Standard Analgesia Research Articles

IV Paracetamol as a sole agent for postoperative pain relief in adult cardiac surgical patients after median sternotomy

Various pain control strategies for pain relief of cardiac surgical patients after median sternotomy were tried include central neuraxial blockade or selective nerve blocks, and drugs such as opioids, and non-steroidal anti-inflammatory drugs (NSAIDS). Paracetamol (Perfalgan, Bristol Meyers Squibb) is available in IV formulation and is being used in many centers as an adjunct to analgesia regimen. In our practice, we have found that IV paracetamol stared at regular intervals after shifting the patient to cardiac surgical ICU(CSICU), helps in significantly reducing the analgesic requirement consequently patients become less sedated after cardiac surgery. After ethics committee approval, and informed patient consent, we did a prospective cohort study of 52 adult cardiac surgical receiving IV paracetamol as the primary pain control agent. A standard anesthesia and analgesia technique was used for all the patients. Postoperatively IV fentanyl infusion was continued at 1 mcg/kg/h till extubation. IV paracetamol was started 30 min before extubation given 1 g (over 30 min) IV and continued 6 h till next 72 h or till chest tube removal. Pain control was assessed by visual analogue scale (VAS) and target VAS value of 3 or less than three was considered adequate. VAS was assessed at extubation, at 3, 6, 12, 24, 36 and 48 h after extubation. The regimen was considered successful if only two or less than two doses of IV fentanyl and/or less than 4 doses of oral tramadol were required to supplement IV paracetamol postoperatively. The patient age ranged from 24 to 78 years, 8 of them were female, CABG was performed in 14 patients, AVR in 8 patients, CABG plus MVR in 6 patients, CABG plus AVR in 10 patients, MVR plus RFA in 6 patients, ASD closure in 4 patients and pulmonary valve implantation in 2 patient. We found that paracetamol was successful as the sole analgesic agent in 38 patients (73%), in 10 patients (19.2%) IV paracetamol was primary regimen (with fentanyl/tramadol as adjunct) and in 4 patients (7.6%) patients IV paracetamol regimen was unsuccessful in pain relief. IV Paracatamol may be used as a sole agent for pain relief with successful results after median sternotomy in selected patients in which opioids, NSAIDS or regional blocks are not indicated or produce undesirable side effects. The results need to be reproduced in a larger group of patients and after determining equipotent doses of opiods, case control studies should be done to evaluate the effects of IV paracetamol after median sternotomy.

1985 PREOPERATIVE TAMSULOSIN FACILITATES URETEROSCOPIC MANAGEMENT OF LOWER URETERIC CALCULI: A PROSPECTIVE RANDOMIZED STUDY

INTRODUCTION AND OBJECTIVES: Tamsulosin is proved to promote spontaneous passage of distal ureteral and juxtavesical calculi. Our aim is to prospectively evaluate the role of neoadjuvant tamsulosin during ureteroscopic treatment of lower ureteric stone. METHODS: One hundred thirty-eight adult patients with lower ureteral calculi underwent ureteroscopic management. Stone length varied from 7 to 12 mm. Before treatment, the patients were randomly divided into 2 groups; the study group (n 70) received tamsulosin 0.4 mg once daily for 3-6 weeks and the control group (n 68) received standard analgesia only. Preoperative medications were blinded to the endourologists. The primary endpoint was the need for intraoperative ureteral dilatation. Postoperative complications were recorded for both groups. RESULTS: Of the 120 patients available for follow up, the need for intraoperative ureteral dilatation was 30% in the study group, compared with 86.7% in the control group (p 0.001). Of the control group, 5% had postoperative pyelonephritis episodes, in contrast to only 1.7% of the study group (p 0.619). CONCLUSIONS: Preopertive tamsulosin simplifies ureteroscopic management of lower ureteric calculi. To the best of our knowledge, this is the first study to show the value of neoadjuvant tamsulosin in ureteroscopic management of distal ureteric calculi.

