Request For Rescue Analgesia Research Articles

Sub-anaesthetic bolus dose of intravenous ketamine for postoperative pain following caesarean section

Background: Effective postoperative analgesia following Caesarean Section is important because parturients are at a higher risk for thromboembolic events due to immobility, increased likelihood of developing postpartum depression (PPD) following inadequate pain control which also can interrupt breastfeeding. Ketamine at sub anesthetic doses has been considered to reduce postoperative pain and analgesic consumption following caesarean section. Aims: The aim of this study was to evaluate the efficacy of sub anesthetic doses of ketamine on post caesarean analgesia. Material and Methods: This randomized double blind, placebo controlled study was conducted on 108 parturients, divided into three groups (36 in each group);Group C- received 2 ml of 0.9% normal saline; Group Ka- received 0.15 mg/kg of ketamine (2 ml) and Group Kb- 0.3 mg/kg of ketamine (2 ml) after 5 min of delivery. Postoperatively VAS score, consumption of rescue analgesic in 24 h and adverse effects were recorded. Statistical analysis was done with Analysis of variance (ANOVA) for continuous variables and Chi-square test for categorical scale. P values less than 0.05 were considered significant. Results: Postoperative VAS scores were significantly higher in control group while the time to the first analgesic requirement was significantly prolonged in Ka group (5.44 ± 1.45 h) and Kb group (6.18 ± 1.61 h) as compared to the control group (4.97 ± 1.48 h). The total number of doses and total dose of rescue analgesic (tramadol) required in 24 hours was significantly less in the Ka group (194.44 ± 53.15 mg) and Kb group (152.78 ± 50.63 mg) as compared to group C (136.11 ± 48.71 mg. Conclusion: Administration of sub-anesthetic doses (0.15 mg/kg and 0.3 mg/kg) of intravenous ketamine enhanced postoperative analgesia and reduced the total rescue analgesic consumption in first 24 h following CS. Ketamine 0.3 mg/kg also increased the time to first postoperative rescue analgesic request.

The Effect of Adding Ketamine or Midazolam to Bupivacaine for Ultrasound-Guided Supraclavicular Brachial Plexus Block for Upper Extremity Surgeries

AbstractBackground: The use of supraclavicular brachial plexus block is one of the most effective anesthetic techniques in operations for the upper extremity. The use of ultrasound guidance for regional anesthesia became popular owing to detection of anatomical variants, painless performance and correct needle placement. Aim of the study is to evaluate the value of adding ketamine or midazolam to bupivacaine when used for ultrasound guided supraclavicular brachial plexus block in upper extremity surgical procedures as regard the quality of surgical anesthesia and post-operative analgesia.Patients and Methods: Seventy adult patients of both sexes aged (18-60) years with ASA physical status I/II sched-uled for elective surgical procedure of the elbow, forearm, wrist and hand. Patients divided into two groups thirty-five patients were given 30ml total volume of 0.5% bupivacaine with midazolam 50μg/kg injected around brachial plexus cluster (Group A) and thirty-five patients were given 30ml general volume contained 0.5% bupivacaine with ketamine 2mg/kg injected around brachial plexus cluster (Group B).Results: There was no significant difference among both groups according to demographic data, hemodynamic changes, onset of motor and sensory block, sedation score, total doses of rescue analgesia and incidence of complications. There was significant prolongation in duration of sensory and motor block, significant decrease in VAS and significant delay in first request of rescue analgesia in Group A.Conclusion: The addition of midazolam (50μg/kg) when used as adjuvants to bupivacaine in ultrasound guided brachial plexus block produced prolongation of sensory and motor block, providing desirable sedation, improved quality of postoperative analgesia and decreased necessities of rescue analgesics in post-operative period.

Bilateral suprazygomatic maxillary nerve block versus palatal block for cleft palate repair in children: A randomized controlled trial

Background and objectivesAirway obstruction and respiratory compromise are frequently encountered complications of cleft palate (CP) repair. We compared the analgesic efficacy of bilateral suprazygomatic maxillary nerve block (SMB) versus palatal block (PB) in pediatric patients undergoing CP repair.Methods90 patients aged 3–24 months were allocated into three groups: Control group (C): patients received general anesthesia only. Maxillary block group (M): patients received ultrasound-guided bilateral SMB using 0.15 ml/kg bupivacaine 0.25%. Palatal block group (P): 0.5 ml bupivacaine 0.25% was injected bilaterally at greater, lesser and nasopalatine foraminae. CHIPPS score, rescue analgesic consumption and time till tolerance of oral feed were assessed.ResultsOn admission to PACU till 8 h postoperative, CHIPPS score was lower in M and P groups compared to C group. At 6 h and 8 h, CHIPPS score was lower in M group compared to P group. Postoperative rescue analgesic consumption was decreased in M and P groups (0.72 ± 2.22 mg) and (3.73 ± 5.92 mg) compared to C group (8.07 ± 5.47 mg) with significantly lower values in M group compared to P group. Time to first request of rescue analgesia was significantly prolonged in M and P groups (482.50 ± 38.62 min) and (260.00 ± 31.62 min) compared to C group (79.71 ± 30.34 min). Time to feed was lower in M and P groups compared to C group.ConclusionUltrasound-guided bilateral SMB provided better postoperative analgesia and decreased rescue analgesic consumption and time to tolerate oral feeding compared to PB without increased side effects.

