Significant Analgesic Benefit Research Articles

Continuous wound infusion catheter as part of a multimodal analgesia regimen for post-Caesarean delivery pain: a quality improvement impact study

BackgroundThe role of continuous wound infusion catheters as part of a multimodal analgesia strategy after Caesarean delivery is unclear. We introduced continuous wound infusion catheters to our multimodal analgesia regimen to evaluate the impact on analgesic outcomes after Caesarean delivery. MethodsAfter institutional review board (IRB) approval, a 4-month practice change was instituted as a quality improvement initiative. In addition to multimodal analgesia, continuous wound infusion catheters for up to 3 days were offered on alternate weeks for all women undergoing Caesarean deliveries. The primary outcome was postoperative in-hospital opioid consumption. Secondary outcomes were static and dynamic pain scores at 24 and 72 h, time until first analgesic request, opioid-related side-effects, length of stay, satisfaction (0–100%), and continuous wound infusion catheter-related complications. ResultsAll women scheduled for Caesarean delivery (n=139) in the 4-month period were included in the analysis, with 70 women receiving continuous wound infusion catheters, and 69 in the control group. Opioid consumption (continuous wound infusion catheter group 11.3 [7.5–61.9] mg morphine equivalents vs control group 30.0 [11.3–48.8] mg morphine equivalents), pain scores (except 24 h resting pain scores which were higher in the control group 2 [1–3] vs 1.5 [0–3] in the continous wound infusion catheters group; P=0.05), side-effects, length of stay, and complications were similar between groups. Satisfaction scores at 24 h were higher with continuous wound infusion catheters (100% [91–100%] vs 90% [86–100%]; P=0.003) with no differences at 72 h. One patient demonstrated symptoms of systemic local anaesthetic toxicity which resolved without significant harm. ConclusionsThe addition of continuous wound infusion catheters to a multimodal analgesia regimen for post-Caesarean delivery pain management demonstrated minimal clinically significant analgesic benefits. Future studies are needed to explore the use of continuous wound infusion catheters in populations that may benefit most from this intervention.

ID: 209955 Dorsal Root Ganglion Stimulation as an Effective Modality for Pelvic Pain From Rectal Cancer

Cancer related pelvic pain severely impairs the quality of life and can be resistant to a variety of interventions. Neuromodulation is emerging as a potential avenue to manage pain and improve quality of life. Unlike Spinal cord stimulators (SCS), dorsal root ganglion (DRG) stimulation targets focal areas and is an attractive target for neurostimulation. Over the past decade, DRG stimulation has become a part of the armamentarium to effectively treat discrete areas of pain particularly resistant to other interventional modalities. A case series showed significant analgesic benefit from DRG stimulation with L1/S2 lead placement in patients with chronic pelvic pain resistant to a variety of other therapies.

Bromelain does not provide significant analgesic and anti-inflammatory benefits over placebo in cats undergoing ovariohysterectomy.

To evaluate the efficacy and safety of bromelain to control pain and inflammation in cats undergoing ovariohysterectomy. 30 client-owned cats undergoing ovariohysterectomy. In a randomized, blinded clinical study, cats were assigned to receive either oral bromelain suspension (40 mg/kg [18 mg/lb]; BG, n = 15) or placebo solution (0.1 mL/kg [0.045 mL/lb]; PG, 15), which were administered 90 minutes before and 12 hours after surgery. The anesthetic protocol included acepromazine, meperidine, propofol, and isoflurane. Pain and sedation were assessed at various time points up to 24 hours post-extubation using the UNESP-Botucatu multidimensional composite pain scale, the Glasgow feline composite measure pain scale, and a descriptive numerical scale. Surgical wound inflammation was measured at the same time points, using a numeric rating scale. Morphine was administered as rescue analgesia. Laboratory data (urea, creatinine, gamma-glutamyl transferase, alkaline phosphatase, the prothrombin time, and the fecal occult blood) were analyzed preoperatively and 24 hours after surgery. Pain/inflammation scores, and analgesic requirements did not differ between groups. Shorter recovery time and lower sedation scores were recorded during the first hour post-extubation in the BG than the PG. Postoperatively, serum creatinine and gamma-glutamyl transferase were lower in the BG compared to PG. Compared to baseline values, all biochemistry variables decreased at 24 hours in the BG. The prothrombin time and fecal occult blood did not differ between groups or over time. Bromelain did not provide significant analgesic and anti-inflammatory benefits over placebo in cats undergoing ovariohysterectomy.

