Supplemental Analgesia Research Articles

Chest pain control with kinesiology taping after lobectomy for lung cancer: initial results of a randomized placebo-controlled study.

Kinesiology taping (KT) is a rehabilitative technique performed by the cutaneous application of a special elastic tape. We tested the safety and efficacy of KT in reducing postoperative chest pain after lung lobectomy. One-hundred and seventeen consecutive patients, both genders, age 18-85, undergoing lobectomy for lung cancer between January 2013 and July 2015 were initially considered. Lobectomies were performed by the same surgical team, with thoracotomy or video-assisted thoracoscopic surgery (VATS) access. Exclusion criteria (n = 25 patients) were: previous KT exposure, recent trauma, pre-existing chest pain, lack of informed consent, >24-h postoperative intensive care unit treatment. After surgery, the 92 eligible patients were randomized to KT experimental group (n = 46) or placebo control group (n = 46). Standard postoperative analgesia was administered in both groups (paracetamol/non-steroidal anti-inflammatory drugs, epidural analgesia including opioids), with supplemental analgesia boluses at patient request. On postoperative day 1 in addition, in experimental group patients a specialized physiotherapist applied KT, with standardized tape length, tension and shape, over three defined skin areas: at the chest access site pain trigger point; over the ipsilateral deltoid/trapezius; lower anterior chest. In control group, usual dressing tape mimicking KT was applied over the same areas, as placebo. Thoracic pain severity score [visual analogue scale (VAS) ranging 0-10] was self-assessed by all patients on postoperative days 1, 2, 5, 8, 9 and 30. The KT group and the control group had similar demographics, lung cancer clinico-pathological features and thoracotomy/VATS ratio. Postoperatively, the two groups also resulted similar in supplemental analgesia, complication rate, mean duration of chest drainage and length of stay. There were no adverse events with KT application. After tape application, KT patients reported overall less thoracic pain than the control group, the difference being significant on postoperative day 5 [median VAS, 2 (interquartile range, 1-3) vs 3 (2-5), P < 0.01] and day 8 [median VAS, 1 (0-2) vs 2 (1-3), P < 0.05]. Moreover, on postoperative day 30 persistence of chest pain (VAS ≥3) was reported less frequently by the KT group than by the control group (7 vs 24%; P = 0.03). KT after lung lobectomy is a safe and effective auxiliary technique for chest pain control. ISRCTN37253470.

Tizanidine for the management of acute postoperative pain after inguinal hernia repair

α2-Agonists are used postoperatively as a component of multimodal analgesia. Tizanidine is a centrally acting α2-agonist with muscle relaxant properties. The aim of this study was to compare the efficacy of tizanidine with placebo in terms of postoperative pain scores, analgesic consumption, return to daily activity and health-related quality of life. A randomised double-blind study. Diskapi Yildirim Beyazit Training and Research Hospital. After obtaining ethical approval and informed patient consent, 60 patients undergoing inguinal hernia repair under general anaesthesia were randomly allocated into one of the two groups. The patients in Group T received tizanidine 4 mg orally 1 h before surgery and twice daily during the first postoperative week. The patients in Group P received the same treatment with a placebo pill. Both the groups received a standard analgesic treatment regimen comprising intravenous dexketoprofen 25 mg prior to induction of anaesthesia, dexketoprofen 25 mg orally three times daily for 1 week and intravenous paracetamol 1 g at the end of surgery. Supplemental analgesia was provided with paracetamol if the visual numerical rating scale (NRS) was at least 4 cm. Postoperative pain was assessed using the NRS. Total analgesic consumption was determined. Return to normal daily activity was evaluated using a five-point daily activity score after the first postoperative week, and health-related quality of life was evaluated using the short form-36 one month after surgery. The patients in Group T had significantly lower NRS pain scores than those in Group P 6, 12 and 24 h postoperatively both at rest and during movement (P < 0.001), and on postoperative days 1, 2, 3 and 4. The analgesic consumption was also lower in patients who received tizanidine. Ten patients (33%) in Group T and 23 patients (77%) in Group P consumed supplemental paracetamol (P < 0.001) after discharge. The daily activity score was lower in Group T than in Group P (P < 0.001), and the short form-36 scores were significantly different in the pain dimension [74 (74 to 100) in Group T and 74 (31 to 80) in Group P, (P < 0.001)] and in the physical component summary score. The addition of tizanidine to the postoperative pain therapy after herniorrhaphy decreased postoperative pain and analgesic consumption and improved return to normal activity and quality of life. ClinicalTrials.gov NCT02016443 (10 October 2013, Principal investigator D. Yazicioğlu).

