE), intention-to-treat, and per protocol estimates were calculated for pain intensity (primary), disability, global rating of symptom change, and function (all secondary) after 2 weeks of follow-up. Compliance was defined as intake of an average of at least 4 of the prescribed 6 tablets of regular paracetamol per day (2660 mg in total) during the first 2 weeks after enrolment. Exploratory analyses using alternative time points and definitions of compliance were conducted. Mean between-group differences in pain intensity on a 0 to 10 scale using the primary time point and definition of compliance were not clinically relevant (propensity-weighted CACE 0.07 [-0.37 to 0.50] P = 0.76; joint modelling CACE 0.23 [-0.16 to 0.62] P = 0.24; intention-to-treat 0.11 [-0.20 to 0.42] P = 0.49; per protocol 0.29 [-0.07 to 0.65] P = 0.12); results for secondary outcomes and for exploratory analyses were similar. Paracetamol is ineffective for acute LBP even for patients who comply with treatment. This reinforces the notion that management of acute LBP should focus on providing patients advice and reassurance without the addition of paracetamol.

Comparison of ultrasound‐guided transmuscular quadratus lumborum block catheter technique with surgical pre‐peritoneal catheter for postoperative analgesia in abdominal surgery: a randomised controlled trial

Following abdominal surgery, the provision of postoperative analgesia with local anaesthetic infusion through both transmuscular quadratus lumborum block and pre-peritoneal catheter have been described. This study compared these two methods of postoperative analgesia following laparotomy. Eighty-two patients 18-85years of age scheduled to undergo elective surgery were randomly allocated to receive either transmuscular quadratus lumborum block or pre-peritoneal catheter block. In the transmuscular quadratus lumborum group, an 18-gauge Tuohy needle was passed through the quadratus lumborum muscle under ultrasound guidance to reach its anterior aspect. A 20-ml bolus of ropivacaine 0.375% was administered and catheters placed bilaterally. In the pre-peritoneal catheter group, 20ml of ropivacaine 0.375% was infiltrated at each of three subcutaneous sub-fascial levels, and pre-peritoneal plane catheters were placed bilaterally. Both groups received an infusion of ropivacaine 0.2% at 5ml.h-1 , continued up to 48h along with a multimodal analgesic regime that included regular paracetamol and patient-controlled analgesia with fentanyl. The primary end-point was postoperative pain score on coughing, assessed using a numerical rating score (0-10). Secondary outcomes were pain score at rest, fentanyl usage until 48h post-operation, satisfaction scores and costs. There was no treatment difference between the two groups for pain score on coughing (p=0.24). In the transmuscular quadratus lumborum group, there was a reduction in numerical rating score at rest (p=0.036) and satisfaction scores on days 1 and 30 (p=0.004, p=0.006, respectively), but fentanyl usage was similar. In the transmuscular quadratus lumborum group, the highest and lowest blocks observed in the recovery area were T4 and L1, respectively. The transmuscular quadratus lumborum technique cost 574.64 Australian dollars more per patient than the pre-peritoneal catheter technique.

A randomised controlled trial of the pectoral nerves-2 (PECS-2) block for radical mastectomy.

We randomly allocated 50 women scheduled for radical mastectomy to pectoral nerves-2 (PECS-2) block (n=25) or no block (n=25), 20 and 22 of whom we analysed for the primary outcome of a cumulative 24-h postoperative morphine dose. We gave intra-operative sufentanil, magnesium, dexamethasone and droperidol. Participants received regular postoperative paracetamol, ibuprofen and patient-controlled intravenous morphine. Pectoral nerves-2 block reduced mean (SD) cumulative 24h postoperative morphine dose from 9.7 (8.9) mg to 5.0 (5.4) mg and 48h morphine dose from 12.8 (12.5) mg to 6.0 (6.5) mg, p=0.04 for both. The mean (SD) pain scores 24h and 48h after surgery were similar with or without block: 0.8 (1.4) vs. 1.2 (1.9), p=0.39; and 0.2 (0.4) vs. 0.9 (1.8), p=0.09, respectively. Rates of postoperative nausea, vomiting and pruritus were unaffected. Rates of chronic pain at six postoperative months were 2/19 and 2/18 after block and no block, respectively, p=0.95.

Impact of paediatric tonsillectomy perioperative management on pain, nausea and recovery: A prospective cohort study.