Significant Analgesic Benefits of Perioperative Duloxetine in Patients Who Have Depressive Symptoms Undergoing Total Hip Arthroplasty: A Randomized Controlled Trial

BackgroundMajor symptoms of depression are commonly observed in patients requiring total hip arthroplasty (THA), and this is associated with increased pain scores and opioid consumption. We aimed to investigate the analgesic effect of duloxetine in these high-risk patients. MethodsAmong 263 patients scheduled for primary unilateral THA, 67 patients who scored at least 8 on the 17-item Hamilton Depression Scale (HAMD) were enrolled in this study. Patients were randomized to the duloxetine group (60 mg daily, from the day of surgery to postoperative day 6) or the placebo group. The postoperative visual analog scale (VAS) score during walking, the VAS score during hip flexion, and resting VAS score was measured. Postoperative morphine consumption, hip range of motion (ROM), Harris hip score (HHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function, postoperative length of stay (LOS), and adverse events were recorded. ResultsThe duloxetine group had significantly lower VAS scores during walking and hip flexion from postoperative day 3 to week 3 than the placebo group. With regard to the resting VAS score, duloxetine showed a better analgesic effect from postoperative day 3 to week 2 than placebo. Patients in the duloxetine group had less consumption of morphine. The duloxetine group exhibited better hip function scores, including ROM, HHS, and WOMAC function scores than the placebo group. No significant difference was observed in LOS or adverse events between groups. ConclusionPerioperative short-term duloxetine provides advantages in decreasing pain, reducing morphine consumption, and increasing hip function in THA patients who have depressive symptoms.

Effects of Lidocaine Injection at Acupuncture Points on Perioperative Analgesia in Cats Undergoing Ovariohysterectomy.

Pharmacopuncture is an acupuncture-related technique that has been used to amplify the therapeutic effects of different medications. To investigate the analgesic efficacy of a lidocaine injection at acupoints in cats undergoing ovariohysterectomy. Thirty cats were randomly distributed into two groups (n = 15, per group). The experimental group received a bilateral administration of lidocaine at the following acupoints: Stomach 36 (ST-36) and Spleen 6 (SP-6) (Lido group). The control group did not receive lidocaine (Control group). All cats were sedated with dexmedetomidine and anesthesia was induced with propofol and maintained with isoflurane. Intraoperatively, fentanyl was given to control cardiovascular responses to surgical stimulation. Postoperative pain was assessed at various time points, up to 24 hours after extubation, using the UNESP-Botucatu multidimensional composite pain scale (MCPS) and Glasgow feline composite measure pain scale (CMPS-Feline). Sedation scores were measured at the same time points. Morphine/meloxicam was administered as rescue analgesia. Data were analyzed using t-tests, Fisher´s exact test, the Mann-Whitney test, and the Friedman test (p < 0.05). Intraoperatively, more cats in the Control group required analgesic supplementation than those in the Lido group, but the difference was not significant (p = 0.65). Postoperative pain, sedation scores, and analgesic requirements did not differ between groups. Rescue analgesia was given to 67% (10/15) of the cats in each group. The administration of lidocaine at ST-36 and SP-6 acupuncture points did not provide significant perioperative analgesic benefits in healthy cats undergoing ovariohysterectomy.

Perioperative analgesic efficacy and safety of erector spinae plane block in posterior cervical spine surgery: a double-blinded, randomized controlled study