Effect of adding nalbuphine to intrathecal bupivacaine with morphine on postoperative nausea and vomiting and pruritus after elective cesarean delivery: a randomized double blinded study.

The use of intrathecal morphine may result in serious side effects in parturients undergoing cesarean delivery. Nalbuphine, is a mu receptor antagonist and a ĸappa receptor agonist. Combinations of opioid agonist and agonist antagonist can decrease the incidence of opioid related side effects. We aimed to investigate the effect of adding nalbuphine, to intrathecal morphine on postoperative nausea and vomiting and pruritus after a cesarean delivery. Eighty parturient undergoing elective cesarean delivery under spinal anesthesia were randomized into two similar groups. Group 1: received 10 mg of 0.5% hyperbaric bupivacaine with 0.2 mg morphine. Group 2: received as a group 1 plus 0.5 mg nalbuphine, with total volume 2.5 mL in both groups. Measurements: Data on the severity of nausea and vomiting were collected using a numerical rating scale and visual analogue scale was used to quantify pruritus. Onset and duration of sensory blockade, Visual Analog Scale for pain, the first time to ask for rescue analgesia and total rescue analgesic consumption were recorded. Nausea and vomiting and pruritus severity scores and number of patients developed nausea and vomiting and pruritus were significantly lower (P<0.001) in group 2. Onset and duration of sensory block, time to first request for rescue analgesia, Visual Analog Scale for pain and paracetamol consumption showed no statistically differences between both groups (P>0.05). We concluded that the addition of nalbuphine to intrathecal bupivacaine plus morphine significantly reduced the incidence and severity of postoperative nausea and vomiting and pruritus without affecting analgesic potency.

Ketamine as an adjunct to bupivacaine in infra-orbital nerve block analgesia after cleft lip repair

We conducted this study to investigate the safety and analgesic efficacy of the addition of Ketamine to Bupivacaine in bilateral extra-oral infra-orbital nerve block in children undergoing cleft lip surgeries. Sixty patients were randomly allocated into two groups (n=30), Group B received infra-orbital nerve block with 2mL of 0.25% Bupivacaine and Group BK received 0.5mg.kg-1 Ketamine for each side added to 1mL of 0.5% Bupivacaine solution diluted up to 2mL solution to 0.25% Bupivacaine concentration. Assessment parameters included; hemodynamics, recovery time, time to first oral intake, postoperative Faces Legs Activity Cry Consolability (FLACC) scores, Four-point Agitation scores, analgesic consumption and adverse effects. Patients in Group BK showed lower postoperative FLACC scores during all recorded time points (p<0.0001). Two patients in Group BK versus 12 in Group B requested for postoperative rescue analgesia (p<0.001). There were no differences between groups in time, minutes (min), to first request for rescue analgesia. Patients in Group BK reported lower analgesic consumption (366.67±45.67 vs. 240.0±0.0mg, p<0.04). The time to first oral intake was significantly reduced in Group BK (87.67±15.41 vs. 27.33±8.68min, p<0.001). Lower postoperative Agitation scores were recorded in Group BK patients that reached a statistical significance at 45min (0.86±0.11 vs. 0.46±0.16, p<0.04) and in the first hour (h) postoperatively (1.40±0.17 vs. 0.67±0.14, p<0.003). Higher parent satisfaction scores were recorded in Group BK (p<0.04) without significant adverse effects. The addition of Ketamine to Bupivacaine has accentuated the analgesic efficacy of infra-orbital nerve block in children undergoing cleft lip repair surgeries.

