Time Of Request For Analgesia Research Articles

Pulse-oximetry Derived Perfusion Index as a Predictor of the Efficacy of Rescue Analgesia After Major Abdominal Surgeries

Study Objective: The use of an easy to apply reliable tool is essential to assess pain in patients in intensive care units. This study aimed primarily to evaluate perfusion index usefulness as an objective indicator of pain. Methods and Measurements: Data were collected from 40 non-intubated adult patients admitted to the surgical intensive care unit postoperatively. The Masimo pulse co-oximetry perfusion index (PI) probe was attached to the patient. At the time of the first request for analgesia (T1), the Behavioural pain scale non-intubated scoring system (BPS-NI) was recorded with the PI and patients' haemodynamics following which rescue analgesia was given. Thirty minutes thereafter (T2), second measurements for the mentioned parameters were taken. Main Results: There was a statistically significant reduction in the BPS-NI score, blood pressure and heart rate after analgesic administration (P-values, <0.001, 0.039 and 0.001, respectively), together with a significant increase in the PI (P-value, 0.004). This means that the PI increases with adequate relief from pain, as indicated by a decrease in BPS-NI score and haemodynamics, but the correlation was not statistically significant between their changes. Conclusion: There was no statistically significant correlation between the PI and the pain score or other clinical indicators of pain either before or after the administration of analgesic.

Efficacy of pre-emptive ultrasound guided transverses abdominis plane block with dexamethasone added to bupivacaine for postoperative analgesia after laparoscopic surgeries: A randomised clinical study

Introduction: Laparoscopic surgeries are commonly performed surgical procedures in day to day practice. These patients require a multimodal postoperative pain treatment regimen that provides high quality analgesia with minimal side effects. Opioids, such as morphine, delivered using a patient-controlled analgesia device, remain the mainstay of postoperative analgesic regimens for such patients. TAP block is a regional anaesthetic technique that has been applied as one segment of a multimodal pain regimen in abdominal surgeries. Addition of dexamethasone as adjuvant to bupivacaine in TAP block provides prolonged post-operative analgesia and better pain control than LA alone. The duration of LA was longer with decreased VAS scores and the time of request for rescue morphine doses was less in dexamethasone group. Objectives: Evaluate efficacy of TAP block in providing post-operative analgesia in laparoscopic surgeries. Evaluate pain severity using VAS. Evaluate need for rescue analgesia. Evaluate safety and adverse effects of TAP block. Group 1 - 15 ml 0.25% Bupivacaine with Dexamethasone 8mg on both sides if surgical incision involved both sides of rectus sheath. Group 2 - 15 ml 0.25% Bupivacaine with normal saline. Results: The duration of analgesia increased considerably in study group. The time for request of analgesia was increased (364.7 min) in study group when compared to control group (148.0 min). Conclusion: dexamethasone to TAP block produces immense post-operative analgesia along with reduced VAS score, increased the duration of analgesia and reduced rescue analgesic dose requirements. Keywords: TAP block, Dexamethasone, VAS score.

Efficacy of ultrasound-guided fascia iliaca compartment block with ropivacaine and dexmedetomidine for postoperative analgesia in hip arthroplasty

Background Suprainguinal fascia iliaca block (FICB) has been reported to provide effective postoperative analgesia in patients with femur fracture. This study aimed to evaluate the effectiveness of FICB with ropivacaine and dexmedetomidine for postoperative analgesia in hip arthroplasty. Patients and methods This prospective, double-blinded, randomized, controlled, clinical study was conducted on 57 patients with American Society of Anesthesiology physical status I–II, aged 50–70 years, undergoing elective hip arthroplasty. Subarachnoid block was given at the L3-4 interspace, and then the patients were divided into three groups according to the drug given in the suprainguinal fascia iliaca after subarachnoid block and before skin incision: group C received 40 ml normal saline, group R received 40 ml ropivacaine 0.2%, and group D received a mixture of dexmedetomidine 2 μg/kg diluted in 0.2% ropivacaine with 40 ml total volume. The primary outcome was evaluation of postoperative analgesia using numerical rating scale, recorded at 30 min and at 1, 3, 6, 9, 12, 15, 18, 21, and 24 h. Analgesic consumption and first analgesic request were the secondary outcomes. Results Numerical rating scale scores were significantly higher in group C when compared with groups R and D, at the 1, 3, and 6 h. Postoperative pethidine consumption during the first 24 h was found to be significantly less in group R and group D when compared with group C. There was a statistically significant difference in the group D when compared with group C and group R, with less number of patients who required rescue analgesic in 24 h and prolonged time for first request of rescue analgesic. Conclusion Addition of dexmedetomidine to ropivacaine in FICB was efficacious in decreasing severity of pain, decreasing total analgesic consumption during the first 24 h, and prolonging the time for first request of analgesia in the postoperative period for patients undergoing hip arthroplasty.