<h3>BACKGROUND CONTEXT</h3> Posterior cervical spine surgeries (PCSS) are typically open surgeries and entail significant postoperative pain. Current perioperative pain management in PCSS is reliant on multimodal analgesia. While perioperative epidural anesthetic infusion can be used in lumbar surgeries, this is not an option in the cervical spine. Pre-emptive regional analgesia through erector spinae plane block (ESPB) has shown significant perioperative analgesic benefits in lumbar spine surgeries. There are no such clinical studies in PCSS. <h3>PURPOSE</h3> To assess the safety and efficacy of ultrasound-guided ESPB for perioperative analgesia in PCSS. <h3>STUDY DESIGN</h3> Prospective, randomized controlled, double-blinded study. <h3>PATIENT SAMPLE</h3> This study included 86 patients requiring sub-axial PCSS with or without instrumentation randomized into two groups, those who underwent ESPB with multimodal analgesia (case) and those with only multimodal analgesia (control). <h3>OUTCOME MEASURES</h3> Demographic and surgical data (blood loss, duration of surgery, perioperative total opioid consumption, muscle relaxants used) were assessed. Postoperatively, the surgical site pain, alertness scale, satisfaction score, time to mobilization and complications were recorded. <h3>METHODS</h3> After anesthesia and prone position, case patients received ultrasound-guided ESPB at the T1 level using 15ml of 0.25% bupivacaine and 8mg dexamethasone bilaterally while the control patients received only standard postoperative multimodal analgesia. <h3>RESULTS</h3> Each group included 43 patients; the two groups were identical in demographic and surgical profile. The intraoperative opioid consumption (119.53±40.35 vs 308.6±189.78; p<0.001) in mcg), muscle relaxant usage (50.00±0.00 mg vs 59.53±3.75 mg, p<0.001), surgical duration (124.77±26.63/ 156.74±37.01 mins; p<0.01) and intraoperative blood loss (310.47±130.73 ml vs 429.77±148.50 ml; p<0.05) were significantly less in the ESPB group. In the postoperative period, the control group's pain score was significantly higher (p<0.001). The Modified Observer Alertness/Sedation Score (MOASS) score and satisfaction scores also showed significant differences between the case and control groups (p<0.001). The mean time required to ambulate (sitting/walking) was statistically less in cases (15.81±6.15/20.72±4.02 hours) when compared to controls (16.86±6.18/ 23.05±8.88 hours) (p<0.001). <h3>CONCLUSION</h3> In patients undergoing PCSS, ESPB is a safe and effective technique with better outcomes than standard multi-modal analgesia alone, in terms of reduced intraoperative opioid requirements and blood loss, better postoperative analgesia and early mobilization. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Perioperative analgesic efficacy and safety of erector spinae plane block in posterior cervical spine surgery—a double blinded, randomized controlled study

Background contentPosterior cervical spine surgery (PCSS) are typically open surgeries and entail significant postoperative pain. Current perioperative pain management in PCSS is reliant on multimodal analgesia. While perioperative epidural anesthetic infusion can be used in lumbar surgeries, this is not an option in the cervical spine. Pre-emptive regional analgesia through erector spinae plane block (ESPB) has shown significant perioperative analgesic benefits in lumbar spine surgeries. There are no such clinical studies in PCSS. PurposeTo assess the safety and efficacy of ultrasound-guided ESPB for perioperative analgesia in PCSS. Study designProspective, randomized controlled, double-blinded study. Patient sampleEighty-six patients requiring sub-axial PCSS with or without instrumentation were randomized into two groups, those who underwent ESPB with multimodal analgesia (case) and those with only multimodal analgesia (control). Outcome measuresDemographic and surgical data (blood loss, duration of surgery, perioperative total opioid consumption, muscle relaxants used) were assessed. Postoperatively, the surgical site pain, alertness scale, satisfaction score, time to mobilization and complications were recorded. MethodsAfter anesthesia and prone position, case patients received ultrasound-guided ESPB at the T1 level using 15 ml of 0.25% bupivacaine and 8 mg Dexamethasone bilaterally while the control patients received only standard postoperative multimodal analgesia. ResultsThere were 43 patients in each group; the two groups were identical in demographic and surgical profile. The intraoperative opioid consumption (119.53±40.35 vs. 308.6±189.78; p<.001) in mcg), muscle relaxant usage (50.00±0.00 mg vs. 59.53±3.75 mg, p<.001), surgical duration (124.77±26.63/ 156.74±37.01 min; p<.01) and intraoperative blood loss (310.47±130.73 ml vs. 429.77±148.50 ml; p<.05) were significantly less in the ESPB group. In the postoperative period, the control group's pain score was significantly higher (p<.001). The Modified Observer Alertness/Sedation Score (MOASS) score and satisfaction scores also showed significant differences between the case and control groups (p<.001). The mean time required to ambulate (sitting/walking) was statistically less in cases (15.81±6.15/20.72±4.02 h) when compared to controls (16.86±6.18/ 23.05±8.88 h; p<.001). ConclusionIn patients undergoing PCSS, ESPB is a safe and effective technique with better outcomes than standard multimodal analgesia alone, in terms of reduced intraoperative opioid requirements and blood loss, better postoperative analgesia and early mobilization.