Postoperative analgesic efficacy of ultrasound-guided ilioinguinal-iliohypogastric nerve block compared with medial transverse abdominis plane block in inguinal hernia repair: A prospective, randomised trial

PurposeAnalgesic efficacy of ultrasound-guided transverse abdominis plane block, administered a little more medially, just close to the origin of the transverse abdominis muscle has not yet been investigated in patients undergoing unilateral inguinal hernia repair. We hypothesised that medial transverse abdominis plane block would provide comparable postoperative analgesia to ilioinguinal-iliohypogastric nerve block in inguinal hernia repair patients. MethodsThis prospective, randomised trial was conducted in 50 ASA I and II male patients≥18 years of age. Patients were randomised into two groups to receive either pre-incisional ipsilateral ultrasound-guided ilioinguinal-iliohypogastric nerve block or medial transverse abdominis plane block, with 0.3ml/kg of 0.25% bupivacaine. Our primary objective was postoperative 24-hour analgesic consumption and secondary outcomes included pain scores, time to first request for rescue analgesic and side effects, if any, in the postoperative period. ResultsThere was no significant difference in the total postoperative analgesic consumption [group I: 66.04mg; group II: 68.33mg (P value 0.908)]. Time to first request for rescue analgesic was delayed, though statistically non-significant (P value 0.326), following medial transverse abdominis plane block, with excellent pain relief seen in 58.3% patients as opposed to 45.8% patients in ilioinguinal-iliohypogastric nerve block group. ConclusionMedial transverse abdominis plane block being a novel, simple and easily performed procedure can serve as an useful alternative to ilioinguinal-iliohypogastric nerve block for providing postoperative pain relief in inguinal hernia repair patients.

Effect of Dexmedetomidine Added to Modified Pectoral Block on Postoperative Pain and Stress Response in Patient Undergoing Modified Radical Mastectomy

Background: The most common surgical procedure for breast cancer is the modified radical mastectomy (MRM), but it is associated with significant postoperative pain. Regional anesthesia can reduce the stress response associated with surgical trauma. Objectives: Our aim is to explore the efficacy of 1 µg/kg dexmedetomedine added to an ultrasound (US)-modified pectoral (Pecs) block on postoperative pain and stress response in patients undergoing MRM. Study Design: A randomized, double-blind, prospective study. Setting: An academic medical center. Methods: Sixty patients with American Society of Anesthesiologists (ASA) physical status I– II (18–60 years old and weighing 50–90 kg) scheduled for MRM were enrolled and randomly assigned into 2 groups (30 in each) to receive a preoperative US Pecs block with 30 mL of 0.25% bupivacaine only (group 1, bupivacaine group [GB]) or 30 mL of 0.25% bupivacaine plus 1 µg/ kg dexmedetomidine (group II, dexmedetomidine group [GD]). The patients were followed-up 48 hours postoperatively for vital signs (heart rate [HR], noninvasive blood pressure [NIBP], respiratory rate [RR], and oxygen saturation [Sao2]), visual analog scale (VAS) scores, time to first request of rescue analgesia, total morphine consumption, and side effects. Serum levels of cortisol and prolactin were assessed at baseline and at 1 and 24 hours postoperatively. Results: A significant reduction in the intraoperative HR, systolic blood pressure (SBP), and diastolic blood pressure (DBP) starting at 30 minutes until 120 minutes in the GD group compared to the GB group (P &lt; 0.05) was observed. The VAS scores showed a statistically significant reduction in the GD group compared to the GB group, which started immediately up until 12 hours postoperatively (P &lt; 0.05). There was a delayed time to first request of analgesia in the GD group (25.4 ± 16.4 hrs) compared to the GB group (17 ± 12 hrs) (P = 0.029), and there was a significant decrease of the total amount of morphine consumption in the GD group (9 + 3.6 mg) compared to the GB group (12 + 3.6 mg) (P = 0.001). There was a significant reduction in the mean serum cortisol and prolactin levels at 1 and 24 hours postoperative in the GD patients compared to the GB patients (P &lt; 0.05). Limitations: This study was limited by its sample size. Conclusion: The addition of 1 µg/kg dexmedetomidine to an US-modified Pecs block has superior analgesia and more attenuation to stress hormone levels without serious side effects, compared to a regular Pecs block in patients who underwent MRM. Key words: Postoperative pain, dexmedetomidine, Pecs block, stress response, breast surgery

Ketamine as an adjunct to bupivacaine in infra-orbital nerve block analgesia after cleft lip repair