Effects of lidocaine and esmolol infusions on hemodynamic changes, analgesic requirement, and recovery in laparoscopic cholecystectomy operations

We compared the effects of lidocaine and esmolol infusions on intraoperative hemodynamic changes, intraoperative and postoperative analgesic requirements, and recovery in laparoscopic cholecystectomy surgery. The first group (n=30) received IV lidocaine infusions at a rate of 1.5mg/kg/min and the second group (n=30) received IV esmolol infusions at a rate of 1mg/kg/min. Hemodynamic changes, intraoperative and postoperative analgesic requirements, and recovery characteristics were evaluated. In the lidocaine group, systolic arterial blood pressures values were lower after the induction of anesthesia and at 20min following surgical incision (p<0.05). Awakening time was shorter in the esmolol group (p<0.001); Ramsay Sedation Scale scores at 10min after extubation were lower in the esmolol group (p<0.05). The modified Aldrete scores at all measurement time points during the recovery period were relatively lower in the lidocaine group (p<0.05). The time to attain a modified Aldrete score of ≥9 points was prolonged in the lidocaine group (p<0.01). Postoperative resting and dynamic VAS scores were higher in the lidocaine group at 10 and 20min after extubation (p<0.05, p<0.01, respectively). Analgesic supplements were less frequently required in the lidocaine group (p<0.01). In laparoscopic cholecystectomies, lidocaine infusion had superiorities over esmolol infusions regarding the suppression of responses to tracheal extubation and postoperative need for additional analgesic agents in the long run, while esmolol was more advantageous with respect to rapid recovery from anesthesia, attenuation of early postoperative pain, and modified Aldrete recovery (MAR) scores and time to reach MAR score of 9 points.

Complications, Pain Control, and Patient Recovery After Local Versus General Anesthesia for Open Inguinal Hernia Repair in Adults—Systematic Review and Meta-analysis

The purpose of this systematic review is to provide an “up-to-date” evidence-based guideline and clarify the possible benefits as well as drawbacks of local anesthesia (LA) and general anesthesia (GA) in open inguinal hernia surgery in adults. Study method comprised randomized controlled trials. Primary outcome measures were complications, pain control, and patient recovery. Secondary outcome measures were patient satisfaction and hernia recurrence. A total of 14 randomized controlled trials contributed to the study. A total of 1677 patients were analyzed, with 953 in the LA group and 724 in the GA group. Complications were statistically less frequent in the LA group compared with the GA group [odds ratio (OR), 0.31; 95% confidence interval (95% CI), 0.15, 0.64). Supplemental intraoperative analgesia had a statistical significance in the LA group, with an OR of 28.93 (95% CI, 7.86, 106.47). Postoperative pain was statistically significantly lower in the LA group [standardized eman difference (SMD), −1.06; 95% CI, −1.64, −0.48)]. Length of stay was shorter for patients who underwent operation under LA compared with those receiving GA (OR, −1.21; 95% CI, −2.08, −0.33]). Time to full mobility was shorter in the LA group, without statistical significance (OR, 3.04; 95% CI, 0.19, 47.90), whereas measuring in SMD showed significance in comparison with GA (SMD, −1.74; 95% CI, −2.34, −1.14). Hernia recurrence was not noted. Patient satisfaction was greater in the LA group (SMD, 0.65; 95% CI, 0.15, 1.15). Compared with GA, LA showed superiority in terms of complications, postoperative pain, length of stay, time to full mobility, and patient satisfaction. Therefore, it appears to be a more appropriate anesthetic technique for open inguinal hernia repair in adults.

Readdressing the role of therapeutic drug monitoring for antiepileptic drugs – A tertiary care hospital experience

Objectives: The aim of this study was to explore the intensity of post-arthroscopy knee pain during the first 24 hours, and to study the influence of pre-operative pain, tourniquet time and amount of surgical trauma on postarthroscopy pain. Methods: In 78 male patients that underwent elective arthroscopic menisectomy or diagnostic arthroscopy of the knee, preoperative and post-operative pain was registered using the Visual Analogue Scale. Variance for repeated measures and for independent observations was analysed. Results: Supplementary analgesia was required for 23% of the patients, more often in the recovery room and between 2 and 8 hours postoperatively. Of all factors analyzed, only time was statistically significant in determining the level of post-operative pain. Supplementary analgesia was required only in patients that underwent operative arthroscopy, and more often in patients with tourniquet time of more than 40 minutes. Conclusion: In conclusions, post-operative time is the most significant factor related to the post-arthroscopy knee pain.