A Systematic Review and Meta-Analysis of Efficacy of Ultrasound-Guided Single-Shot Quadratus Lumborum Block for Postoperative Analgesia in Adults Following Total Hip Arthroplasty.

To evaluate the efficacy of ultrasound-guided single-shot quadratus lumborum block (QLB) for postoperative analgesia in adults following total hip arthroplasty (THA). Systematic review and meta-analysis. Perioperative period. Adult patients undergoing THA. Studies were identified by performing searches in the following electronic databases, PubMed (Medline), Cochrane Central Registry of Trials (CENTRAL), and Google Scholar. We sought studies in adult patients undergoing THA, comparing QLB with a control group (no block, sham block or any other ultrasound guided regional nerve blocks). A total of 774 patients from 10 studies (7 randomized controlled, one controlled clinical and two retrospective study) were included in this meta-analysis. The 24 hour opioid consumption was similar in both the groups (WMD -4.09; 95% CI [-9.00, 0.83]; P = 0.10; I2 = 95%). The pain scores at rest at 24 hours was significantly less in QLB group (WMD -0.62; 95% CI [-1.15, -0.10]; P = 0.02; I2 = 75%). The difference in pain scores was however not clinically significant. The pain scores on movement at 24 hours, time to first analgesic request, and time to discharge from hospital were similar in both the groups. QLB as part of multimodal analgesia did not result in any significant analgesic benefits in patients undergoing hip arthroplasty in terms of either postoperative opioid consumption or pain scores at rest and on movement. Overall, the level of certainty is low. Further, well-designed trials are required to verify the results.

Methylprednisolone Does Not Reduce Acute Postoperative Pain After Cardiac Surgery: Subanalysis of a Randomized Clinical Trial.

Pain after cardiac surgery is largely treated with opioids, but their poor safety profile makes nonopioid medications attractive as part of multimodal pathways. Anti-inflammatory drugs reduce acute postoperative pain, but the role of steroids in reducing acute poststernotomy pain is unclear. We evaluated the association between the intraoperative administration of methylprednisolone and postoperative analgesia, defined as a composite of pain scores and opioid consumption, during the initial 24 hours after cardiac surgery. We conducted a post hoc retrospective analysis of a large clinical trial in which adults having cardiac surgery were randomized 1:1 to receive 2 intraoperative doses of 250 mg IV methylprednisolone or placebo. Pain scores and opioid consumption were collected during the initial 24 hours after surgery. Methylprednisolone was considered to be associated with better pain control than placebo if proven noninferior (not worse) on both pain scores (defined a priori with delta of 1 point) and opioid consumption (delta of 20%) and superior to placebo in at least 1 of the 2 outcomes. This test was repeated in the opposite direction (testing whether placebo is better than methylprednisolone on postoperative pain management). Of 251 eligible patients, 127 received methylprednisolone and 124 received placebo. Methylprednisolone was noninferior to placebo on pain with difference in mean (CI) pain scores of -0.25 (-0.71 to 0.21); P < .001. However, methylprednisolone was not noninferior to placebo on opioid consumption (ratio of geometric means [CI]: 1.11 [0.64-1.91]; P = .37). Because methylprednisolone was not noninferior to placebo on both outcomes, we did not proceed to superiority testing based on the a priori stopping rules. Similar results were found when testing the opposite direction. In this post hoc analysis, we could not identify a beneficial analgesic effect after cardiac surgery associated with methylprednisolone administration. There are currently no data to suggest that methylprednisolone has significant analgesic benefit in adults having cardiac surgery.

Oral morphine analgesia for preventing pain during invasive procedures in non-ventilated premature infants in hospital: the Poppi RCT