Understanding and Treating Neuropathic Pain

Maladaptive neuropathic pain results from injury or disease of the nervous system. It is typically chronic and frequently intractable. Standard analgesics, such as opioids, are of little use, while gabapentinoids (pregabalin and gabapentin) are not universally effective. In peripherally generated neuropathic pain, an initial inflammatory response releases a variety of mediators, including cytokines and prostaglandins that alter ion channel expression in primary afferent neurons. This initiates ectopic activity in sensory nerves and results in the release of ATP and a second group of mediators from primary afferent terminals. The level of spinal microglial activation is altered such that microglia releases a third set of mediators, notably brain-derived neurotrophic factor (BDNF), in the spinal dorsal horn. Through various mechanisms, BDNF increases excitatory synaptic transmission whilst decreasing inhibitory transmission. The resulting “central sensitization” contributes to hyperalgesia, causalgia, and allodynia that are associated with neuropathic pain. It is suggested that targeting ion channels in the sensory nerves and excitatory transmission in the dorsal horn may lead to urgently needed new treatments for neuropathic pain. It is also suggested that the effectiveness of gabapentinoids may be increased by combining these agents with the TRPV1 agonist capsaicin.

Spinal anesthesia for elective cesarean section is associated with shorter hospital stay compared to general anesthesia

This prospective study aims to compare maternal and neonatal effects of spinal and general anesthesia for elective cesarean section. Term parturients receiving routine spinal (Group SA, n=95) or general (Group GA, n=93) anesthesia and standard postoperative analgesia for elective cesarean section were included in this study. Operation time, incision-hysterotomy (TS-H) and hysterotomy-umbilical cord clamping (TH-U) intervals, oxytocine requirement, intraoperative fluids, ephedrine requirement, incidence of hypotension, time to first analgesic requirement (Tanalg), pethidine consumption, adverse events, time to first breastfeeding, oral food intake (TOI), flatulence (TF), defecation (TD), mobilization, and postoperative hospital stay were compared between the groups. Newborn Apgar scores, umbilical venous blood gas analysis, incidence of hypoglycemia, nutritional support, phototherapy and ventilatory support were also analyzed. Spinal anesthesia was associated with longer TS-H and TH-U durations, lower oxytocine requirements, higher incidence of hypotension, increased ephedrine and fluid consumption, and delayed Tanalg. Furthermore, TOI, TF, TD and postoperative hospital stay was shorter in patients given spinal anesthesia when compared with patients given general anesthesia (48h vs. 52 h, respectively; p<0.01). No difference in postoperative analgesic consumption and neonatal outcomes, except 1st min Apgar scores and umbilical blood gas analysis, was detected. Spinal anesthesia, when compared to general anesthesia shortens postoperative hospital stay with early return of gastrointestinal functions in elective cesarean section.

Objectifying Acupuncture Effects by Lung Function and Numeric Rating Scale in Patients Undergoing Heart Surgery

Rationale. Poststernotomy pain and impaired breathing are common clinical problems in early postoperative care following heart surgery. Insufficiently treated pain increases the risk of pulmonary complications. High-dose opioids are used for pain management, but they may cause side effects such as respiratory depression. Study Design. We performed a prospective, randomized, controlled, observer-blinded, three-armed clinical trial with 100 patients. Group 1 (n = 33) and Group 2 (n = 34) received one 20 min session of standardized acupuncture treatment with two different sets of acupoints. Group 3 (n = 33) served as standard analgesia control without additional intervention. Results. Primary endpoint analysis revealed a statistically significant analgesic effect for both acupuncture treatments. Group 1 showed a mean percentile pain reduction (PPR) of 18% (SD 19, P < 0.001). Group 2 yielded a mean PPR of 71% (SD 13, P < 0.001). In Group 1, acupuncture resulted in a mean forced vital capacity (FVC) increase of 30 cm3 (SD 73) without statistical significance (P = 0.303). In Group 2, posttreatment FVC showed a significant increase of 306 cm3 (SD 215, P < 0.001). Conclusion. Acupuncture revealed specific analgesic effects after sternotomy. Objective measurement of poststernotomy pain via lung function test was possible.