Validation of a New "Objective Pain Score" Vs. "Numeric Rating Scale" For the Evaluation of Acute Pain: A Comparative Study.

Background:Pain scores are used for acute pain management. The assessment of pain by the patient as well as the caregiver can be influenced by a variety of factors. The numeric rating scale (NRS) is widely used due to its easy application. The NRS requires abstract thinking by a patient to assign a score to correctly reflect analgesic needs, and its interpretation is subject to bias.Objectives:The study was done to validate a 4-point objective pain score (OPS) for the evaluation of acute postoperative pain and its comparison with the NRS.Patient and Methods:A total of 1021 paired readings of the OPS and NRS of 93 patients who underwent laparotomy and used patient-controlled analgesia were evaluated. Acute pain service (APS) personnel recorded the OPS and NRS. Rescue analgesia was divided into two incremental levels (level 1-paracetamol 1 g for NRS 2 - 5 and OPS 3, Level 2-Fentanyl 25 mcg for NRS ≥ 6 and OPS 1 and 2). In cases of disagreement between the two scores, an independent consultant decided the rescue analgesia.Results:The NRS and OPS agreed across the range of pain. There were 25 disagreements in 8 patients. On 24 occasions, rescue analgesia was increased from level 1 to 2, and one occasion it was decreased from level 2 to 1. On all 25 occasions, the decision to supplement analgesia went in favor of the OPS over the NRS. Besides these 25 disagreements, there were 17 occasions in which observer bias was possible for level 2 rescue analgesia.Conclusions:The OPS is a good stand-alone pain score and is better than the NRS for defining mild and moderate pain. It may even be used to supplement NRS when it is indicative of mild or moderate pain.

Minimum Effective Concentration of Bupivacaine in Ultrasound-Guided Femoral Nerve Block after Arthroscopic Knee Meniscectomy: A Randomized, Double-Blind, Controlled Trial

Background: Adequate analgesia is important for early hospital discharge after meniscectomy. A femoral nerve block may reduce the need for systemic analgesics, with fewer side effects; however, motor block can occur. Ultrasound-guided femoral nerve block may reduce the required local anesthetic concentration, preventing motor block. Objective: The primary objective of this study was to determine the lowest effective analgesic concentration of bupivacaine in 50% (EC50) and in 90% (EC90) of patients for a successful ultrasoundguided femoral nerve block in arthroscopic knee meniscectomy. Study Design: This was a prospective, randomized, double-blind, controlled trial. Settings: This study was conducted at Hospital São Domingos. Methods: A total of 52 patients undergoing arthroscopic knee meniscectomy were submitted to ultrasound-guided femoral nerve block using 22 mL bupivacaine. The bupivacaine concentration given to a study patient was determined by the response of the previous patient (a biased-coin design up–down sequential method). If the previous patient had a negative response, the bupivacaine concentration was increased by 0.05% for the next case. If the previous patient had a positive response, the next patient was randomized to receive the same bupivacaine concentration (with a probability of 0.89) or to have a decrease by 0.05% (with a probability of 0.11). A successful block was defined by a numerical pain intensity scale score &lt; 4 (0 = no pain; 10 = worst imaginable pain) in 3 different evaluations. If the pain intensity score was ≥ 4 (moderate or severe pain) at any time, the block was considered failed. General anesthesia was induced with 30 μg/kg alfentanil and 2 mg/ kg propofol, followed by propofol maintanance, plus remifentanil if needed. Postoperative analgesia supplementation was performed with dipyrone; ketoprofen and tramadol were given if needed. Data Measurements: The following parameters were evaluated: numerical pain intensity score, duration of analgesia, supplementary analgesic dose in 24 hours, and need for intraoperative remifentanil. Results: The EC50 was 0.160 (95% CI: 0.150 – 0.189), and EC90 was 0.271 (95% CI: 0.196 – 0.300). There was no difference in numerical pain intensity score for the different concentrations of bupivacaine. A successful block was achieved in 45 patients, with no difference according to bupivacaine concentration. Time to first analgesic supplementation dose was longer for bupivacaine concentrations ≥ 0.3% (543.8 ± 283.8 min.), compared to 0.25% (391.3 ± 177.8 min.) and &lt; 0.25% (302.3 ± 210.1 min.). There were no differences in supplementary analgesic dose in 24 hours nor in the use of intraoperative remifentanil according to bupivacaine concentration. Limitations: The analgesic effect was measured only during the first 2 hours. Conclusions: Bupivacaine EC50 for ultrasound-guided femoral nerve block was 0.160 (95% CI: 0.150 – 0.189), and EC90 was 0.271 (95% CI: 0.196 – 0.300). Key words: Postoperative analgesia, femoral block, ultrasound-guided, bupivacaíne minimum concentration, arthroscopic meniscectomy