Ultra-low-dose naloxone added to fentanyl and lidocaine for peribulbar anesthesia: A randomized controlled trial

PurposePurpose was to evaluate the quality of the block and the duration of postoperative analgesia when ultra-low-dose of naloxone added to fentanyl and lidocaine for peribulbar anesthesia.MethodsSixty adult patients of both sexes, ASA I and II scheduled for open globe cataract surgery in the Ophthalmology Department Tanta University Hospital were included in this randomized prospective clinical trial.The patients were randomized into 2 groups (30 patients each). Group I: patients received 50 μg fentanyl and lidocaine 2% with hyaluronidase 15 IU/ml. Group II: patients received 100 ηg naloxone, 50 μg fentanyl and lidocaine 2% with hyaluronidase 15 IU/ml.Total akinesia was scored every 2 min till the best akinesia score. Onset, best akinesia score, total injected volume, number of patients needed supplemental injection, time of first request for analgesia and, any complication were recorded. Pain was assessed during and after surgery at 30, 60, 90 min, 2, 3, 4, 6 and 8 h postoperatively, using Visual Analogue Score; 0 = no pain, to 10 = maximum pain.ResultsThe time to first rescue analgesic was significantly longer in group II (7.73 ± 0.98) than group I (4.30 ± 0.47). The IOP was increased significantly at 2 min post-injection then, it became insignificant at 10 min postinjection compared to the preinjection values in both groups. There were few minor complications with no significant difference between groups.ConclusionAddition of ultra-low-dose naloxone to fentanyl and lidocaine for peribulbar anesthesia prolongs the duration of postoperative analgesia without increasing the adverse effects.

Preoperative gabapentin alone or in combination with dexamethasone on postoperative pain relief after abdominal hysterectomies. A randomized controlled trial

ObjectivesTo investigate the role of combining preoperative gabapentin with dexamethasone in the management of post-operative pain following abdominal hysterectomy.MethodsThis prospective randomized double blinded study included 60 females scheduled for abdominal hysterectomy under general anesthesia. They were randomized into three equal groups [20 patients each]; group C [Control]: received oral placebo and intravenous 2 cc normal saline 0.9%, group G [Gabapentin]: received 800 mg gabapentin orally and intravenous 2 cc normal saline 0.9% and group GD [Gabapentin/Dexamethasone]: received 800 mg gabapentin orally and intravenous 8 mg/2 cc dexamethasone. Intraoperative fentanyl requirement, postoperative pain, sedation and nausea and vomiting were assessed at 2, 6, 12 and 24 h postoperative. Time of the first request for analgesia and total postoperative meperidine dose over 24 h were calculated.ResultsIntraoperative fentanyl requirement, time of the first analgesic request, total 24 h meperidine consumption and VAS score at 2 and 6 h postoperatively showed highly statistically significant difference between group (GD) [added dexamethasone to gabapentin] and gabapentin (G) alone or control (C), meanwhile there was statistically significant difference between (G) and (C) groups. VAS score was statistically significant lower among the three studied groups when assessed at 12 h postoperatively. There were no statistically significant differences among the three groups as regards the postoperative sedation scale. PONV was highly statistically significant less observed in groups (GD) and (G) at 2 h and statistically significant less observed at 6 h postoperatively when compared to the control group (C).ConclusionGabapentin alone reduced the intraoperative and postoperative opioid requirement as well as postoperative pain and PONV which was significant in comparison with the placebo effect in the control. Obviously these effects were more prominent and highly significant when dexamethasone was added to gabapentin.

Comparative efficacy of two different dosages of intrathecal magnesium sulphate supplementation in subarachnoid block.

Spinal anaesthesia is the primary anaesthetic technique for many types of surgeries. Adjuncts to the local anaesthetics (LA) used in spinal anaesthesia can exhibit undesirable side-effects like respiratory depression, urinary retention, pruritis, haemodynamic instability and nausea and vomiting, limiting their use. Magnesium when used in therapeutic doses avoids all of these side-effects. We conducted a randomized double blind study on 90 patients, 30 in each group, scheduled for orthopaedic lower limb surgery under subarachnoid block. Group I: received bupivacaine (0.5%), 12.5 mg + 0.5 ml of preservative free 0.9% normal saline, Group II received bupivacaine (0.5%), 12.5 mg + 0.2 ml (50 mg) of preservative free 25 % magnesium sulphate + 0.3 ml of preservative free 0.9% normal saline Group III: received bupivacaine (0.5%) 12.5 mg + 0.3 ml (75 mg) of 25 % magnesium sulphate + 0.2 ml of preservative free 0.9% normal saline for subarachnoid block. The onset and duration of sensory block, the highest dermatomal level of sensory block, motor block, time to complete motor block recovery and duration of spinal anaesthesia were recorded. ANOVA was applied to determine the significance of difference between different groups. If p-value was significant then Turkey's Post Hoc Multicomparison test was applied. Values of p<0.05 were considered to be statistically significant. The time of maximum sensory block, time of onset of motor block, duration of sensory block, duration of motor block and time of analgesia request were prolonged in patients given magnesium 50mg and 75mg along with local anaesthetic intrathecally. N-methyl-D-aspartate (NMDA) receptor antagonist, magnesium when administered intrathecally along with local anaesthetics prolongs the duration of spinal analgesia without adverse effects.