Background Identifying better pain management strategies for painful procedures performed in neonatal care is a clinical priority. Retinopathy of prematurity screening and heel-lance blood tests are essential clinical procedures, but adequate pain relief is not currently provided because of a lack of evidence-based analgesia. Morphine provides effective analgesia in older children and adults, but efficacy in infants is controversial. Morphine is, however, commonly used intravenously for sedation in ventilated infants. Objective The primary objective was to investigate whether or not a single 100 µg/kg morphine sulphate dose administered orally prior to painful clinical procedures provides effective analgesia. Design Single-centre, prospective, randomised controlled trial. Setting John Radcliffe Hospital, Oxford, UK. Participants Thirty-one infants of 34–42 weeks’ gestational age, requiring a heel lance and retinopathy of prematurity screening on the same test occasion. Interventions The study interventions were 100 µg/kg of oral morphine sulphate (intervention arm) or placebo (control arm) 1 hour before the clinically required procedures. Main outcome measures There were two co-primary outcomes: Premature Infant Pain Profile-Revised score (a higher score implies more nociceptive processing) during the 30-second period after retinopathy of prematurity screening, and the magnitude of noxious-evoked brain activity (a higher activity implies more nociceptive processing) following the heel lance. Physiological stability and safety were secondary outcomes. Results After 31 participants were randomised (30 studied and one withdrew), the predefined safety stopping boundary was passed as 3 of the 15 infants who received morphine had apnoeas requiring resuscitation with non-invasive positive-pressure ventilation in the 24 hours after drug administration, compared with 0 of the 15 infants who received placebo [difference in proportion 0.2, 80% confidence interval (adjusted to allow for planned multiple analyses) 0.05 to 1.00; p = 0.085]. The trial was therefore stopped because of profound respiratory adverse effects of morphine without suggestion of analgesic efficacy. There was no significant difference between the trial arms for either primary outcome (Premature Infant Profile-Revised score following retinopathy of prematurity screening mean score ± standard deviation – morphine: 11.1 ± 3.2; Premature Infant Pain Profile-Revised score following retinopathy of prematurity screening mean score ± standard deviation – placebo: 10.5 ± 3.4; mean difference in Premature Infant Pain Profile-Revised score following retinopathy of prematurity screening score 0.5, 95% confidence interval –2.0 to 3.0, p = 0.66; noxious-evoked brain activity following heel lancing median activity – morphine: 0.99, interquartile range 0.40–1.56; noxious-evoked brain activity following heel lancing median activity – placebo: 0.75, interquartile range 0.33–1.22; and median difference in noxious-evoked brain activity following heel lancing 0.25, 95% confidence interval –0.16 to 0.80, p = 0.25). Limitations The trial lacked power for the primary outcome measures because of early cessation. However, there was a trend across modalities favouring placebo, suggesting that it was unlikely that a clinically significant analgesic benefit would have been detected in the original proposed sample of 156 infants. Conclusions The administration of 100 µg/kg of oral morphine to non-ventilated premature infants has the potential for harm without analgesic benefit. Oral morphine is not recommended for retinopathy of prematurity screening, and caution is strongly advised if this is being considering for other acute painful procedures in non-ventilated premature infants. Future work Further clinical trials are essential to ascertain effective pain management for retinopathy of prematurity screening. Using multimodal measures with detailed physiological recordings provides a rigorous approach to assess analgesic efficacy and adverse effects, leading to greater mechanistic understanding of the drug effects. This is essential in future clinical trials of analgesics in infants. Patient and public involvement The research team worked closely with an on-site charity during the trial design, conduct, oversight and dissemination. Trial registration Clinical Controlled Trials ISRCTN82342359; EudraCT 2014-003237-25. Funding This project was funded by the Efficacy and Mechanism Evaluation programme, a Medical Research Council and National Institute for Health Research partnership. Funding was also received for the trial from the Wellcome Trust (reference numbers 095802 and 102076). The report will be published in full in Efficacy and Mechanism; Vol. 6, No. 9. See the National Institute for Health Research’s Journals Library website for further project information.

Ketamine Infusions for Chronic Pain: A Systematic Review and Meta-analysis of Randomized Controlled Trials

