Total Amount Of Morphine Research Articles

Ultrasound-guided continuous erector spinae plane block versus thoracic epidural analgesia in open nephrectomy for renal malignancy: a randomized controlled study

Background & objective: Pain during nephrectomy has been reported to be extremely intense and may trigger complex biochemical and physiological stress response if managed inadequately. Erector spinae plane block (ESPB) and thoracic epidural analgesia (TEA) both have been advocated for pain management in adult patients undergoing open nephrectomy under general anesthesia. We compared the efficacy and the dynamics of both of these procedures. Methodology: This was a randomized, double-blinded, controlled trial involving 54 patients were undergoing open nephrectomy for malignant kidney tumors. All patients were ASA class II, had a BMI 20-40 kg/m2, and were between the ages of 18-65 y. Through random assignment, people were divided into two identical, equivalent groups: Group A (n = 27) received TEA, whereas Group B (n = 27) received US-guided continuous ESPB. Mean arterial pressure (MAP) and intraoperative heart rate (HR) were recorded before and after incision, and at 30 min, 1 h, and 1.5 h. Postoperative HR, MAP were recorded at 6 h and 12 h, both at rest and when moving. Numerical rating scale (NRS) score was used to compare the intensity of postoperative pain. Results: Postoperative HR, MAP, at 6 h and 12 h, at rest and when moving, were substantially reduced in the TEA group than those in the ESPB group. The NRS score of the ESPB group was substantially greater than that of the TEA group. In contrast to the TEA group, much more total amount of morphine was consumed in the ESPB group. The time to first rescue analgesia was substantially shorter in ESPB group than that of the TEA group. Conclusions: The results of our study prove that US guided erector spinae plane block is effective in providing postoperative analgesia, decreasing use of intraoperative and postoperative opioids in patients having open nephrectomy. However, it is still inferior to thoracic epidural analgesia in terms of pain control after 6 h postoperatively. Otherwise, erector spinae plane block has fewer side effects compared to thoracic epidural analgesia. So, it may be used as an alternative to thoracic epidural analgesia. Key words: Erector Spinae Plane Block; Epidural Analgesia; Open Nephrectomy; Pain, Postoperative; Ultrasound Citation: Wadood MA, Abdelrahman MA, Mostafe MM, Abdelghafar EM. Ultrasound-guided continuous erector spinae plane block versus thoracic epidural analgesia in open nephrectomy for renal malignancy: a randomized controlled study, Anaesth. pain intensive care 2024;28(1):26-32; DOI: 10.35975/apic.v28i1.2377 Received July 24, 2023; Revised: September 08, 2023; Accepted: October 03, 2023

IPACK block with spinal anesthesia compared to fentanyl-based spinal anesthesia for postoperative analgesia following arthroscopic meniscectomy: a randomized, prospective study

BackgroundLocal anesthesia and intrathecal narcotics are utilized to provide postoperative analgesia. IPACK (infiltration between the knee capsule and popliteal artery) is a new localized analgesic approach for knee surgery. This randomized study aimed to compare fentanyl-based spinal anesthesia and IPACK block-based spinal anesthesia for postoperative analgesia in patients undergoing arthroscopic meniscectomy.ResultsIn group F, the VAS (visual analog scale) was higher than in group I, whereas the total amount of morphine was lower in group I (P < .05). In group F (3.92 ± 1.54), the initial painkiller request occurred earlier than in group I (8.82 ± 0.44). In addition, total morphine administrated in group F (20.81 ± 0.69) was significantly higher than in group I (9.54 ± 0.73) (P < .05). Group I had a higher level of patient satisfaction 24 h after surgery than group F (P < .05). In the current study, there were no significant adverse effects linked to the use of fentanyl. Moreover, no complications associated with the IPACK block were detected.ConclusionsThe combination of IPACK block and hyperbaric bupivacaine spinal anesthesia is an effective treatment for initial postoperative pain following arthroscopic meniscectomy, according to the findings of this study. IPACK block prolongs postoperative analgesia more than intrathecal fentanyl.Trial registrationThis study was registered with Clinical Trials Registry (NCT05833776).

Intravenous acetaminophen does not reduce morphine use for pain relief in emergency department patients: A multicenter, randomized, double-blind, placebo-controlled trial.

BackgroundPain is one of the main reasons to present to emergency departments (EDs). Opioids are indispensable for acute pain management but are associated with side effects, misuse, and dependence. The aim of this study was to test whether a single dose of intravenous (IV) acetaminophen (paracetamol) can reduce the use of morphine for pain relief and/or morphine‐related adverse events (AEs).MethodsED patients >18 years with acute pain (i.e., Numeric Rating Scale [NRS] > 4) were screened for eligibility. Patients with analgesia in the past 6 h, chronic pain, or clinical instability were excluded. Patients were randomized in a 1:1 ratio to receive either morphine 0.1 mg/kg and 1 g acetaminophen IV or morphine 0.1 mg/kg and placebo IV. The intervention was double‐blinded. Additional morphine 0.05 mg/kg IV was administered every 15 minutes until pain relief (defined as NRS < 4) and whether the pain recurred. The primary outcome was the mean morphine dose for pain relief. Secondary outcomes were the total amount of morphine given, time to achieve pain relief, and AEs.ResultsA total of 220 patients were randomized and 202 evaluated for the primary outcome. The mean morphine dose for pain relief was similar in both groups (acetaminophen 0.15 mg ± 0.07 mg/kg, placebo 0.16 ± 0.07 mg/kg). There were no differences in the total amount of morphine given (acetaminophen 0.19 ± 0.09 mg/kg, placebo 0.19 ± 0.1 mg/kg), the time to achieve pain relief (acetaminophen 30 min [95% CI 17–31 min], placebo 30 min [95% CI 30–35 min]), and the frequency of AEs (overall 27.4%). Time to pain recurrence did not differ significantly between the groups (hazard ratio 1.23 [0.76–1.98], p = 0.40).ConclusionsIn ED patients, acetaminophen had no additional effect on pain control or morphine‐sparing effect at the time of first morphine administration. Titrated morphine with the algorithm used was highly effective, with 80% of all patients reporting pain relief within 60 min of starting therapy.