Tonsillectomy procedures are a core element of paediatrics; however, perioperative management differs. This study aimed to describe tonsillectomy management, including the burden of pain, nausea and delayed recovery. A prospective cohort study was undertaken through an audit of tonsillectomy perioperative practice and recovery and survey interviews with family members 7-14 days post-surgery. The study was undertaken at an Australian tertiary referral paediatric hospital between June and September 2016. The audit included 255 children undergoing tonsillectomy, with 127 family members interviewed. Most participants underwent adenotonsillectomy (n = 216; 85%), with a primary diagnosis of obstructive sleep apnoea (n = 205; 80%) and a mean age of 7 years (standard deviation; 3.9). A variety of intra-operative pain relief and antiemetics was administered. Pain was present in 29% (n = 26) of participants at ward return, increasing to 32-45% at 4-20 h and decreasing to 21% (n = 15) at discharge. A third of the children (32%; n = 41) had moderate to severe pain at post-discharge interview, and 30% (n = 38) experienced nausea at home. Most parents (82%; n = 104) were still giving regular paracetamol at 7 days post-operatively, and 31% (n = 39) had finished their oxycodone. Of the participants, 14% (n = 26) presented to the emergency department within 7 days of discharge; 8% (n = 20) of the total cohort were re-admitted. There was variety in perioperative and post-discharge care. Pain scores were infrequently documented post-tonsillectomy, and parents are generally dissatisfied with the management of post-operative pain and nausea. Further research is needed to provide a more consistent approach to perioperative management to promote recovery.

Intravenous Paracetamol in Adjunct to Intravenous Ketoprofen for Postoperative Pain in Children Undergoing General Surgery: A Double-Blinded Randomized Study.

Background and objectives: The combination of non-steroidal anti-inflammatory drugs and paracetamol is widely used for pediatric postoperative pain management, although the evidence of superiority of a combination over either drug alone is insufficient. We aimed to find out if intravenous (i.v.) paracetamol in a dose of 60 mg kg−1 24 h−1, given in addition to i.v. ketoprofen (4.5 mg kg−1 24 h−1), improves analgesia, physical recovery, and satisfaction with postoperative well-being in children and adolescents following moderate and major general surgery. Materials and Methods: Fifty-four patients were randomized to receive either i.v. paracetamol or normal saline as a placebo in adjunct to i.v. ketoprofen. For rescue analgesia in patients after moderate surgery, i.v. tramadol (2 mg kg−1 up two doses in 24 h), and for children after major surgery, i.v. morphine-patient-controlled analgesia (PCA) were available. The main outcome measure was the amount of opioid consumed during the first 24 h after surgery. Pain level at 1 and over 24 h, time until the resumption of normal oral fluid intake, spontaneous urination after surgery, and satisfaction with postoperative well-being were also assessed. Results: Fifty-one patients (26 in the placebo group and 25 in the paracetamol group) were studied. There was no difference in required rescue tramadol doses (n = 11 in each group) or 24-h morphine consumption (mean difference (95% CI): 0.06 (–0.17; 0.29) or pain scores between placebo and paracetamol groups. In patients given morphine-PCA, time to normal fluid intake was faster in the paracetamol than the placebo subgroup: median difference (95% CI): 7.5 (1.3; 13.7) h, p = 0.02. Parental satisfaction score was higher in the paracetamol than the placebo group (mean difference: –1.3 (–2.5; –0.06), p = 0.04). Conclusions: There were no obvious benefits to opioid requirement or analgesia of adding regular intravenous paracetamol to intravenous ketoprofen in used doses. However, intravenous paracetamol may contribute to faster recovery of normal functions and higher satisfaction with postoperative well-being.