EFFECT OF ZONISAMIDE ON CHRONIC CONSTRICTION INJURY INDUCED NEUROPATHIC PAIN IN MALE SD RATS

There is considerably research evidence supporting a palliative role for voltage-gated sodium and T-type calcium channels in neuropathic pain conditions. Hence, the present study was undertaken to assess the ability of zonisamide (a sodium and Ttype calcium channel blocker) to relieve various symptoms of neuropathic pain in the chronic constriction injury rat model of neuropathic pain. Zonisamide (80 & 50 mg/kg) or saline was administered in a blinded, randomized manner by intraperitoneal injection from postoperative day (POD) 7 to 13. Paw withdrawal duration (PWD) to spontaneous pain, chemical allodynia and mechanical hyperalgesia, and paw withdrawal latency (PWL) to mechanical allodynia and thermal hyperalgesia were tested before surgery, before and after zonisamide or saline administration (from POD7 to 13) and after the withdrawal of treatment (from POD14 to 36). Systemic zonisamide relived neuropathic pain symptoms in a dose dependent manner. All PWDs were significantly decreased and PWLs were significantly increased after zonisamide administration compared with saline control measurements. However, zonisamide had non-uniform effect on chemical allodynia. Results of zonisamide were also compared with standard drug pregabalin (50 & 30 mg/kg) and found that zonisamide should be considered as an ulternative pharmacological tool for treatment of neuropathic pain that is largely refractory to standard analgesics such as pregabalin.

Natural Variation in the μ-opioid Gene OPRM1 Predicts Increased Pain on Third Day After Thoracotomy

The mechanism whereby acute postsurgical pain can persist and become chronic remains unknown. Thoracotomy is a common procedure with a high incidence of long-term pain for which acute postsurgical pain is an established risk factor. Therefore, the genetic basis of elevations in acute postsurgical pain after thoracotomy was investigated. A cohort of thoracotomy patients participating in an ongoing trial of outcomes after cancer were enrolled. A standard combined general and epidural anesthetic and surgical approach were used. All patients received a standardized postoperative epidural analgesia regimen. Postoperatively, pain scores were determined and blood was collected for genotyping. Our a priori hypothesis was that variability of genes involved in nociception and analgesic therapy would predict pain score ≥3 of 10 on the third postoperative day. Ninety patients with pain and genotyping data on postoperative day 3 were examined. We found no association between markers in COMT, COX1, COX2, and TRPV1 and postoperative pain. We demonstrated several statistically significant associations with 4 single nucleotide polymorphism markers in OPRM1 (odds ratio, 95% confidence intervals): rs634479 (0.4, 0.17, 0.97), rs499796 (0.35, 0.13, 0.92), rs548646 (0.47, 0.23, 0.97), and rs679987 (0.1, 0.01, 0.84). From these, we inferred 2 haplotype blocks in OPRM1 where both had a frequency of 9% and P=0.03 and 0.04. Previously published functional single nucleotide polymorphisms in OPRM1 and COMT were not associated with increased pain on the third postoperative day. We identified previously unpublished haplotypes of the OPRM1 receptor that predicted increases in self-reported pain on the third postoperative day after thoracotomy. These findings require replication and further refinement before their impact on patient care can be determined.