Long-term safety and effectiveness of once-daily, single-entity, extended-release hydrocodone over 76 weeks of an open-label study in patients with chronic noncancer and nonneuropathic pain

Objective: To evaluate long-term use of Hysingla® ER (HYD), a single-entity, extended-release, once-daily hydrocodone bitartrate tablet with abuse-deterrent properties in patients with moderate-to-severe chronic noncancer and nonneuropathic pain.Methods: This open-label study consisted of a dose-titration period (up to 45 days), a 52-week maintenance period and a 24-week extension period. Opioid-naïve or opioid-experienced patients with controlled or uncontrolled chronic pain conditions were treated with HYD 20–120 mg daily. Supplemental nonopioid and short-acting opioid analgesics were permitted. This paper presents the results of 106 patients who continued HYD treatment for up to 76 weeks.Primary safety measures included the incidence of adverse events, as well as audiologic, clinical laboratory and electrocardiogram measurements. Effectiveness was measured by the change between baseline and the overall 76-week treatment period in “average pain over the last 24 h” (0 = no pain, 10 = pain as bad as you can imagine), Brief Pain Inventory-Short Form survey, Medical Outcomes Study 36-Item Short Form Health Survey, Medical Outcomes Study Sleep Scale-Revised and concomitant nonstudy opioid analgesic use.Results: Among 410 patients who completed the maintenance period, 106 continued into the extension. Of these, 83 (78%) completed the entire 76-week treatment period. Treatment-emergent adverse events were typical of those observed with μ-opioid agonists. No study drug abuse or diversion was reported. Clinically important analgesia and functional improvement were achieved during the dose-titration period and were maintained in most patients throughout 76 weeks without the need for continued HYD dose increases or changes in concomitant nonstudy opioid analgesics. The mean pain score was 6.1 at baseline, 3.8 at the end of the dose titration period and 3.8 through 76 weeks.Conclusions: HYD was generally well tolerated. No unexpected safety concerns emerged. Pain control was sustained throughout 76 weeks of treatment.

Vaginal hysterectomy using local anesthesia and analgesics

Context: Vaginal hysterectomy for pelvic organ prolapse is often performed under general or regional anesthesia. However, the performance of this operative procedure under local anesthetic has potential benefits, especially in resource-poor settings. Aims: The aim of this study was to review the outcome of vaginal hysterectomy and pelvic floor repair using local anesthesia and supplementary analgesia. Settings and Design: The study was retrospective and the setting was a cottage hospital in the northern Nigeria. Subjects and Methods: A review of the case records of women who underwent a vaginal hysterectomy and pelvic floor repair for uncomplicated 4th degree (Stage III) uterovaginal prolapse, using local lidocaine infiltration and supplemental pentazocine injection. Statistical Analysis Used: Descriptive statistics and frequencies were used to describe the population and outcomes of surgery. Results: Eighteen women successfully had vaginal hysterectomy and pelvic floor repair using local anesthesia with supplemental pentazocine intramuscular injection. Four (22.2%) of the women required supplemental pentazocine injection. The mean duration of surgery was 101.67 (± 14.14) min and the average hospital stay was 36.22 (± 17.16) h. Thirteen (72.2%) women were satisfied with the surgery, anesthesia, and early ambulation while the others desired a totally painless surgery in addition to the early ambulation and short hospitalization. Conclusions: The use of local anesthesia for vaginal hysterectomy and pelvic floor repair was successful in patients with severe uterovaginal prolapse. A larger, randomized controlled study is recommended.

Comparative study of intrathecal bupivacaine 0.5% with bupivacaine 0.5% and buprenorphine low dose for postoperative analgesia in lower abdominal surgeries