(390) Neck of Femur Fractures: An Audit on Current Care in Rotorua Hospital

Neck of femur (NOF) fractures are common and associated with mortality, poor functional outcome and significant financial costs.1 A 2018 bi-national registry recently reported a total of 2291 cases in New Zealand.2 We audited the current practice of care of NOF fracture patients in Rotorua Hospital, New Zealand and looked for areas of quality improvement. A prospective audit of patients who sustained NOF fractures with surgical management was conducted from October-December 2018, (n=24). We noted pain scoring was an issue; 37.5 % patients had regular and appropriate pain scoring. 91.7% had pre-operative nerve blocks in Emergency Department. All patients were on regular Paracetamol and as needed short-acting opiates. 54.2% had a pain score ≤ 5/10 at rest. 87.5% did not ambulate Day 1 post surgery, 7 of these were due to inadequate analgesia. 29.2% of patients were noted to be confused during the admission in the orthopaedic unit and 8.33% were formally diagnosed with delirium. Only 4.17% had their cognition assessed pre-operatively. The average length of stay in hospital is 11.9 days with 5 readmissions. Pain is a limiting factor for early planned mobilisation. Consequently, we have conducted education on pain scoring to nursing staff and pre-operative cognitive assessment to the medical staff, and currently trialling an analgesia regime guide for all NOF fractures. Rotorua Hospital appears to be achieving the goal of surgery within 48 hours3 but there is room for improvement regarding pre-operative cognitive assessment and post-operative mobilisation. We would like to thank the Department of Anaesthetics including the Acute Pain Clinical Nurse Specialists, Dr Michelle Bloor (Geriatrician), and the Department of Orthopaedics.

Spinal Anesthesia for Laparoscopic Cholecystectomy in Parkinson’s disease

Parkinson's disease, a neurodegenerative disorder, presents with resting tremor, muscle rigidity and bradykinesia. Affecting multiple organ-systems, it's an important cause of peri-operative morbidity. General anaesthesia may deteriorate cardio-pulmonary and neuro-cognitive functions; moreover, medications used may interact with anti-parkinsonian agents. Spinal anaesthesia is usually avoided in Parkinson's disease. However, it offers neurologic monitoring and less surgical stress response and avoids complications of general anaesthesia. This case report aims to demonstrate application of spinal anaesthesia for laparoscopic cholecystectomy in a Parkinson's elderly with pulmonary dysfunction and anticipated difficult airway management. Sensory blockade of third thoracic dermatome was achieved. Bupivacaine was instilled intra-peritoneally. Surgery was smooth at low intra-abdominal pressure. Regular Paracetamol provided satisfactory post-operative analgesia. Single episode of post-operative vomiting was effectively managed. Without deterioration, patient was discharged from hospital on third day. Spinal anaesthesia is a valid technique for laparoscopic cholecystectomy in needy patients with multiple peri-operative risks. Keywords: Laparoscopic cholecystectomy; Parkinson's disease; spinal anaesthesia.

Implementing a standardised discharge analgesia guideline to reduce paediatric post tonsillectomy pain

ObjectivesTo reduce readmission for pain control post-paediatric tonsillectomy. IntroductionPaediatric tonsillectomy is a common procedure in the UK. Uncontrolled pain at home is a common reason for re-admission and therefore adequate analgesic control following paediatric tonsillectomy is vital for a smooth post-operative recovery. Analgesic regimens at a district general hospital in England were audited and a standardised protocol was subsequently implemented. MethodsA retrospective audit from September 2014 to August 2015 was completed. Discharge analgesic regimens and readmission rates post-tonsillectomy for recurrent tonsillitis in 2–17 year-old children were studied in a large general hospital in the United Kingdom. A standardised weight-based algorithm was used to dose scheduled regular paracetamol for 2 weeks. Second cycle prospective audit ran from December 2015 to November 2016. ResultsIn cycle 1, 151 children (mean age, 7.9 years) underwent tonsillectomy for tonsillitis, 25 (16.6%) of whom were readmitted. 12 (7.9%) experienced postoperative haemorrhage, 13 (8.6%) required pain control, and one (1.2%) had infection. The discharging analgesic regimen varied widely and often included purchase of over-the-counter ibuprofen and paracetamol. In cycle 2, 118 children (mean age, 8.8 years) underwent tonsillectomy, 17 (14.4%) were readmitted; 12 (10.2%) had post-operative haemorrhage, 0 needed pain control, 5 (4.2%) had other problems. There was a significant reduction in readmission for pain control (p = 0.0027) from 7.3% to 0% in the study. There was no significant change in overall readmission rate (16.6%–14.4%) or postoperative haemorrhage rate (8.9% overall). DiscussionAnalgesia prescription post tonsillectomy varies widely and over the counter prescriptions of ibuprofen and paracetamol is based on age rather than weight with patients receiving inadequate analgesic doses. A readily available standardised postoperative analgesic protocol can significantly reduce readmission rates for pain control following paediatric tonsillectomy.