Hemodynamic Changes Associated With Spinal Anesthesia for Cesarean Delivery in Severe Preeclampsia

Background Hemodynamic responses to spinal anesthesia (SA) for cesarean delivery in patients with severe preeclampsia are poorly understood. This study used a beat-by-beat monitor of cardiac output (CO) to characterize the response to SA. The hypothesis was that CO would decrease from baseline values by less than 20%. Methods Fifteen patients with severe preeclampsia consented to an observational study. The monitor employed used pulse wave form analysis to estimate nominal stroke volume. Calibration was by lithium dilution. CO and systemic vascular resistance were derived from the measured stroke volume, heart rate, and mean arterial pressure. In addition, the hemodynamic effects of phenylephrine, the response to delivery and oxytocin, and hemodynamics during recovery from SA were recorded. Hemodynamic values were averaged for defined time intervals before, during, and after SA. Results Cardiac output remained stable from induction of SA until the time of request for analgesia. Mean arterial pressure and systemic vascular resistance decreased significantly from the time of adoption of the supine position until the end of surgery. After oxytocin administration, systemic vascular resistance decreased and heart rate and CO increased. Phenylephrine, 50 mug, increased mean arterial pressure to above target values and did not significantly change CO. At the time of recovery from SA, there were no clinically relevant changes from baseline hemodynamic values. Conclusions Spinal anesthesia in severe preeclampsia was associated with clinically insignificant changes in CO. Phenylephrine restored mean arterial pressure but did not increase maternal CO. Oxytocin caused transient marked hypotension, tachycardia, and increases in CO.

Hemodynamic Changes Associated with Spinal Anesthesia for Cesarean Delivery in Severe Preeclampsia

Hemodynamic responses to spinal anesthesia (SA) for cesarean delivery in patients with severe preeclampsia are poorly understood. This study used a beat-by-beat monitor of cardiac output (CO) to characterize the response to SA. The hypothesis was that CO would decrease from baseline values by less than 20%. Fifteen patients with severe preeclampsia consented to an observational study. The monitor employed used pulse wave form analysis to estimate nominal stroke volume. Calibration was by lithium dilution. CO and systemic vascular resistance were derived from the measured stroke volume, heart rate, and mean arterial pressure. In addition, the hemodynamic effects of phenylephrine, the response to delivery and oxytocin, and hemodynamics during recovery from SA were recorded. Hemodynamic values were averaged for defined time intervals before, during, and after SA. Cardiac output remained stable from induction of SA until the time of request for analgesia. Mean arterial pressure and systemic vascular resistance decreased significantly from the time of adoption of the supine position until the end of surgery. After oxytocin administration, systemic vascular resistance decreased and heart rate and CO increased. Phenylephrine, 50 mug, increased mean arterial pressure to above target values and did not significantly change CO. At the time of recovery from SA, there were no clinically relevant changes from baseline hemodynamic values. Spinal anesthesia in severe preeclampsia was associated with clinically insignificant changes in CO. Phenylephrine restored mean arterial pressure but did not increase maternal CO. Oxytocin caused transient marked hypotension, tachycardia, and increases in CO.

Demand and utilisation of labour analgesia service by Nigerian women

SummaryThis study sought to determine the clinical correlates of the demand and utilisation of labour analgesia resources by Nigerian women in labour. All consenting women were interviewed on arrival at the Unit and while in labour. Biodata, options for relief of labour pain, request for analgesia, method of analgesia, VAS score and cervical score at time of request for analgesia were obtained. A total of 288 women in labour were studied. Of these, 108 (37.5%) patients were aware that the pain of labour can be relieved but only 26.0% had prenatal information on labour analgesia. However, 85.1% of the patients would want their pain of labour relieved. A total of 112 (38.9%) did receive analgesia during labour. Cervical dilatation of <4 cm at presentation to the Unit and nulliparity were likely factors for pain treatment during labour (p = 0.001, χ2 test). There is poor utilisation of labour analgesia services. Improved antenatal information on labour analgesia may boost the utilisation of these resources by Nigerian women in labour.