Background: Opiods, like buprenorphine, have been widely used for providing pain relief postoperatively and their advantages of neuraxial narcotics over systemic narcotics are well established. When compared to local anaesthetics, they offer good analgesia while allowing early ambulation of the patient by sparing sympathetic and motor nerves. This study was conducted to compare the efficacy of bupivacaine alone and in combination with low dosage of buprenorphine. Methods: 80 patients between the ages 20-60 undergoing lower abdominal surgeries were divided into 2 groups of 40 each after taking detailed history and undergoing the necessary preliminary tests. Patients in the Group I was given 17.5mg of 0.5% Hyperbaric Bupivacaine along with 60ug of Buprenorphine. The patients in Group II received 17.5mg of 0.5% Hyperbaric Bupivacaine. Onset and duration of analgesia were recorded. The efficacy of analgesia was recorded based on VAS score. Side effects, time of recovery also were noted. Results: In this retrospective study we found that incidence of colorectal carcinoma is more between 40-60 years of age with male predominance; lymph node metastasis is more than metastasis in any other sites. CT scan can diagnose lymphatic metastasis and infiltration in surrounding tissue more accurately. Percentage of sphincter saving procedure was low in rectal malignancies in our study. Conclusions: The onset of analgesia was within 5 minutes in 100% of the cases in Group I while in Group II it was upto 9 minutes. The mean of the duration of analgesia was 15h 33mins and 3 h 18 mins in Group I and II respectively. The pain scoring through VAS in the 2 groups showed that most of the patients in Group I had 0 to mild pain till about 12 hours while in Group II the analgesic effect was felt only till the first 2 hours. The supplementary analgesic was required on Group II within 4 hours post operatively while in Group I the requirement was only after 12 hours. The major side effect among the patients was vomiting and nausea in 12 patients in Group I followed by urinary retention in 6 patients. While in Group II only 6 patients had nausea and no other side effect. Pruritis was observed in 1 patient in Group I Respiratory distress, drowsiness, headache and backache was not observed in any of the cases.

Combination Therapy with Continuous Three-in-One Femoral Nerve Block and Periarticular Multimodal Drug Infiltration after Total Hip Arthroplasty

Background. Various postoperative pain relief modalities, including continuous femoral nerve block (CFNB), local infiltration analgesia (LIA), and combination therapy, have been reported for total knee arthroplasty. However, no studies have compared CFNB with LIA for total hip arthroplasty (THA). The aim of this study was to compare the efficacy of CFNB versus LIA after THA. Methods. We retrospectively reviewed the postoperative outcomes of 93 THA patients (20 men, 73 women; mean age 69.2 years). Patients were divided into three groups according to postoperative analgesic technique: CFNB, LIA, or combined CFNB+LIA. We measured the following postoperative outcome parameters: visual analog scale (VAS) for pain at rest, supplemental analgesia, side effects, mobilization, length of hospital stay, and Harris Hip Score (HHS). Results. The CFNB+LIA group had significantly lower VAS pain scores than the CFNB and LIA groups on postoperative day 1. There were no significant differences among the three groups in use of supplemental analgesia, side effects, mobilization, length of hospital stay, or HHS at 3 months after THA. Conclusions. Although there were no clinically significant differences in outcomes among the three groups, combination therapy with CFNB and LIA provided better pain relief after THA than CFNB or LIA alone, with few side effects.

Ultrasound‐guided parasternal Pecs block: a new and useful supplement to Pecs I and serratus anterior plane blocks

SummaryWe describe the use of ultrasound‐guided parasternal Pecs (pectoral nerves) block for pain relief following mastectomy and reconstructive breast surgery. This new ultrasound‐guided parasternal Pecs block provides effective supplementary analgesia when the established block techniques (e.g. Pecs I and serratus anterior block) together with multimodal analgesics fail to ameliorate pain arising from the parasternal area supplied by the anterior cutaneous branches of the intercostal nerves T2‐T6. In this report, the patient undergoing reconstructive breast surgery continued to complain of severe pain even after substantial systemic opioids had been administered postoperatively in the recovery area. When the patient was administered the established Pecs I and serratus anterior blocks the pain was initially reduced markedly, but recurred in the parasternal area. Following administration of an ultrasound‐guided parasternal Pecs block, the pain disappeared and the patient was pain‐free when discharged to the ward.

Comparison between caudal levobupivacaine versus levobupivacaine–nalbuphine for postoperative analgesia in children undergoing hernia repair: A randomized controlled double blind study

ObjectivesCaudal analgesia is widely used in children; the aim of this trial was to evaluate the efficacy of adding nalbuphine to local anesthetic in pediatric patients undergoing hernia repair.Patients and methodsThis randomized double-blind controlled trial was done in department of anesthesia, Cairo University hospitals, and 40 patients with ASA physical status classification I–II, aged 2–7 years were enrolled in this study and randomly assigned into 2 groups; group L received caudal levobupivacaine 1 ml/kg with concentration of 0.25% and group LN received caudal 0.125% levobupivacaine with volume of 1 ml/kg plus 0.2 mg/kg nalbuphine. Pain was evaluated immediately after emergence (FLACC 0 h), after 1 h in the PACU, after 2, 3, 4, 5, 6 and 12 h by the FLACC pain score (Face, Leg, Activity, Crying, Consolability). First time of rescue analgesic, total dose of rescue analgesic and side effects were observed for 12 h.ResultsFLACC pain scores were much less in LN group compared to L group (p value < 0.001) after the second hour. The first time for postoperative analgesic requirement was significantly longer in LN group (384 ± 23.1 min) compared to L group (202.20 ± 23.42 min) (p value > 0.001). The total dose of postoperative supplementary analgesia (intravenous paracetamol infusion) in the first 12 h was significantly lower in LN group (200.5 ± 65.5 mg) in comparison with L group (355.25 ± 69.9 mg) (P < 0.05).ConclusionsCombining caudal anesthesia using levobupivacaine and nalbuphine provided prolonged time of analgesia with no reported side effects.