Time course of subacute pain after transoral robotic surgery (TORS) for oropharyngeal squamous cell carcinoma versus traditional bilateral tonsillectomy in adults – a case–control study

Objective: To examine pain after Transoral Robotic Surgery (TORS) for oropharyngeal squamous cell carcinoma (OPSCC) versus traditional bilateral tonsillectomy in adults.Methods: Pain evolvement was assessed in a prospective case–control design of 16 consecutive patients treated with TORS for early stage OPSCC versus 12 patients, who underwent bilateral tonsillectomy on suspicion of malignant disease. The TORS group received an optimized analgesia regime of preoperative oral celecoxib and gabapentin, intra- and postoperative high-dose intravenous dexamethasone, and regular postoperative oral contalgin, gabapentin, celecoxib, paracetamol and rescue morphine. The tonsillectomy group received the departmental standard analgesia regime with low-dose preoperative oral dexamethasone, celecoxib and paracetamol. Postoperative regular analgesia consisted of oral NSAID and paracetamol with weak opioids prescribed as required. Pain intensity was recorded at rest and during swallowing twice a day.Results: The median pain intensity on postoperative day (POD) 1–4 was 2 in the TORS group versus 4.5 in the tonsillectomy group. From POD 5-10 median pain intensity was 3.5 and 4, respectively. The median length of stay was 5 days in the TORS group and less than 24 hours in the tonsillectomy group.Conclusion: With an optimized analgesia regime TORS for OPSCC can be performed with postoperative pain levels comparable to bilateral tonsillectomy in adults.

Continuous transversus abdominis plane block vs intermittent bolus for analgesia after abdominal surgery: a randomized trial

BackgroundContinuous and intermittent bolus techniques of transversus abdominis plane (TAP) blocks have been used for analgesia after abdominal surgery. Although both are effective, there are no studies comparing them. The aim of this study is to compare analgesia and cost-effectiveness between these groups.MethodsAfter obtaining ethical approval, 20 American Society of Anesthesiologists ASA grade I to III patients undergoing elective abdominal surgery were recruited with 10 patients allocated to each arm. Bilateral ultrasound-guided TAP blocks were performed with an initial bolus of 0.5% ropivacaine 20 mL per side, followed by catheter insertion. After surgery, the continuous infusion group received 0.2% ropivacaine 8 mL/hour on each side and the intermittent bolus group received doses of 0.2% ropivacaine 20 mL per side every 8 hours for 48 hours. Both groups received intravenous fentanyl patient-controlled analgesia and regular oral paracetamol. Parameters recorded included numerical rating scores for pain and post-operative analgesic consumption at baseline (time 0) and at 1 hour, 1 day and 2 days post-operatively. The duration of catheter insertion, complications, patient satisfaction and information regarding costs were also recorded. Patient satisfaction was assessed utilizing a 4-point “Likert” scale on day 2 and on day 30. Pain and Likert scores were analysed by non-parametric sum rank test and all two-sampled t-tests assumed unequal variances.ResultsThere was no difference between duration of TAP block, anesthetic and surgical technique and length of stay (p=0.23). Primary outcomes: pain scores at rest and cough were not significantly different (p=0.20) between the groups. Satisfaction scores were similar at day 2 and 30 (p=0.77). However, the bolus group was more cost-effective (AU$347.98 vs AU$429.43).ConclusionContinuous or bolus TAP blocks are effective analgesic techniques in abdominal surgery, with bolus technique being more economical.

Identifying, highlighting and reducing polypharmacy in a UK hospice inpatient unit using improvement Science methods

Polypharmacy, the concurrent use of multiple medications by one individual is a growing global issue driven by an ageing population and increasing prevalence of multi-morbidity[1]. Polypharmacy can be problematic: interactions...

Alveolar Bone Grafting: Donor Site Review of 100 Consecutive Cases in Cleft Lip and Palate.

Review of patients who underwent secondary alveolar bone grafting for total inpatient stay, postoperative complications, and postoperative analgesic requirements. Retrospective analysis of medical records. Tertiary care center as part of a regional cleft lip and palate network. All patients who underwent secondary alveolar bone grafting from the iliac crest. Local anesthetic was infiltrated overlying the anterior iliac crest. An incision was made to conform to the future skin crease and avoid muscle dissection. The cartilaginous cap was incised and raised, and cancellous bone was then harvested. The cavity was packed with hemostatic cellulose and closed in layers. All patients received postoperative antibiotics. All patients were prescribed regular paracetamol (acetaminophen) and ibuprofen if there were no contraindications. Oral morphine was available when requested. Length of stay, postoperative analgesic requirements, and postoperative donor site and oral complications. From 100 consecutive patients, 92 (92%) of the patients were discharged the day after surgery; one (1%) patient required four nights of monitoring for postoperative pyrexia of unknown origin. All patients received regular paracetamol, and the majority (86%) did not require oral morphine. Complications included seroma (4%), superficial donor site abscess (1%), postoperative pyrexia of unknown origin (2%), gingival bleeding (2%), and oral infection (2%). The findings suggest that donor site pain may be well controlled with simple, regular analgesia. Children tolerated this procedure well and were safely discharged the day after surgery. Alveolar bone grafting from the iliac crest was found to have low complication rates.