ObjectivesWe conducted this study to investigate the safety and analgesic efficacy of the addition of Ketamine to Bupivacaine in bilateral extra-oral infra-orbital nerve block in children undergoing cleft lip surgeries. MethodsSixty patients were randomly allocated into two groups (n=30), Group B received infra-orbital nerve block with 2mL of 0.25% Bupivacaine and Group BK received 0.5mg.kg−1 Ketamine for each side added to 1mL of 0.5% Bupivacaine solution diluted up to 2mL solution to 0.25% Bupivacaine concentration. Assessment parameters included; hemodynamics, recovery time, time to first oral intake, postoperative Faces Legs Activity Cry Consolability (FLACC) scores, Four-point Agitation scores, analgesic consumption and adverse effects. ResultsPatients in Group BK showed lower postoperative FLACC scores during all recorded time points (p<0.0001). Two patients in Group BK versus 12 in Group B requested for postoperative rescue analgesia (p<0.001). There were no differences between groups in time, minutes (min), to first request for rescue analgesia. Patients in Group BK reported lower analgesic consumption (366.67±45.67 vs. 240.0±0.0mg, p<0.04). The time to first oral intake was significantly reduced in Group BK (87.67±15.41 vs. 27.33±8.68min, p<0.001). Lower postoperative Agitation scores were recorded in Group BK patients that reached a statistical significance at 45min (0.86±0.11 vs. 0.46±0.16, p<0.04) and in the first hour (h) postoperatively (1.40±0.17 vs. 0.67±0.14, p<0.003). Higher parent satisfaction scores were recorded in Group BK (p<0.04) without significant adverse effects. ConclusionsThe addition of Ketamine to Bupivacaine has accentuated the analgesic efficacy of infra-orbital nerve block in children undergoing cleft lip repair surgeries.

Dexamethasone Compared to Dexmedetomidine as an Adjuvant to Local Anesthetic Mixture in Peribulbar Block for Vitreoretinal Surgery. A Prospective Randomized Study.

Background:Dexamethasone or dexmedetomidine may improve the quality of peribulbar block.Aim:The aim of this study is to compare the effects of adding either dexamethasone or dexmedetomidine to peribulbar block on the efficacy, intraocular pressure (IOP), time to first analgesic request, total analgesic requirement, and side effects in patients undergoing vitreoretinal surgery.Design:This was a clinical prospective randomized study.Patients and Methods:One hundred and fifty adult patients scheduled for vitreoretinal surgery with peribulbar block were randomized into three groups (50 patients each). Group I received 3.5 ml of 0.5% bupivacaine and 3.5 ml of 2% lidocaine + 1 ml normal Saline. 4 mg dexamethasone and 25 μg dexmedetomidine in 1 ml were added to the local anesthetic mixture in Groups II and III respectively. Onset and duration of sensory and motor blocks, adequate time to start surgery, IOP, time to first request of rescue analgesia, total analgesic consumption, and side effects were recorded. The statistical software SPSS 16 was utilized for statistical analysis.Results:Dexamethasone and dexmedetomidine groups showed significantly prolonged duration of corneal anesthesia (234.07 ± 1.37 and 233.54.1.97 min respectively), prolonged lid and globe akinesia (194.27 ± 1.63 and 194.73 ± 2.35 min respectively) with prolonged time to first request of analgesia and less consumption of rescue analgesia as compared to control group (P < 0.05) with non significant differences between both groups (P > 0.05). The onset of corneal anesthesia as well as lid and globe akinesia were enhanced in dexmedetomidine group compared to the other two groups (P < 0.05). In addition, the measurement of IOP was significantly less in the dexmedetomidine group after 10 min. All the patients were hemodynamically stable with no side effects observed.Conclusion:The addition of dexamethasone and dexmedetomidine to local anesthetic mixture in peribulbar block for vitreoretinal surgeries provided safe and effective block with prolonged duration and decreased requirements of postoperative analgesia with better quality for dexmedetomidine group regarding the fast onset of the block and reduced IOP.

Effect of epidural levobupivacaine with or without dexamethasone soaked in gelfoam for postoperative analgesia after lumbar laminectomy: A double blind, randomised, controlled trial

Background and Aims:Postoperative pain results in prolonged hospital stay and delayed return to normal activity. This study was conducted with the aim of evaluating the analgesic efficacy of gelfoam soaked in levobupivacaine with or without dexamethasone placed in the epidural space in patients undergoing lumbar laminectomy.Methods:Ninety adult patients were randomised into three groups. Gelfoam was soaked in 12 mL of 0.9% sodium chloride in Group P, 10 mL of 0.25% levobupivacaine + 2 mL of 0.9% sodium chloride in Group L, and 10 mL of 0.25% levobupivacaine + 2 mL of dexamethasone in group LD. The primary outcome was time to first request for rescue analgesia. Total 24-h tramadol consumption, and postoperative visual analog scale (VAS) scores were recorded. Chi-square test and analysis of variance test were used, and P < 0.05 was considered significant.Results:75 patients completed the study. Time to first rescue analgesia was longer in group LD [10.11 ± 3.10 h] compared with group L [6.48 ± 2.36 h] and group P [1.76 ± 1.13 h]. Total 24-h tramadol consumption was lower in group LD (88 ± 66.58 mg) and group L (120 ± 70.7 mg) compared with group P (280 ± 64.5 mg). Postoperative VAS scores were lower in group LD and group L compared with group P, both at rest and on movement.Conclusion:Epidural gelfoam soaked in levobupivacaine and dexamethasone prolongs the duration of analgesia and decreases rescue analgesic consumption and VAS score postoperatively, in patients undergoing lumbar laminectomy.