Effects of Dexmedetomidine on Serum Interleukin-6, Hemodynamic Stability, and Postoperative Pain Relief in Elderly Patients under Spinal Anesthesia.

The beneficial effects of dexmedetomidine (DEX) have not been extensively investigated in elderly patients receiving spinal anesthesia. This study evaluated the effects of intravenous DEX infusion on stress and hemodynamic response, as well as on postoperative analgesia in elderly patients undergoing total knee arthroplasty (TKA). We randomly allocated 45 adult patients to 3 patient groups (n=15 each): uni-saline group patients underwent unilateral TKA with saline administration, uni-DEX group patients underwent unilateral TKA with DEX administration, and bilateral-DEX group patients underwent bilateral TKA with DEX administration. Serum interleukin-6 (IL-6) levels were significantly lower in the bilateral-DEX group than in the uni-saline group 6 and 24h postoperatively, and were negatively correlated with total DEX dosage 24h postoperatively. Bradycardia occurred more frequently in the uni-DEX and bilateral-DEX groups than in the uni-saline group. The total dose of required supplementary analgesics was significantly higher in the uni-saline group than in the uni-DEX and bilateral-DEX groups 6h postoperatively. The results indicate that perioperative intravenous DEX administration decreases postoperative serum IL-6 levels in patients undergoing bilateral TKA, and has a postoperative analgesic effect in patients undergoing unilateral or bilateral TKA.

Efficacy of Sciatic Nerve Block for Pain Management in below Knee Orthopaedic Surgery.

Perioperative pain management is an integral part of anaesthesia and patients are most satisfied if there is minimal or no pain after surgery. Sciatic nerve block provides postoperative pain relief after below knee surgery and knee surgery. Many studies with different approaches for sciatic nerve block have been conducted to demonstrate the efficacy of sciatic nerve block with different local anaesthetic drugs over the past decade. To study the efficacy of single-shot sciatic nerve block for postoperative pain management in below knee orthopaedic surgery. Sixty patients of American Society of Anaesthesiologists (ASA) grade I and II aged 18 to 60 years of either sex (male or female) scheduled for unilateral below knee open orthopaedic surgery under spinal anaesthesia and ready to participate in this study were included. Sciatic nerve block with Bupivacaine was given by classic (posterior) approach of Labat using peripheral nerve stimulator and /or ultra sound. Intraoperatively heart rate, noninvasive mean BP, respiratory rate, ECG, SpO2 was monitored. Pain was assessed using "Visual Analogue Scale" (VAS) postoperatively. Diclofenac sodium was given as rescue analgesia when VAS was > 3. Time of supplemental analgesia was noted. Mean VAS was maximum at 18 hours, 16 (26.7%) patients did not require any rescue analgesia, whereas 93.4% patients did not require rescue analgesia upto 18 hours after surgery. Mean VAS score of the patients who did not require rescue analgesia was 2.06 at 24 hours postoperatively which is far below the level where rescue analgesia was required. The mean time by which rescue analgesia was given was 19.3 hours with standard deviation of ± 3 hours. Inj. diclofenac sodium 75 mg was given intravenously as rescue analgesia when VAS score exceeded 3. No adverse systemic toxicity of Bupivacaine was observed within 24 hours after the operation. Single shot sciatic nerve block provided effective pain relief to majority of the patients upto 18 hours in below knee orthopaedic surgery and also decreased analgesic drugs requirement postoperatively. Sciatic nerve block was safe with no adverse effects.

Dexamethasone as an Adjuvant to Bupivacaine in Supraclavicular Brachial Plexus Block in Paediatrics for Post-operative Analgesia.