Quantifying the risk of nosocomial infection within Ebola Holding Units: a retrospective cohort study of negative patients discharged from five Ebola Holding Units in Western Area, Sierra Leone.

A central pillar in the response to the 2014 Ebola virus disease (EVD) epidemic in Sierra Leone was the role of Ebola Holding Units (EHUs). These units isolated patients meeting a suspect case definition, tested them for EVD, initiated appropriate early treatment and discharged negative patients to onward inpatient care or home. Positive patients were referred to Ebola Treatment Centres. We aimed to estimate the risk of nosocomial transmission within these EHUs. We followed up a cohort of 543 patients discharged with a negative EVD test from five EHUs in the Western Area, Sierra Leone, and examined all line-listed subsequent EVD tests from any facility in the Western Area to see whether the patient was retested within 30 days, matching by name, age and address. We defined possible readmissions as having the same name and age but uncertain address, and confirmed readmissions where name, age and address matched. We found a positive readmission rate of 3.3% (18 cases), which included 1.5% confirmed readmissions (8 cases) and 1.8% possible readmissions (10 cases). This is lower than rates previously reported. We cannot ascertain whether EVD was acquired within the EHUs or from re-exposure in the community. No demographic or clinical variables were identified as risk factors for positive readmission, likely due to our small sample size. These findings support the EHU model as a safe method for isolation of suspect EVD patients and their role in limiting the spread of EVD.

Analgesia following adenotonsillar surgery in children: is Oramorph required in addition to paracetamol and ibuprofen?

BackgroundRecent advice against codeine use in children prompted our unit to prescribe Oramorph as required, in addition to regular paracetamol and ibuprofen, as post-(adeno)tonsillectomy analgesia. This study investigated whether Oramorph was in fact required. MethodsFollowing (adeno)tonsillectomy, parents were telephoned and asked whether they used Oramorph. ResultsOf 56 children studied, 41 (73.2%) were given Oramorph. In the 15 (26.8%) that were not, this was because parents felt it was not required in 14 children, and in 1 case, it was due to worries about side effects. Overall, 14 carers (25.0%) expressed concerns about Oramorph use, mostly over possible side effects. ConclusionWhen regular paracetamol and ibuprofen are used post-(adeno)tonsillectomy, nearly three quarters of children require Oramorph as well. Prescribing Oramorph as required, in addition to regular paracetamol and ibuprofen, is appropriate following adenotonsillar surgery.

Standard Preoperative Analgesia with or without Fascia Iliaca Compartment Block for Femoral Neck Fractures

To compare the visual analogue score (VAS) for pain in patients with femoral neck fracture who received standard preoperative analgesia with or without fascia iliaca compartment block (FICB). In patients with femoral neck fracture, 69 patients who received standard preoperative analgesia (regular paracetamol 1g 4 times a day, codeine 60 mg 4 times a day, and opioid 10 mg 2 hourly as required) were compared with 50 patients who received standard preoperative analgesia plus FICB. VAS for pain at rest and on movement (hip flexion) was assessed before FICB and 15 minutes, 2 and 8 hours after FICB. The amount of additional opioid required and the incidence of opioid overdose (necessitating administration of naloxone) were determined. VAS for pain was significantly lower after standard analgesia plus FICB than standard analgesia alone (p=0.001). The analgesic effect (pre-score minus post-score) of standard analgesia plus FICB did not differ between genders (p=0.57) or fracture patterns (p=0.79). 19 (38%) patients with standard analgesia plus FICB required no additional opioid analgesia. Compared with standard analgesia alone, addition of FICB reduced the mean dose of opioid from 6.2 to 2.0 (p=0.001) and the number of opioid overdose from 7.2% to 0% (p=0.001). No patient had any complication following FICB. In patients with femoral neck fracture, FICB reduced the need for additional opioid analgesia and avoided the risk of opioid overdose and respiratory depression.