IV ketamine is widely used to treat patients with chronic pain, yet the long-term impact remains uncertain. We synthesized evidence from randomized control trials to investigate the effectiveness of IV ketamine infusions for pain relief in chronic conditions and to determine whether any pain classifications or treatment regimens are associated with greater benefit. We searched Medline, Embase, and Google Scholar, as well as the clinicaltrials.gov website from inception through December 16, 2017 for randomized control trials comparing IV ketamine to placebo infusions for chronic pain that reported outcomes for ≥48 hours after the intervention. Three authors independently screened the studies, pooled the data, and appraised risk of bias. Random-effects model was used to calculate weighted mean differences for pain scores and secondary outcomes. Our primary outcome was the lowest recorded pain score ≥48 hours after cessation of treatment. Secondary outcomes included responder rate and adverse effects. Among 696 studies assessed for eligibility, 7 met inclusion criteria. All studies except one were at high risk of bias. These studies randomly assigned 211 patients with neuropathic (n = 2), mixed (n = 2), and nonneuropathic (nociplastic or nociceptive) (n = 3) pain. Three studies reported significant analgesic benefit favoring ketamine, with the meta-analysis revealing a small effect up to 2 weeks after the infusion (mean difference in pain scores, -1.83 points on a 0-10 numerical rating scale; 95% CI, -2.35 to -1.31 points; P < .0001). In the 3 studies that reported responder rates, the proportion with a positive outcome was greater in the ketamine than in the placebo group (51.3% vs 19.4%; relative risk, 2.43; 95% CI, 1.10-5.40; P = .029; I = 0.0%). No differences were noted based on pain classification or condition. Compared to low-dose ketamine studies and investigations that evaluated non-complex regional pain syndrome conditions, a small but nonsignificant greater reduction in pain scores was found among studies that either utilized high-dose ketamine therapy (P = .213) or enrolled complex regional pain syndrome patients (P = .079). Evidence suggests that IV ketamine provides significant short-term analgesic benefit in patients with refractory chronic pain, with some evidence of a dose-response relationship. Larger, multicenter studies with longer follow-ups are needed to better select patients and determine the optimal treatment protocol.

Erector Spinae Plane (ESP) Block: a New Paradigm in Regional Anesthesia and Analgesia

The erector spinae plane (ESP) block is an ultrasound-guided regional anesthesia technique that has enjoyed unprecedented popularity since its description in 2016. This review summarizes the applied anatomy, technical performance, and clinical application of the ESP block. Dissection and imaging studies indicate that paravertebral local anesthetic spread is a primary mechanism of action of the ESP block. A large volume of case report literature supports its efficacy in myriad clinical settings, including thoracic surgery, thoracic trauma, cardiac surgery, abdominal surgery, spine surgery, and painful conditions of the upper and lower limbs. Several randomized controlled trials have also been published that report significant analgesic benefit compared with systemic analgesia alone. The ESP block is a highly effective and versatile technique for the management of acute and chronic pain. Further studies are needed to definitively determine its efficacy compared with more established techniques.

Intravenous Dexamethasone and Its Effect on Blood Glucose in Adult Nondiabetic Patients undergoing General Anesthesia for Superficial Surgery

ABSTRACT Dexamethasone is commonly used for the prevention of postoperative nausea and vomiting (PONV). It also has significant postoperative analgesic benefits. In spite of these advantages, it is seen that intravenous (IV) dexamethasone may affect the blood glucose profile of the patient and healing of wounds. We have studied the effects of IV dexamethasone administered at induction on blood glucose concentrations in adult, nondiabetic patients under general anesthesia (GA) for superficial surgeries, e.g., ear surgeries, breast surgeries, and hernia surgeries. How to cite this article Gala AA, Bhirud PH, Chellam S. Intravenous Dexamethasone and Its Effect on Blood Glucose in Adult Nondiabetic Patients undergoing General Anesthesia for Superficial Surgery. Res Inno in Anesth 2017;2(2):64-67.

Tanezumab in the treatment of chronic musculoskeletal conditions

ABSTRACTIntroduction: The management of pain associated with chronic musculoskeletal conditions represents a significant challenge for the clinician. There remains a need for novel medications that have a significant analgesic benefit and are also safe and well tolerated. Both pre-clinical and clinical data have provided evidence of the role of nerve growth factor (NGF) in a multitude of pain eliciting conditions. Therefore, the development of monoclonal antibodies to NGF for chronic painful musculoskeletal conditions has generated interest.Areas covered: This manuscript is a review that examines both the pharmacological properties and clinical studies of tanezumab, the most widely studied antibody to NGF, for management of osteoarthritis (OA) and low back pain. In addition, the safety and tolerability profile and development history of tanezumab are also discussed.Expert opinion: Most studies provide strong support for the ability of tanezumab to provide clinically meaningful pain relief in individuals with these conditions, with longer-term studies suggesting durability of effect. The adverse event profile appears favorable, assuming the risk mitigation strategies are effective at reducing the incidence of joint-related side effects. Further data are being collected to define the optimal dose and dosing strategy in both OA and chronic low back pain.

Lack of Analgesic Effect Induced by Ropivacaine Wound Infiltration in Thyroid Surgery: A Randomized, Double-Blind, Placebo-Controlled Trial.