Comparison of parturient - controlled remifentanil with epidural bupivacain and sufentanil for labour analgesia: Randomised controlled trial

Epidural analgesia (EA) has significant contraindications including coagulation disorders and parturient refusal. One alternative is intravenous self-administered analgesia using the ultra short-acting opioid remifentanil (rPCA). We compared the efficiency and safety of standard epidural analgesia with parturient-controlled intravenous analgesia using remifentanil as well as personal satisfaction. We enrolled twelve ASA I classified women with singleton pregnancy who delivered vaginally in the period 3/2010-5/2010 and who received rPCA (n=12) in standard analgesic protocol: 20 µg boluses using PCA pump with a lockout interval of 3 min. The control group consisted of 12 pregnant women who received EA (n=12): 0.125% bupivacaine with sufentanil 0.5 µg/mL in top-up boluses every hour until delivery. Data were acquired from standard Acute Pain Service (APS) form and patient medical records (demographic, labour course parameters), Visual Analogue Scale (VAS), Bromage Scale (BS) and adverse effects of analgesia. There were no demographic or labour course parameter differences between groups (P>0.05). The differences in VAS decrease (P=0.056) and parturient satisfaction (P=0.24) during the whole analgesia administration were statistically insignificant. The main limitation of the study was small sample and enrolment of healthy singleton pregnant women only. Remifentanil use in obstetric analgesia is a viable alternative to EA, especially in cases of EA contraindications and parturient disapproval.

Impacto de la implantación y desarrollo de la analgesia epidural administrada por la paciente para el tratamiento del dolor del parto. Encuesta en un hospital universitario en Chile

ObjectiveAnalgesia for labor is a legal obligation in Chile. In our institution we implemented patient controlled analgesia for pain relief during labor. We describe the perception of the several professionals involved in the medical care of patients in labor in terms of effectiveness, usefulness, satisfaction, and safety. Material and methodsA self-reported questionnaire was given to the professionals involved, and the obstetrical and neonatal outcomes were recorded along with the workload indices. Twenty-five structured questions were presented with a Likert type score to evaluate analgesia quality, workload of professionals involved, adverse effects, patient satisfaction, and healthcare workers satisfaction. Finally, a question was asked about the overall perception. ResultsWe found that the overall perception of the analgesic technique was (mean) 6.0 (SD) (0.88). A decrease in the anesthesiologist workload was observed, without affecting obstetric outcomes. ConclusionConsidering the study design limitations, absence of knowledge of economical impact, and the satisfaction level of patients under standard epidural analgesia, we recommend the patient controlled analgesia technique due to its good obstetric outcomes, general satisfaction and workload decrease.

Analgesic efficacy of continuous femoral nerve block commenced prior to operative fixation of fractured neck of femur.

BackgroundPeripheral nerve blocks are effective in treating acute pain, thereby minimizing the requirement for opiate analgesics. Fractured neck of femur (FNF) is a common, painful injury. The provision of effective analgesia to this cohort is challenging but an important determinant of their functional outcome. We investigated the analgesic efficacy of continuous femoral nerve block (CFNB) in patients with FNF.MethodsFollowing institutional ethical approval and with informed consent, patients awaiting FNF surgery were randomly allocated to receive either standard opiate-based analgesia (Group 1) or a femoral perineural catheter (Group 2). Patients in Group 1 received parenteral morphine as required. Those in Group 2 received a CFNB comprising a bolus of local anaesthetic followed by a continuous infusion of 0.25% bupivacaine. For both Groups, rescue analgesia consisted of intramuscular morphine as required and all patients received paracetamol regularly. Pain was assessed using a visual analogue scale at rest and during passive movement (dynamic pain score) at 30 min following first analgesic intervention and six hourly thereafter for 72 hours. Patient satisfaction with the analgesic regimen received was recorded using verbal rating scores (0-10). The primary outcome measured was dynamic pain score from initial analgesic intervention to 72 hours later.ResultsOf 27 recruited, 24 patients successfully completed the study protocol and underwent per protocol analysis. The intervals from recruitment to the study until surgery were similar in both groups [31.4(17.7) vs 27.5(14.2) h, P = 0.57]. The groups were similar in terms of baseline clinical characteristics. For patients in Group 2, pain scores at rest were less than those reported by patients in Group 1 [9.5(9.4) vs 31(28), P = 0.031]. Dynamic pain scores reported by patients in Group 2 were less at each time point from 30 min up to 54 hours [e.g at 6 h 30.7(23.4) vs 67.0(32.0), P = 0.004]. Cumulative morphine consumption over 72 h was less in Group 2. Patient satisfaction scores were greater in Group 2 [9.4(1.1) vs 7.6(1.8), P = 0.014].ConclusionsCFNB provides more effective perioperative analgesia than a standard opiate-based regimen for patients undergoing fixation of FNF. It is associated with lesser opiate use and greater patient satisfaction.