A new analgesia regimen after (adeno) tonsillectomy in children: a pilot study

The objective was to ascertain the efficacy of a new analgesic regimen introduced in children undergoing (adeno)tonsillectomy in view of the ban on codeine use in children <12 years by the European Medicines Agency (EMA) and UK Medicines and Healthcare Products Regulatory Agency (MHRA). Prospective pilot study at a paediatric tertiary referral centre. A total of 176 children undergoing (adeno) tonsillectomy over a 5-month period (Sept 2013-Jan 2014) were included in the study. Data were prospectively collected on analgesia used peri-operatively and patients were discharged on regular paracetamol and ibuprofen for 7 days and three doses of oral morphine sulphate solution to be used on days 3, 4 and 5. Pain scores were recorded on days 1-10 post-operatively using the Wong Baker Faces Pain Rating scale. The pain scores were significantly better (P-value < 0.0001) in children who were compliant with morphine (n = 93) than those who were not (n = 32). We also found that children who were compliant with morphine were less likely to seek help out of hours (P-value < 0.001). Oral morphine sulphate solution provides a reasonable alternative to codeine, albeit one should bear in mind that parental concerns and adverse effects of the drug were seen in a minority of patients (n = 11) and anaesthetists were reluctant to prescribe the drug in cases of severe OSA or associated central apnoeas (n = 7).

Double blind randomized comparative study of transdermal fentanyl patch for post operative pain relief in major abdominal surgery as a component of multimodal analgesic therapy

Background: There are various methods of alleviating post-operative pain, multimodal analgesia is the recommended practice. Fentanyl patch can also be used in the management of acute postoperative pain. We have done a study to compare the efficacy of fentanyl patch to a placebo patch as a part of multimodal analgesic strategy. Methods: Forty four patients were randomized into two groups. Groups were named as FP (Fentanyl patch) and P (Placebo). The Patch was placed 10-12 hours before surgery and patient was monitored for 72 hours postoperatively for pain by NRS (Numeric Rating Scale). All the patients received regular Paracetamol and Diclofenac Sodium. Tramadol was given as rescue analgesia if the NRS scale was more than 5. Data was analysed using Windows stat version 9.2 from Indostat services. Results: There was statistically significant difference in the consumption of Tramadol in patients with FP group (19.44 mg) as compared to P group (72.22mg) over 72 hours. The Numerical Rating scale was also much lower in the FP group at 8, 16, 24, 32, 40, 48, 56, 64 and 72 hours. Maximum difference in the pain score being at 24 hours for the FP group. No difference in the Sedation, Pruritus, Respiratory depression, Nausea and vomiting scores in the two groups. Conclusions: Transdermal Fentanyl Patch of 25 µg/hr when applied 10-12 hours before surgery provides effective postoperative pain relief after major abdominal surgery as a part of multimodal analgesia.

Randomized controlled trial of the effect of regular paracetamol on influenza infection.

Background and objectiveAnti‐pyretic treatment is recommended in the management of influenza infection. In animal models anti‐pyretic treatment increases mortality from influenza. We investigated the effects of paracetamol on viral and clinical outcomes in adults with influenza infection.MethodsThis is a randomized, double‐blind, placebo‐controlled trial of adults aged 18–65 years with influenza‐like illness and positive influenza rapid antigen test. Treatments were 1 g paracetamol four times a day, or matching placebo, for 5 days. Pernasal swabs were taken for influenza quantitative RT‐PCR at Baseline and Days 1, 2 and 5. Temperature and symptom scores were recorded for 5–14 days or time of resolution respectively. The primary outcome variable was area under the curve (AUC) for quantitative PCR log10 viral load from Baseline to Day 5.ResultsA total of 80 participants were randomized: no one was lost to follow up, and one withdrew after 4 days. There were 22 and 24 participants who were influenza PCR‐positive in placebo and in paracetamol groups respectively. Mean (SD) AUC PCR log10 viral load was 4.40 (0.91) in placebo and 4.64 (0.88) in paracetamol; difference was −0.24, 95% CI: −0.78 to 0.29, P = 0.36. In all participants there were no differences in symptom scores, temperature, time to resolution of illness and health status, with no interaction between randomized treatment and whether influenza was detected by PCR.ConclusionRegular paracetamol had no effect on viral shedding, temperature or clinical symptoms in patients with PCR‐confirmed influenza. There remains an insufficient evidence base for paracetamol use in influenza infection.Clinical trial registration: ACTRN12611000497909 at the Australian New Zealand Clinical Trials Registry.