The Effect of Fentanyl or Dexmedetomidine on the Ultrasound-Guided Paravertebral Block for Patients Undergoing Renal Surgeries: Randomized Controlled Trial

Objective: This study aimed to investigate the effect of the continuous paravertebral block using either fentanyl or dexmedetomidine as an additive to bupivacaine in patients undergoing renal surgeries. Methods: Ninety adult patients presented for renal surgeries under general anesthesia and ultrasound-guided continuous paravertebral block were allocated in this study and randomly distributed into three groups. All the patients received a loading and a maintenance doses of local anesthetic mixtures composed of bupivacaine alone in Control group with addition of fentanyl or dexmedetomidine in Fentanyl and Dexmedetomidine groups. The measurements included the postoperative analgesic consumption, the time for the first request for rescue analgesia, postoperative pain scores, hemodynamic parameters, and incidence of complication. Results: The addition of fentanyl or dexmedetomidine to plain bupivacaine in continuous paravertebral block significantly decreased the dose of postoperative morphine consumption from (11.33 ± 5.05 mg) to (7.33 ± 4.59 mg) (7.80 ± 4.15mg), significantly prolonged the time for first request of rescue analgesia from (6.87 ± 3.81 h) to (9.80 ± 4.50 h) (10.80 ± 5.22 h), and significantly decrease VAS score 2 h and 6 h postoperatively with insignificant difference between fentanyl and dexmedetomidine (p>0.05). Conclusion: Fentanyl or dexmedetomidine can be helpful as an adjuvant to bupivacaine (0.25%) in the continuous paravertebral block as they decreased the postoperative analgesic consumption without increased incidence of complication.

Efficacy of Magnesium Sulfate Added to Local Anesthetic in a Transversus Abdominis Plane Block for Analgesia Following Total Abdominal Hysterectomy: A Randomized Trial

Background: Major abdominal surgeries are associated with severe pain, which can affect respiratory and cardiac functions if insufficiently treated; this increases postoperative morbidity. Objective: We aim at evaluating the efficacy of magnesium sulfate as an adjuvant to local anesthetic in an ultrasound-guided transversus abdominis plane (TAP) block for postoperative analgesia in total abdominal hysterectomy. Study Design: A prospective, randomized, double-blinded clinical trial. Setting: An academic medical center. Methods: This study is registered at https://clinicaltrials.gov (no.: NCT02930707). This randomized, double-blinded clinical trial included 60 women undergoing total abdominal hysterectomy that were divided into 2 groups (30 patients per group). Group I received a TAP block with 20 mL per side of 0.25% bupivacaine plus 2 mL magnesium sulphate 10% (200 mg). Group II received a TAP block with 20 mL per side of 0.25% bupivacaine. Visual analog scale (VAS) scores, the time of the first analgesic request, total morphine consumption, and any side effects were assessed and recorded. Results: The mean postoperative VAS score was significantly reduced in group I compared to group II in all of the time-points except after 10 hours. The mean time of the first request for rescue analgesia was significantly prolonged in group I (15.67 hrs.) compared to group II (7.33 hrs.) (P &lt; 0.001), and the mean total morphine consumption, over the first 24 hours postoperatively, was significantly lower in group I (7.63 ± 2.93 mg) than in group II (16.20 ± 3.24 mg) (P &lt; 0.001). No significant difference in side effects was observed. Limitations: Sample size. Conclusion: The addition of 200 mg of magnesium sulfate to bupivacaine in an ultrasound-guided TAP block significantly reduced postoperative opioid requirements, prolonged the duration of analgesia, and reduced the VAS score in patients who underwent abdominal hysterectomy, without significant side effects. Key words: Magnesium sulfate, TAP block, postoperative pain, total abdominal hysterectomy

The effect of morphine added to bupivacaine in ultrasound guided transversus abdominis plane (TAP) block for postoperative analgesia following lower abdominal cancer surgery, a randomized controlled study