Alpha-Blockers Impact Stent-Related Symptoms: A Randomized, Double-Blind, Placebo-Controlled Trial

Ureteral stents are indispensable tools in endourology, although they often are associated with bothersome lower urinary tract symptoms. This study was conducted to evaluate the effect of alfuzosin on urinary symptoms, quality of life, and pain in patients after Double-J ureteral stent placement in a randomized, placebo-controlled trial. This study was conducted from July 2008 to May 2009. A total of 130 patients underwent placement of a Double-J stent after retrograde semirigid ureteroscopy for ureteral stones. They were randomized in two groups. Group 1 (n=65) received alfuzosin 10 mg once daily and group 2 (n=65) received placebo for 1 week. Both groups also received standardized analgesia. The stent symptoms were measured and recorded 1 week after the procedure. Statistical analyses were performed using the chi-square test and Student t test with P<0.05 considered significant. The demographic profile including patient and stone-related parameters were comparable. Group 1 had significantly less urinary symptoms (P<0.05). The quality-of-life assessment was better in the alfuzosin arm than in the placebo arm (P<0.001). The mean pain score was 1.15 in group 1 and 3.89 in the placebo group (P<0.001). None of the patients in either of the arms withdrew from treatment; there were minimal adverse effects in the treatment arm. The limitation of the current work includes relatively smaller sample size and use of single type of stent. Alfuzosin 10 mg once daily in patients with a Double-J stent significantly decreases the bothersome urinary symptoms, besides decreasing significantly the pain associated with the stent.

Intraperitoneal lignocaine (lidocaine) versus bupivacaine after laparoscopic cholecystectomy: Results of a randomized controlled trial

BackgroundIntraperitoneal local anesthetics have been shown to improve postoperative pain after laparoscopic cholecystectomy (LC). However, the choice of local anesthetic agent is debatable. We compared the analgesic efficacy of intraperitoneal lignocaine (lidocaine) versus bupivacaine after elective LC. MethodsWe conducted a double-blind, randomized, controlled trial. We randomized consecutive patients undergoing LC into two groups. Group L received 10 mL 2% lignocaine (lidocaine), whereas Group B received 10 mL 0.5% bupivacaine, each diluted in 10 mL normal saline. All patients underwent standard perioperative anesthesia and analgesia protocol. We assessed patients at 0, 4, 8, 12, and 24 h postoperatively for pain using the visual analogue scale and verbal rating scale, and the need for additional analgesic medications. ResultsWe analyzed a total of 206 patients: 106 in Group L and 100 in Group B. Demographic details were similar between groups (P > 0.05). Abdominal pain decreased significantly with time in both groups, with a similar mean response profile (P < 0.001). There was no statistically significant difference between groups with regard to abdominal or shoulder pain by both visual analogue scale and verbal rating scale at all five time intervals (P > 0.05). There was also no significant difference in the side effect profile of both drugs (P > 0.05). A lower proportion of patients in Group B required additional narcotic analgesia (87%) compared with Group L (94%). This difference was marginally significant (P = 0.057). ConclusionsBupivacaine and lignocaine (lidocaine) are both safe and equally effective at decreasing postoperative pain after LC.