Anesthesia (5)

Use of intravenous patient‐controlled analgesia for the documentation of synergy between tramadol and metamizol. (Hospital Universitario del Mar, Barcelona, Spain) Br J Anaesth 2000;85:217–223.This study involved 101 posthysterectomy patients who received at the time of analgesia request (TAR) tramadol (100 mg, Group I) or metamizol (1.2 g, Group II) alone, or combined in 1:1 (Group III), 1:0.3 (Group IV), or 1:3 (Group V) ratio. After 15 min, they received the same treatment by IV patient‐controlled analgesia. Pain intensity (VAS‐PI), analgesic consumption, and adverse effects were assessed at TAR, and periodically for 24 h. Data were analyzed using interaction indexes and isobolograms. All treatments produced equivalent VAS‐PI, percent efficacy, and adverse effects; all other treatments were addictive. Comment by Octavio Calvillo, MD, PhD.Synergistic interactions either beneficial or adverse between analgesic drugs remains to be studied quantitatively. The authors propose a new method to quantitate such interactions; this is based on analgesic requirements (IV‐PCA) and pain intensity (VAS‐PI). Data were analyzed using interaction indexes and isobolograms. Isobols are graphic representations of equally effective doses of 2 or more agents. The mean doses of each drug that produces a given response are plotted on the axes of the graph. A zero interaction line (isobol) connects these isoeffective doses in the axis. Using this approach the authors studied 101 posthysterectomy patients. Patients received at the time of analgesia request (TAR) tramadol (100 mg, Group I) or metamizol (1.2 g, Group II), alone or combined 1:1 (Group III), 1:0.3 (Group IV) or 1:3 (Group V). All treatments produced equivalent VAS‐PI, percent efficacy, and adverse effects. Drugs combined in 1:1 ratio synergy became evident both for the analgesic and adverse effects; all other treatments were additive.

Use of intravenous patient-controlled analgesia for the documentation of synergy between tramadol and metamizol

The quantification of the synergistic interactions (beneficial and adverse) of analgesic drug combinations in humans has been elusive. We propose a new procedure based on analgesic requirements (i.v.-PCA) and pain intensity (VAS-PI). One hundred and one post-hysterectomy patients received at the time of analgesia request (TAR) tramadol (100 mg, group I) or metamizol (1.2 g, group II) alone, or combined in 1:1 (III), 1:0.3 (IV) or 1:3 ratio (V). After 15 min, they received the same treatment by PCA. VAS-PI, analgesic consumption and adverse effects were assessed at TAR, and periodically for 24 h. Data were analysed using interaction indexes and isobolograms. All treatments produced equivalent VAS-PI, per cent efficacy and adverse effects. When drugs were combined in a 1:1 ratio, synergy was present for the analgesic and adverse effects; all other treatments were additive.

Combined Spinal and Epidural Analgesia in a Parturient With Severe Myasthenia Gravis

Background and ObjectivesA 27-year-old woman with a history of myasthenia gravis presented for vaginal delivery.MethodsA combined spinal epidural was initiated with 7.5 μg intrathecal sufentanil at the time of first request for analgesia followed by 140 mg epidural lidocaine prior to spontaneous vaginal delivery.ResultsThe patient had a pain-free spontaneous vaginal delivery uncomplicated by muscle weakness.ConclusionCombined spinal and epidural anesthesia using intrathecal opioids initially provides labor analgesia with minimal muscle weakness in the parturient with myasthenia gravis.

Spinal Anesthesia with Bupivacaine and Fentanyl in Geriatric Patients

We assessed the risks and benefits of the administration of fentanyl during spinal anesthesia in the elderly. Forty patients (70-83 yr) undergoing knee or hip replacement were studied. Preoperatively, cognitive function (minimental state examination [MMSE]), associated pathology, medications, and treatment were evaluated. Patients had spinal anesthesia with 12.5 mg bupivacaine plus saline (SS; n = 21) or 25 micrograms fentanyl (FN; n = 19). The number of ailments and drugs per patient were 2.5 and 2.3, respectively; 35%-44% of disorders were untreated, 16%-26% were symptomatic, and 33% were adequately treated. Groups were comparable regarding demographic data and characteristics of the spinal block. Group FN had more pruritus (P < 0.02) and lower SaO2 (P < 0.007), but prevalence of side effects was similar. Pain intensity (visual analog scale [VAS], facial expression test [FET] at the time of analgesia request (TAR) was lower in Group FN (P < 0.01). A poor correlation between VAS and FET (range 0.42-0.58) was obtained. MMSE at hospital discharge was no different from preoperative values. Our results show that 25 micrograms of spinal fentanyl do not modify spinal anesthesia in the elderly, but induces pruritus and O2 desaturation. The decrease in postoperative pain intensity and the preservation of cognitive function would justify the use of spinal fentanyl in the elderly.