ObjectivesTransversus abdominis plane (TAP) block used for management of surgical abdominal pain by injecting local anesthetics into the plane between the internal oblique and transversus abdominis muscles. We aimed to explore the effect of adding morphine to bupivacaine in ultrasound guided TAP-block in patients undergoing lower abdominal cancer surgery. Study designRandomized, double-blind, prospective study. Clinical trial identifier: NCT02566096. SettingAcademic medical center. PatientsSixty patients were enrolled in this study after ethical committee approval. InterventionsPatients divided into 2 groups (30 each): Bupivacaine group (GB): given ultrasound guided TAP-block 20ml 0.5% bupivacaine diluted in 20ml saline; Morphine group (GM): given ultrasound guided TAP-block with 20ml 0.5% bupivacaine+10mg morphine sulphate diluted in 20ml saline. MeasurementsPatients were observed for total morphine consumption, time for first request of rescue analgesia, sedation scores, hemodynamics and side effects for 24h postoperatively. ResultsMorphine added to bupivacaine in TAP block compared to bupivacaine alone reduced total morphine consumption (5.33±1.28mg) (10.70±3.09mg) respectively (p<0.001), prolonged the time to first request of analgesia (10.40±4.96h) (6.97±3.26h) respectively (p<0.008), with a statistically significant decrease in (VAS-M) in GM compared with GB at 12h postoperatively (p<0.002). No significant differences in hemodynamics, respiratory rate, oxygen saturation, sedation score, and side effects except for nausea were observed (p>0.05). ConclusionAddition of morphine to bupivacaine in TAP block is effective method for pain management in patients undergoing major abdominal cancer surgery without serious side effects.

Efficacy of Preoperative Administration of Paracetamol-Codeine on Pain following Impacted Mandibular Third Molar Surgery: A Randomized, Split-Mouth, Placebo-Controlled, Double-Blind Clinical Trial

Objectives. The aim of this study was to determine the effectiveness of preoperative administration of single-dose of paracetamol-codeine, in the relieving of acute postoperative pain after the surgical removal of an impacted mandibular third molar. Materials and Methods. The study cohort consisted of 32 Caucasian outpatients, giving a total of 64 bilateral symmetrical impacted mandibles. Patients were randomized in two experimental groups to receive a preoperative oral dose of paracetamol-codeine (analgesic group) or a placebo (placebo group) at the first and second surgeries. Study participants were asked to record pain intensity scores during the operation and the next 2 days, the time of the first request for rescue analgesic, and the total number of postoperative-supplement paracetamol-codeine tablets. Results. The pain intensity score on the first day was significantly lower in the analgesic group than in the placebo group (p < 0.001). The time to using rescue therapy was significantly longer in the analgesic group than in the placebo group (p = 0.004). The number of paracetamol-codeine tablets used postoperatively did not differ between the analgesic and placebo groups (p = 0.104). Conclusions. Preoperative paracetamol-codeine is effective in providing immediate postoperative pain control after third molar surgery and in delaying the initial onset of pain. This trial is registered with ClinicalTrials.gov Identifier (Registration Number): NCT03049878.

Effect of Verapamil as an Adjuvant to Levobupivacaine in Supraclavicular Brachial Plexus Block.

Background:Many adjuvants have been used with local anesthetics to reduce the time of onset and prolong the duration of analgesia in brachial plexus blocks. However, few studies are there using verapamil as an adjuvant with levobupivacaine.Aims:This study aims to study the effects of verapamil as adjuvant to levobupivacaine in supraclavicular block for upper extremity surgery.Methods:In this double-blinded clinical trial, 60 American Society of Anesthesiologist Class I and II patients posted to undergo upper extremity surgery were divided into 2 different groups randomly. In Group A, the patients received 30 ml levobupivacaine 0.5% plus 2 ml normal saline and Group B patients received 30 ml levobupivacaine 0.5% plus 5 mg verapamil diluted to 2 ml normal saline for supraclavicular block. Time of request for rescue analgesia, onset and duration of sensory motor blocks and changes in hemodynamic parameters were studied and analyzed. P < 0.001 was considered statistically significant.Results:Time for a request for rescue analgesia was 425.80 ± 90.46 min in Group B and 366.13 ± 70.42 min in Group A which was clinically significant. The mean of sensory and motor block onset time in Group B was less than in Group A, the difference between the two groups being statistically significant (P < 0.001). In Group A, mean duration of sensory block was 316.13 ± 91.08 min and in Group B was 375.83 ± 114.48 min, which was statistically significant (P < 0.001).Conclusion:The addition of verapamil as an adjuvant to levobupivacaine in brachial plexus blockade delayed the requirement of rescue analgesia with decreased onset time and prolonged duration of sensory and motor block characteristics.

Postoperative Analgesic Efficacy of Bilateral Transversus Abdominis Plane Block in Patients Undergoing Midline Colorectal Surgeries Using Ropivacaine: A Randomized, Double-blind, Placebo-controlled Trial.