A Randomized, Controlled Trial Comparing Acetaminophen Plus Ibuprofen versus Acetaminophen Plus Codeine Plus Caffeine (Tylenol 3) after Outpatient Breast Surgery

The combination of acetaminophen, codeine, and caffeine (Tylenol 3, T3) is a standard postoperative analgesia after breast surgery despite the adverse effects and variable efficacy of narcotics. This study compared the efficacy of a nonnarcotic approach (acetaminophen and ibuprofen; AcIBU) to T3 after outpatient breast surgery. This double-blind randomized equivalence trial involved patients undergoing outpatient breast surgery. Patients were randomized (stratified by procedure type) to receive AcIBU or T3 four times daily for 7days, or until free of pain. Pain intensity, measured four times daily by the visual analog scale, was the primary outcome; secondary outcomes were pain relief with analgesic, days until freedom from pain, adverse effects, discontinuation of drug as a result of adverse effects, and patient satisfaction. There were 71 patients randomized to AcIBU and 70 patients to T3. Repeated measures analysis showed no significant difference in average pain intensity over 7days (AcIBU 19.9mm vs. T3 20.6mm; P=0.78). Similarly, there was no significant difference in pain relief with analgesic (P=0.46). Although no difference in the incidence of adverse effects was observed (P=0.94), discontinuation of the study drug as a result of adverse effects was more common with T3 (19% vs. 6%; P=0.018). No significant differences were identified in days until freedom from pain or patient satisfaction; 92% of AcIBU and 89% of T3 patients were satisfied with their pain control (P=0.55). AcIBU is a safe, effective method of pain control after outpatient breast surgery. Compared to T3, it provides at least equivalent analgesia and has a more tolerable adverse effect profile.

Electrospun drug-eluting sutures for local anesthesia

We have developed a local anesthetic-eluting suture system which would combine the function and ubiquity of the suture for surgical repair with the controlled release properties of a biodegradable polymeric matrix. Drug-free and drug-loaded poly(lactic-co-glycolic acid) (PLGA) sutures were fabricated by electrospinning, with or without the local anesthetic bupivacaine. The tensile strength of the electrospun sutures decreased as drug content increased, but strains remained relatively similar across all groups. Sutures released their entire drug payload over the course of 12days and maintained approximately 12% of their initial tensile strength after 14days of incubation in vitro. In a rat skin wound model, local analgesia was achieved 1day after surgery and lasted approximately 1week in 90% of treated animals (n=10, p<0.05), and all wounds were able to heal normally without the need for further reinforcement. The sutures caused tissue reaction in vivo that was comparable to that seen with a commercially available suture composed of PLGA. Such sutures may enhance perioperative analgesia and mitigate the need for standard postoperative opioid analgesics.

Assessment of pain in sedated and mechanically ventilated patients: an observational study

Critically ill patients often undergo unpleasant procedures. We quantified the effects of an unpleasant stimulus on physiological and behavioral parameters and evaluated how they are modified by sedation and analgesia. A 6-month study in the 30-bed intensive care unit (ICU) of a university hospital examined 21 sedated patients from various diagnostic groups. Hemodynamic and respiratory parameters, pupil size, facial expression, muscle tone, body movement, and the Richmond Agitation-Sedation Scale (RASS) score were measured before and during intratracheal suctioning, first in sedated patients, after sedation was stopped, and after an opioid bolus. Before intratracheal suctioning, patients had RASS scores of -1.8 ± 1.2 (mean ± standard deviation; sedation), -0.6 ± 1.7 (sedation stop), and -0.9 ± 1.4 (analgesia) (P = 0.014). Intratracheal suctioning significantly increased RASS during both sedation (to -0.6 ± 1.7) and sedation stop (to 1.0 ± 1.5) (both P < 0.01), but not during analgesia. Systolic blood pressure increased during sedation (by 9 ± 10 mmHg), during sedation stop (by 15 ± 17 mmHg) and during analgesia (by 9 ± 4 mmHg; all P < 0.01), but diastolic pressure only during sedation and sedation stop (both P < 0.01). Facial expression, body movement, and muscle tone changed significantly during the episodes of intratracheal suctioning. Heart rate, tidal volume, and pupil size remained stable under all conditions. Intratracheal suctioning evoked significant changes in some physiological and behavioral parameters. Some physiological changes were suppressed by analgesia, but at our ICU's standard doses, neither analgesia nor sedation attenuated changes in behavioral parameters at the intensity tested.