Surgical site infiltration with local anesthetic reduces analgesic requests in various types of surgeries. Because thyroid surgery may induce severe postoperative pain, we tested the hypothesis that ropivacaine surgical site infiltration would significantly decrease postoperative administration of morphine in patients undergoing thyroid surgery. We performed a double-blind, placebo-controlled superiority trial to assess the efficacy of surgical site analgesia with ropivacaine (10 mL, 75 mg) performed at the end of thyroid surgery in adult patients. The primary end point was the proportion of patients not requiring IV morphine in the postanesthesia care unit. One hundred sixty-three patients completed the study, 85 in the placebo group and 88 in the ropivacaine group. The proportion of patients requiring morphine administration in the postanesthesia care unit (55% vs 53%, P = 0.80), the dose of IV morphine administered (5.6 ± 6.1 vs 5.5 ± 6.0 mg, P = 0.90), the total dose of opioids administered (expressed as oral morphine equivalent dose: 64 ± 27 vs 69 ± 29 mg, P = 0.20), and the visual analog pain scale over the first 24 hours were not significantly different between groups. The incidence of adverse events (36% vs 39%, P = 0.88), morphine-related adverse events (19% vs 17%, P = 0.84), serious adverse events (0% vs 2%, P = 0.50), and the patient satisfaction scores (9 ± 1 vs 9 ± 1, P = 0.70) was not significantly different between the 2 groups. Surgical site analgesia with ropivacaine at the end of thyroid surgery is not associated with any significant analgesic benefit.

Comparison of caudal and intravenous dexamethasone as adjuvants for caudal epidural block: A double blinded randomised controlled trial.

Background and Aims:Dexamethasone has a powerful anti-inflammatory action with significant analgesic benefits. The aim of this study was to compare the efficacy of dexamethasone administered through intravenous (IV) and caudal route on post-operative analgesia in paediatric inguinal herniotomy patients.Methods:One hundred and five paediatric patients undergoing inguinal herniotomy were included and divided into three groups. Each patient received a single caudal dose of ropivacaine 0.15%, 1.5 mL/kg combined with either corresponding volume of normal saline (Group 1) or caudal dexamethasone 0.1 mg/kg (Group 2) or IV dexamethasone 0.5 mg/kg (Group 3). Baseline, intra- and post-operative haemodynamic parameters, pain scores, time to rescue analgesia, total analgesic consumption and adverse effects were evaluated for 24 h after surgery. Unpaired Student's t-test and analysis of variance were applied for quantitative data and Chi-square test for qualitative data. Time to first analgesic administration was analysed by Kaplan–Meier survival analysis and log-rank test.Results:Duration of analgesia was significantly longer (P < 0.001), and total consumption of analgesics was significantly lower (P < 0.001) in Group II and III compared to Group I. The incidence of nausea and vomiting was higher in Group I (31.4%) compared to Group II and III (8.6%).Conclusions:Addition of dexamethasone both caudally or intravenously as an adjuvant to caudal 0.15% ropivacaine significantly reduced the intensity of post-operative pain and prolonged the duration of post-operative analgesia with the significant advantage of caudal over IV route.

Intravenous ibuprofen as an adjunct in acute postoperative pain: A review

Background: Postoperative pain can have a significant effect on patient recovery. Studies suggest that 82% patients experience some pain following surgery, of those 47% complaining of moderate pain, 39% experiencing severe to very severe pain. The failure to adequately treat postoperative pain is due to limitations of monotherapy with opioid analgesics. Intravenous ibuprofen is a nonsteroidal antiinflammatory drug with anti-inflammatory, antipyretic, and analgesic properties that may be related to prostaglandin synthetase inhibition and have been shown to reduce opioid requirements with better postoperative pain management. This paper reviews analgesic outcomes of intravenous ibuprofen as an adjunct to opioid for acute postoperative pain in adults.Methods: Relevant studies were searched using cochrane database of systematic reviews, embase and pubmed databases using key words about intravenous ibuprofen and postoperative pain that were appropriate to each database.Results: Tools to assess pain intensity such as visual analog scale, verbal response scale and self-report of pain scores at rest and with movement have been studied. Multimodal approach with preemptive use of nonsteroidal anti-inflammatory drugs for treatment of postoperative pain is considered.Conclusion: Randomized controlled trials and other studies concluded that postoperative pain control protocols can now consider inclusion of intravenous ibuprofen as an adjunct in multimodal approach to offer patients a significant analgesic benefit while reducing the risks associated with opioid administration.Journal of Society of Anesthesiologists of Nepal 2015; 2(1): 21-24