Background:Ultrasound-guided transversus abdominis plane (TAP) block is done as a part of multimodal analgesia for pain relief after abdominal surgeries. This prospective randomized, double-blind, placebo-controlled trial was conducted to evaluate the postoperative analgesic efficacy of bilateral TAP block in patients undergoing midline colorectal surgeries using ropivacaine.Materials and Methods:Eighty patients scheduled for elective colorectal surgeries involving midline abdominal wall incision under general anesthesia were enrolled in this prospective randomized controlled trial. Group A received TAP block with 20 ml of 0.2% ropivacaine on either side of the abdominal wall, and Group B received 20 ml of normal saline. The time to request for rescue analgesia, total analgesic consumption in 24 h, and satisfaction with the anesthetic technique were assessed.Results:The mean visual analog scale scores at rest and on coughing were higher in control group (P > 0.05). Time (min) to request for the first rescue analgesia was prolonged in study group compared to control group (P < 0.001). The total tramadol consumption in 24 h postoperatively was significantly high in control group (P < 0.001). Nausea/vomiting was more common in control group (P > 0.05). The level of satisfaction concerning postoperative pain control/anesthetic technique was higher in study group (P < 0.001).Conclusion:TAP block produces effective and prolonged postoperative analgesia in patients undergoing midline colorectal surgery. It is a technically simple block to perform with a high margin of safety. It produces a considerable reduction in mean intravenous postoperative tramadol requirements, reduction in postoperative pain scores, and increased time to first request for further analgesia, both at rest and on movement.

Efficacy and Safety of Ketamine Added to Local Anesthetic in Modified Pectoral Block for Management of Postoperative Pain in Patients Undergoing Modified Radical Mastectomy

Background: Breast surgery is an exceedingly common procedure with an increased incidence of acute and chronic pain. Pectoral nerve block is a novel peripheral nerve block alternative to neuro-axial and paravertebral blocks for ambulatory breast surgeries. Objectives: This study aims to compare the analgesic efficacy and safety of modified Pecs block with ketamine plus bupivacaine versus bupivacaine in patients undergoing breast cancer surgery. Study Design: A randomized, double-blind, prospective study. Setting: Academic medical center. Methods: This study is registered at www.clinicaltrials.gov under number: (NCT02620371) after approval by the ethics committee of South Egypt Cancer Institute, Assuit University, Assuit, Egypt. Sixty patients aged 18 – 60 years scheduled for modified radical mastectomy were enrolled and randomly assigned into 2 groups (30 patients each): Control group patients were given ultrasound-guided, Pecs block with 30 mL of 0.25% bupivacaine only. Ketamine group patients were given ultrasound-guided, Pecs block with 30 mL of 0.25% bupivacaine plus ketamine hydrochloride (1 mg/kg). Patients were followed up for 48 hours postoperatively for vital signs, VAS score, first request of rescue analgesia and total morphine consumption, sedation score, and side effects. Results: Ketamine plus bupivacaine in Pecs block compared to bupivacaine alone prolonged the mean time of first request of analgesia (18.25 ± 1.98), (12.56 ± 2.64), respectively (P &lt; 0.001), reduced total morphine consumption (12.50 ± 4.63), (18.86 ± 6.28), respectively (P = 0.016). With no significant difference in hemodynamics, respiratory rate, oxygen saturation, VAS and sedation scores, and side effects observed between the 2 groups (P &gt; 0.05). Limitations: This study is limited by its sample size. Conclusion: The addition of ketamine to modified Pecs block prolonged the time to first request of analgesia and reduced total opioid consumption without serious side effects in patients who underwent a modified radical mastectomy. Key words: Ketamine, bupivacaine, pecs block, postoperative, pain, breast cancer

The effects of perineural dexmedetomidine on the pharmacodynamic profile of femoral nerve block: a dose-finding randomised, controlled, double-blind study.