Assessing carrageenan‐induced locomotor activity impairment in rats: Comparison with evoked endpoint of acute inflammatory pain

Most animal models currently used to evaluate antinociceptive efficacy of analgesics rely on the assessment of evoked pain behaviours as primary endpoints. Here, we have developed and characterized the carrageenan-induced locomotor activity impairment (CLAIM) model to objectively assess non-evoked inflammatory pain behaviour in rats. In this model, 100 µL of 1% carrageenan was subcutaneously injected into the plantar aspect of the right hind paw and exploratory behaviour in the novel testing chamber was recorded using an automated locomotor activity system. Carrageenan-injected animals exhibited an exploratory behavioural deficit 2-7 h following injection compared to saline-injected animals. The severity of impairment was carrageenan dose related, and sensitive to the light intensity in the testing room. The effects of standard analgesics on CLAIM were examined 2 or 3 h following carrageenan injection. Diclofenac and ibuprofen, in a dose range exerting no effect on locomotor activity in naïve rats, exhibited dose-related reversal of CLAIM (ED(50) = 1.5 and 5.0 mg/kg, respectively), with comparable efficacy on carrageenan-induced thermal hyperalgesia (ED(50) = 2.0 and 6.0 mg/kg, respectively). Gabapentin and duloxetine produced no reversal of CLAIM, or attenuation of thermal hyperalgesia. Efficacy discrepancy was noted for morphine on thermal hyperalgesia and CLAIM. Additionally, amphetamine dose dependently reversed CLAIM, and similarly increased locomotor activity in normal animals. The results presented here demonstrate that CLAIM provides an objective assessment of non-evoked pain behaviours for acute inflammatory pain. The pharmacological profile of standard analgesics supports that CLAIM model can be used to identify agents to treat acute inflammatory pain in the clinic.

Ultrasound-guided transversus abdominis plane block does not improve analgesia after elective caesarean section when intrathecal diamorphine is used-A randomised double-blind controlled trial

Context: Previous studies comparing transversus abdominis plane (TAP) block and opioids for postoperative analgesia for caesarean section under spinal anaesthesia have been performed in the absence of a long-acting intrathecal opioid or with intrathecal morphine. In our unit, we use spinal diamorphine for caesarean sections under spinal anaesthesia. We wished to establish whether the performance of ultrasound-guided TAP blocks should be introduced into routine practice. Materials and Methods: Following local ethics committee approval, 53 parturients presenting for elective caesarean section were recruited. All patients received a spinal anaesthetic with 0.5% heavy bupivacaine and 300 mcg diamorphine. The study was completed by 48 patients who were randomised to undergo postoperative TAP blocks with 20 mL to each side of either 0.25-0.5% bupivacaine (n = 23) or normal saline (n = 25). Standard postoperative analgesia comprised of regular diclofenac and paracetamol, and subcutaneous morphine on request via an indwelling subcutaneous cannula. A blinded investigator assessed each patient at 2, 6, and 24 h postoperatively. Results: There were no statistically significant differences in postoperative morphine requirements or visual analogue pain scores between the two groups. The incidence of side effects was similar. Conclusions: We conclude the ultrasound-guided TAP block does not improve analgesia following elective caesarean section under subarachnoid block with intrathecal diamorphine and its routine implementation during utilisation of a multimodal analgesic regimen may not be beneficial.