Misuse of non-prescription codeine containing products: Recommendations for detection and reduction of risk in community pharmacies

Misuse of opioid analgesics is an emergent global public health concern. Codeine has an identified abuse liability, given its effect and development of tolerance within a short timeframe on regular or excessive use. Estimation and management of misuse of over the counter (OTC) codeine containing products are hampered by widespread and easy availability and the heterogeneous and hidden nature of misuse. Continued debate around availability centre on increasing evidence of misuse, dependence and adverse health effects associated with presence of non-opioid agents (paracetamol, ibuprofen) in combination products, and lack of evidence of a significant clinical analgesic benefit of combining low dose codeine in OTC products. Limited up scheduling that still enables purchase of codeine products without a prescription, and varied measures of pharmacist intervention at point of sale have not succeeded in curtailing therapeutic and non-therapeutic forms of misuse. This commentary broadly discusses the concepts of medication misuse, codeine's potential for misuse and dependence, characteristics of codeine misuse in general, harms from OTC codeine products in particular, ‘unique issues’ with OTC codeine products, the problems with scheduling solutions and pharmacy based interventions targeting users, along with the supports needed for these interventions. The recent introduction of new OTC combinations of non-opioid agents which provide greater analgesic efficacy than OTC codeine combination analgesics with no risk of opioid dependence provides a satisfactory alternative to these widely misused products.

Enhancement of ropivacaine caudal analgesia using dexamethasone or magnesium in children undergoing inguinal hernia repair.

Background:Caudal analgesia is the most commonly used technique providing intra- and postoperative analgesia for various pediatric infraumbilical surgical procedures but with the disadvantage of short duration of action after single injection. Caudal dexamethasone and magnesium could offer significant analgesic benefits. We compared the analgesic effects and side-effects of dexamethasone or magnesium added to caudal ropivacaine in pediatric patients undergoing inguinal hernia repair.Materials and Methods:A total of 105 (1-6 years) were randomly assigned into three groups in a double-blinded manner. After a standardized sevoflurane in oxygen anesthesia, each patient received a single caudal dose of ropivacaine 0.15% 1.5 mL/kg combined with either magnesium 50 mg in normal saline 1 mL (group RM), dexamethasone 0.1 mg/kg in normal saline 1 mL (group RD), or corresponding volume of normal saline (group R) according to group assignment. Postoperative analgesia, use of analgesics, and side-effects were assessed during the first 24 h.Results:Addition of magnesium or dexamethasone to caudal ropivacaine significantly prolonged analgesia duration 8 (5-11) h and 12 (8-16) h, respectively compared with 4 (3-5) h with the use of ropivacaine alone. The incidence of postoperative rescue analgesia was significantly higher in group R compared with groups RM and RD. The time to 1st analgesic dose was significantly longer in groups RM and RD (500 ± 190 and 730 ± 260 min) respectively compared with group R (260 ± 65 min). Group R patients achieved significantly higher Children's Hospital of Eastern Ontario Pain Scale and Faces Legs Activity Cry Consolability scores (4th hourly) compared with groups RM and RD patients (8th and 12th hourly, respectively).Conclusion:The addition of dexamethasone or magnesium to caudal ropivacaine significantly prolonged the duration of postoperative analgesia in children undergoing inguinal hernia repair. Also the time to 1st analgesic dose was longer and the need for rescue postoperative analgesic was reduced and without increase in incidence of side effects.

Comparing the Effects of Single Shot Sciatic Nerve Block Versus Posterior Capsule Local Anesthetic Infiltration on Analgesia and Functional Outcome After Total Knee Arthroplasty: A Prospective, Randomized, Double-Blinded, Controlled Trial

Peripheral nerve blocks appear to provide effective analgesia for patients undergoing total knee arthroplasty. Although the literature supports the use of femoral nerve block, addition of sciatic nerve block is controversial. In this study we investigated the value of sciatic nerve block and an alternative technique of posterior capsule local anesthetic infiltration analgesia. 100 patients were prospectively randomized into three groups. Group 1: sciatic nerve block; Group 2: posterior local anesthetic infiltration; Group 3: control. All patients received a femoral nerve block and spinal anesthesia. There were no differences in pain scores between groups. Sciatic nerve block provided a brief clinically insignificant opioid sparing effect. We conclude that sciatic nerve block and posterior local anesthetic infiltration do not provide significant analgesic benefits.