This randomised, controlled, double-blind study investigated the effects of different doses of perineural dexmedetomidine on the pharmacodynamic profile of femoral nerve block in patients undergoing arthroscopic knee surgery. Ultrasound-guided femoral nerve block was performed before general anaesthesia using 25ml of bupivacaine 0.5% combined with normal saline in the control group, and 25μg, 50μg or 75μg of dexmedetomidine in three treatment groups (n=15 for each group). All patients received a standard general anaesthetic and multimodal postoperative analgesic regimen. The use of the 50μg and 75μg dose levels of dexmedetomidine was associated with reduction of the onset time, extension of the duration of block, prolonged time to the first postoperative request for rescue analgesia, and reduced postoperative morphine requirements. The times to first request for postoperative analgesia were mean (SD) 10.8 (1.6)h in the control group and 11.0 (7.1), 21.8 (3.0) and 28.6 (10.0) in the 25μg, 50μg and 75μg treatment groups, respectively. These times were significantly longer in the 50μg and 75μg treatment groups compared with the 25μg (p<0.0001) and control group (p<0.0001). The total 24-h postoperative morphine consumption was 7.6 (5.1)mg in the control group, and 6.5 (3.5), 3.9 (3.4), 1.8 (2.6) in the 25μg, 50μg and 75μg treatment groups, respectively. Postoperative morphine consumption was significantly higher in the control group compared with the 50μg (p=0.045) and the 75μg (p=0.001) treatment groups. The best analgesic profile was achieved at the 75μg dose, but this was associated with increased risk of hypotension.

Intrathecal Dexmedetomidine, Ketamine, and their Combination Added to Bupivacaine for Postoperative Analgesia in Major Abdominal Cancer Surgery

Background: Intrathecal ketamine has been studied extensively in animals, but rarely in humans. Intrathecal dexmedetomidine prolongs the duration of spinal anesthesia. Objective: To investigate the efficacy and safety of intrathecal dexmedetomidine, ketamine, or both when added to bupivacaine for postoperative analgesia in major abdominal cancer surgery. Design: Double-blinded, randomized, controlled trial. Setting: Academic medical center. Methods: Ninety patients were randomly allocated to receive either intrathecal 10 mg of hyperbaric bupivacaine 0.5% and 5 µg of dexmedetomidine (group I, n = 30), 10 mg of hyperbaric bupivacaine 0.5% and 0.1 mg/kg ketamine (group II, n = 30), or 10 mg of hyperbaric bupivacaine 0.5% and 5 µg of dexmedetomidine plus 0.1 mg/kg of ketamine (group III, n = 30). Hemodynamics, pain score, time to first request of analgesia, total PCA morphine consumption, sedation score, and adverse effects in the first 24 hours postoperatively were recorded. Results: Time to first request of analgesia was longer in group II (7.42 ± 1.43 h) and group III (13.00 ± 7.31h) compared to group I (3.50 ± 1.57 h). PCA morphine consumption was less in group III (6.67 ± 2.8 mg) compared to group I (9.16 ± 3.63 mg) and group II (8.66 ± 3.49 mg). Group III showed lower postoperative pain scores, and a higher incidence of postoperative sedation (P &lt; 0.03). Limitations: This study is limited by its relatively small sample size. Conclusion: In conclusion, the combination of intrathecal dexmedetomidine and ketamine provided superior postoperative analgesia, prolonged the time to first request of rescue analgesia, and reduced the total consumption of PCA morphine, without serious side effects compared to either drug alone. Key words: Intrathecal, ketamine, dexmedetomidine, lower abdominal cancer surgery

Ultrasound-guided single- vs double-level thoracic paravertebral block for postoperative analgesia in total mastectomy with axillary clearance

ObjectivesThoracic paravertebral block (TPVB) for breast surgery reduces acute and chronic postoperative pain. Using ultrasound for administering the block makes it easier, with its administration at multiple levels decreasing the number of unblocked segments. We conducted this study to evaluate the efficacy and safety of single- vs double-level ultrasound-guided TPVB in patients undergoing total mastectomy with axillary clearance under general anesthesia. DesignThis is a prospective, randomized study. SettingRecovery room and operation theater. PatientsSixty ASA I and II patients, aged 18 to 60 years, who were scheduled to undergo total mastectomy with axillary clearance under general anesthesia were enrolled in the study. InterventionsPatients received either single- (group S) or double-level (group D) ultrasound-guided TPVB at T4 or at T2 and T5 levels, respectively, using 0.3 mL/kg of 0.5% ropivacaine. MeasurementsPrimary outcome measure was 24-hour analgesic consumption, and secondary outcomes included number of segments blocked, postoperative pain scores, time to first request for rescue analgesic, and any side effects. ResultsThe mean total amount of rescue analgesic given in group S was 175.3 ± 70 mg and in group D was 115.7 ± 48 mg (P = .002). Median number of segments showing less sensation to pinprick was 3 in group S and 4 in group D (P < .001). The mean time to first request for rescue analgesic was 533 ± 124 minutes in group S and was 611 ± 214 minutes in group D (P = .118). ConclusionPatients receiving double-level TPVB had significantly less 24-hour analgesic consumption in the postoperative period than those in the single-level TPVB group. This could be due to decreased pain sensation to pinprick in significantly greater number of segments in the double-level TPVB group.