A Randomized, Double-Blind, Placebo-Controlled Study of the Analgesic Efficacy of Intravenous Acetaminophen in Ambulatory Surgery

Purpose: We investigated whether intraoperative intravenous acetaminophen has the potential to reduce pain after ambulatory surgery and reduce time to discharge from the post anaesthesia care unit and hospital. Methods: We tested this hypothesis by conducting a prospective randomized, double-blind clinical trial in patients undergoing ambulatory surgery. A total of 145 patients were randomized to pre and postoperative placebo (50), intravenous (IV) operative and postoperative oral acetaminophen (49), and pre and postoperative oral acetaminophen (48). Results: The primary end point; visual analogue scale mean pain intensity over 24 hours after completion of surgery, was not significantly different between the 3 groups, control group 2.0 (1.6), mean (SD), (IV) acetaminophen group 2.1 (1.9) and oral acetaminophen group 2.1 (1.6); (p=0.93). Time to fitness for discharge from the postoperative care unit (p=0.77) and time to fitness for discharge from hospital (p=0.27) also did not vary significantly between the three groups. Conclusion: The addition of intraoperative IV acetaminophen to a standard analgesia regimen in patients undergoing ambulatory surgery did not significantly improve pain control or discharge times after surgery compared with pre and postoperative oral acetaminophen or placebo.

Uterine Artery Embolization as Nonsurgical Treatment of Uterine Myomas

The purpose of this study was to evaluate safety, efficacy or complications of uterine artery embolization (UAE). Patients with symptomatic uterine fibroids (n = 157) were treated by selective bilateral UAE using 350–500 μm sized polyvinyl alcohol particles. Bilateral UAE was successful in 152 (96.8%) cases. Baseline measures of clinical symptoms and MRI taken before the procedure were compared to those taken 3, 6, and 12 months after embolotherapy. Also, complications and outcomes were analyzed after procedure. All patients had an uneventful recovery and were able to return to normal activity within two weeks of embolization. After the procedure, most patients experienced crampy pelvic pain, of variable intensity, which was well managed with the standard analgesia protocol. Five (3%) of participants had persisting amenorrhea after procedure. None reported any new gynecologic or medical problem during the follow-up period. There were no deaths and no major permanent injuries. Reductions in mean uterine volume were 61% (P < 0.01) and in dominant fibroid volume 66% (P≤0.01). The follow-up showed significant improvement of bleeding. In conclusion, uterine artery embolization is a successful, minimal invasive treatment of uterine fibroids that preserves the uterus, had minimal complications, and requires short hospitalization and recovery.

Tamsulosin for the management of distal ureteral stones in children: A prospective randomized study

PurposeBased on efficacy demonstrated in the adult population, tamsulosin was evaluated with regard to facilitating ureteral stone expulsion in children presenting with distal ureteric calculi. Patients and methodsA prospective randomized controlled study involving 61 children with distal ureteric calculi <12 mm was performed. The children were randomly divided into two groups. Group I (study group, n = 33) received tamsulosin and standard analgesia, and Group II (placebo group, n = 28) received standard analgesia and placebo. Patients were offered a closely monitored trial for spontaneous stone passage in the 4-week period prior to definitive therapy. The stone expulsion rate, number and duration of pain episodes, need for analgesia and possible side effects of medications were observed. ResultsAll patients completed the study and none were excluded due to side effects. No significant differences were found between the groups for age, gender and stone size. Mean patient age was 8.1 ± 6.8 years. There were 25 females and 36 males. The stone-free rate was 87.8% in Group I (29/33), compared with 64.2% (18/28) in Group II. A mean stone expulsion time of 8.2 and 14.5 days was recorded for Group I and II respectively, and this difference was statistically significant (P < 0.001). ConclusionsMedical expulsion therapy for lower ureteric stones is a successful procedure in children. Tamsulosin demonstrated no clinically significant adverse effect, while proving to be a safe and effective treatment option.