Sensory blockade of the brachial plexus with local anaesthetics for perioperative analgesia leads to stable haemodynamics intraoperatively, smoother emergence from general anaesthesia and decreased need for supplemental analgesics or suppositories in the Post-operative period. However, increasing the duration of local anaesthetic action is often desirable because it prolongs surgical anaesthesia and analgesia. Various studies in adults prove that steroids increase the duration of action of local anaesthetics when used as adjuncts. The study aimed at determining the efficacy of dexame-thasone as an adjuvant to bupivacaine for Post-operative analgesia following sensory blockade of the brachial plexus in paediatrics. The study was divided into two groups of 15 each, group BD receiving dexamethasone (0.1mg/kg) as an adjunct to bupivacaine 0.125% and group B receiving bupivacaine alone. The duration of analgesia was taken as time from completion of the block to the patient receiving rescue analgesia, the haemodynamics were measured until 180 minutes after surgery, the incidence of Post-operative Nausea and Vomiting (PONV) was measured. The duration of analgesia in the group BD was 27.1±13.4 hours and was significantly higher as compared to the group B, in which it was 13.9±11.3 hours (p<0.05). The pulse rate measured Post-operatively between both groups at 20 minutes (p-value 0.634), 60 minutes (p-value 0.888), 120 minutes (p-value 0.904) and 180 minutes (p-value 0.528) showed no statistical significance. Likewise the mean blood pressure measured between the two groups at 20 minutes, 60 minutes, 120 minutes and 180 minutes Post-operatively showed no significance. There was no significant difference in incidence of PONV in both groups with p-value of 0.624. Dexamethasone as an adjuvant to local anaesthetic in brachial plexus blocks significantly, prolongs duration of analgesia in children undergoing upper limb surgeries.

Patient experience in fast-track hip and knee arthroplasty--a qualitative study.

To explore the lived experience of patients in fast-track primary unilateral total hip and knee arthroplasty from the first visit at the outpatient clinic until discharge. Fast-track has resulted in increased effectiveness, including faster recovery and shorter length of stay to about two days after hip and knee arthroplasty. However, the patient perspective in fast-track with a median length of stay of less than three days has been less investigated. A qualitative design. A phenomenological-hermeneutic approach was used, inspired by Paul Ricoeur's theory of narrative and interpretation. Eight patients were included. Semi-structured interviews and participant observation were performed. Three themes emerged: dealing with pain; feelings of confidence or uncertainty - the meaning of information; and readiness for discharge. Generally, the patients were resistant to taking analgesics and found it difficult to find out when to take supplementary analgesics; therefore, nursing staff needed enough expertise to take responsibility. Factors that increased patients' confidence: information about fast-track, meeting staff before admission and involving relatives. In contrast, incorrect or conflicting information and a lack of respect for privacy led to uncertainty. In preparing for early discharge, sufficient pain management, feeling well-rested and optimal use of time during hospitalisation were important. The study shows the importance of dealing with pain and getting the right information and support to have confidence in the fast-track programme, to be ready for discharge and to manage postoperatively at home. In fast-track focusing on early discharge, there is an increased need for evidence-based nursing practice, including a qualified judgement of what is best for the patient in certain situations. The knowledge should be gleaned from: research; the patients' expertise, understanding and situation; and nurses' knowledge, skills and experience.

Alpha-2 adrenoceptor agonists as adjuncts to peripheral nerve blocks in children: a meta-analysis.

Adult meta-analyses have verified that adjunct use of alpha-2 adrenoceptor agonists (A2AA) together with local anesthetics (LA) will prolong the duration of peripheral nerve blocks. The standard use of A2AAs for peripheral nerve blockade has recently been recommended also in children, but the evidence base in support of this suggestion has to date been equivocal. The purpose of this meta-analysis was to produce evidence-based data regarding the effect in children. Following a thorough literature search, five randomized controlled trials were included in a meta-analysis. Raw data from all studies were gathered and aggregated into patients randomized to receive plain LA (Group PLA) or LA mixed with either adjunct clonidine or dexmedetomidine (Group ADJ). The main outcome parameter was block duration (time to first administration of supplemental analgesic based on predetermined pain scores) analyzed by survival statistics. The total number of supplemental analgesic doses during the first 24 postoperative hours and serious side effects were included as secondary outcomes. Pooling of the study data generated 141 patients in Group PLA and 142 patients in Group ADJ (overall n = 283; age: 0.8-13 years; weight 8-47 kg). Block duration was significantly prolonged (9.75 h vs 3.75 h) compared to the use of plain LA. Survival statistics verified a beneficial effect of using adjunct A2AAs [the log rank (Mantel-Cox) test (P = 0.0078), Gehan-Breslow-Wilcoxon test (P = 0.0027), and hazard ratio (1.653; 95% CI: 1.142 to 2.395)]. The number of patients that needed ≥ 2 doses of supplemental analgesics was higher in Group PLA (n = 19) compared to Group ADJ (n = 6) (P = 0.0088). No serious side effects were reported. This meta-analysis provides evidence-based support for the use of adjunct alpha-2 adrenoceptor agonists when performing peripheral nerve blocks in children.

Eletroacupuntura na analgesia trans e pós-operatória de cadelas submetidas à ovariosalpingohisterectomia

Objetivou-se com este estudo avaliar o efeito analgésico trans e pós-operatório da eletroacupuntura em onda denso-dispersa e frequências 3 e 200Hz, nos pontos E44, R3 e BP4, compará-lo com a analgesia promovida pelos pontos BP6, E36 e VB 34, e pela morfina, em cadelas submetidas à ovariosalpingohisterectomia (OSH). Teve-se como hipótese que a eletroacupuntura nos pontos E44, R3 e BP4 resultaria em controle da dor trans e pós-operatória melhor ou igual àquele promovido pela eletroacupuntura nos pontos BP6, E36 e VB34 e pela morfina. Trinta e seis cadelas submetidas à cirurgia eletiva de OSH foram distribuídas em blocos ao acaso em três grupos com 12 animais. Em dois grupos foi realizada eletroacupuntura denso-dispersa, com frequência de 3 e 200Hz, sendo que, no primeiro grupo (GEA), foram estimulados os pontos BP4, E44, R3 e, no segundo grupo (GEB), os pontos BP6, E36, VB34. Nesses dois grupos, foram administrados 1,5mL de solução fisiológica por via IM. No terceiro grupo (GF), foi realizada acupuntura em três pontos falsos e o aparelho de eletroacupuntura foi acoplado, mas não foi ligado, e administrou-se morfina na dose de 0,5mg/kg, diluída em solução fisiológica de modo que o volume total foi de 1,5mL por via IM. Foram avaliados os parâmetros cardiovasculares e respiratórios durante o período pré e transoperatório. A avaliação de dor pós-operatória foi realizada durante 12 horas, e a analgesia suplementar com morfina foi realizada quando o escore de dor alcançou valores iguais ou superiores a nove pontos (total de 27) de acordo com a "Escala de dor da Universidade de Melbourne" (EDUM). O grupo GEB apresentou pressão arterial estável, menor variação da Etiso e menor requerimento analgésico no pós-operatório. Nos grupos GEA e GF houve aumento da Etiso e da pressão arterial nos momentos de maior manipulação cirúrgica. Os maiores escores de dor foram obtidos em MP0 (momento da extubação) no GEA (8) e em MP1(1h após a extubação) no GF (9). O GF apresentou o maior requerimento analgésico no pós-operatório e foram realizados 17 resgates em 6 animais. Os acupontos R3, E44 e BP4, utilizados na eletroacupuntura com a frequência de 3 e 200Hz, não são capazes de promover ação antinociceptiva satisfatória no período transoperatório. O efeito analgésico pós-operatório promovido pela eletroestimulação nos acupontos R3, E44 e BP4 é inferior ao proporcionado pelos acupontos E36, BP6 e VB34 e superior ao obtido com a morfina.

Failed Obstetric Spinal Anesthesia in a Nigerian Teaching Hospital: Incidence and Risk Factors.

In a retrospective survey, we found 1% cases with complete and partial failure of spinal anesthesia for cesarean delivery between 2008 and 2010, which we attributed to underreporting because of the study design. In this prospective study, we determined the incidence of failed spinal anesthesia and identified the factors that increased its risk. This prospective, observational study consisted of all spinal anesthetics administered for cesarean delivery surgery from January 2011 to December 2013. Our definition of failure covered complete (preoperative) failure to achieve a pain-free operative condition and pain during surgery (intraoperative failure). Of a total of 3568 cesarean deliveries, there were 3239 (90.8%) spinal blocks, and the overall failure was 294 (9.1%). These were rescued by conversion to general anesthesia (22.8%) and repeating spinal (23.1%) and IV analgesic supplementation (54.1%). Analysis by logistic regression model indicated that factors associated with failure were the level of experience of the anesthesia provider as shown by senior registrar (adjusted risk ratio [RR], 1.4; 95% confidence interval [CI], 1.0-1.9), >1 lumbar puncture attempt (adjusted RR, 1.5; 95% CI, 1.1-1.9), and use of the L4/L5 interspace (adjusted RR, 1.7; 95% CI, 1.4-2.0). The rate of failed spinal anesthesia from this study was high. The independent predictors of failure were multiple lumbar puncture attempts, use of the L4/L5 interspace, and the level of experience of the anesthesia provider. It is imperative to develop clear guidelines to standardize our obstetric spinal anesthetic practice as well as the management of failures.