Effects of Low-Dose Ketamine Infusion on Alleviating the Opioid Burden for Patients Undergoing Myomectomy Surgery.

ObjectiveRecent research has focused on the use of N-methyl-D-aspartate (NMDA) receptor antagonists for pain management. Several drugs are known to have this action, including ketamine, which exerts its main analgesic effect through NMDA receptor antagonism. This study aimed to evaluate the effect of low-dose ketamine infusion on opioid exposure for patients undergoing myomectomy surgery under general anaesthesia.MethodsA total of 70 women were included in this prospective double-blind trial study. The patients included in this study were American Society of Anaesthesiologists physical status I–II, aged between 18 and 50 years and scheduled for laparotomy myomectomy surgery. Patients were randomised to receive either a bolus of 0.2 mg kg−1 of ketamine followed by a continuous infusion of 0.2 mg kg−1 hr−1 during the operation or a placebo of normal saline. Both groups also received morphine as needed for pain relief. The primary outcome was the total amount of morphine used during the intraoperative and postoperative periods. Intraoperative and postoperative mean blood pressure, heart rate and postoperative visual analogue scale for pain were assessed.ResultsTotal mean morphine consumption was significantly lower in the ketamine group than in the control group (26±3.5 mg vs. 34.7±3.3 mg, respectively, p<0.05). However, there were no statistical differences between the groups regarding haemodynamics, postoperative pain score and complications.ConclusionThe use of ketamine in low infusion doses intraoperatively during an elective myomectomy procedure produced an opioid-sparing effect by reducing perioperative morphine consumption without significant side effects.

Effect of bilateral ultrasound-guided erector spinae blocks on postoperative pain and opioid use after lumbar spine surgery: A prospective randomized controlled trial

ABSTRACT Background: The control of postoperative pain following major lumbar spine surgeries remains a major challenge for anesthesiologists, and many new strategies and methods have been developed for pain control. This study’s main objective was to evaluate the efficacy of the bilateral ultrasound-guided erector spinae plane block (US-ESPB) as a method for perioperative pain management in patients undergoing lumbar spine surgeries. Methods: This double-blinded prospective randomised controlled study was conducted on 140 patients aged between 18 and 65 years; all were scheduled for elective lumbar spine surgeries. Patients were randomly allocated into one of the two groups: the ESPB group (n = 70) or the control group (n = 70). All patients received bilateral US-ESPB after induction of general anaesthesia, in the ESPB group; 20 mL of levobupivacaine 0.25% were used, while 20 mL normal saline was given to the control group instead. The primary endpoint was the total amount of morphine consumed during the intraoperative and the first 24 postoperative hours. Secondary endpoints included, time to first request of rescue analgesia as well as incidence of adverse effects. Results: The total amount of morphine consumed during the intraoperative and the first 24 postoperative hours was found to be significantly lower in the ESPB group compared to the control group (P < 0.001). Moreover, the time to first analgesic request was significantly longer in patients receiving ESPB as analgesia (P < 0.001). No statistically significant differences were observed between the two groups regarding complications. Conclusion: Bilateral US-ESPB is useful intervention for providing adequate pain management in lumbar spine surgeries.

Paracetamol (acetaminophen) for prevention or treatment of pain in newborns.

Newborn infants have the ability to experience pain. Hospitalised infants are exposed to numerous painful procedures. Healthy newborns are exposed to pain if the birth process consists of assisted vaginal birth by vacuum extraction or by forceps and during blood sampling for newborn screening tests. To determine the efficacy and safety of paracetamol for the prevention or treatment of procedural/postoperative pain or pain associated with clinical conditions in neonates. To review the effects of various doses and routes of administration (enteral, intravenous or rectal) of paracetamol for the prevention or treatment of pain in neonates. We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 4), MEDLINE via PubMed (1966 to 9 May 2016), Embase (1980 to 9 May 2016), and CINAHL (1982 to 9 May 2016). We searched clinical trials' databases, Google Scholar, conference proceedings, and the reference lists of retrieved articles. We included randomised and quasi-randomised controlled trials of paracetamol for the prevention/treatment of pain in neonates (≤ 28 days of age). Two review authors independently extracted data from the articles using pre-designed forms. We used this form to decide trial inclusion/exclusion, to extract data from eligible trials and to request additional published information from authors of the original reports. We entered and cross-checked data using RevMan 5 software. When noted, we resolved differences by mutual discussion and consensus. We used the GRADE approach to assess the quality of evidence. We included nine trials with low risk of bias, which assessed paracetamol for the treatment of pain in 728 infants. Painful procedures studied included heel lance, assisted vaginal birth, eye examination for retinopathy of prematurity assessment and postoperative care. Results of individual studies could not be combined in meta-analyses as the painful conditions, the use of paracetamol and comparison interventions and the outcome measures differed. Paracetamol compared with water, cherry elixir or EMLA cream (eutectic mixture of lidocaine and prilocaine) did not significantly reduce pain following heel lance. The Premature Infant Pain Profile score (PIPP) within three minutes following lancing was higher in the paracetamol group than in the oral glucose group (mean difference (MD) 2.21, 95% confidence interval (CI) 0.72 to 3.70; one study, 38 infants). Paracetamol did not reduce "modified facies scores" after assisted vaginal birth (one study, 119 infants). In another study (n = 123), the Échelle de Douleur et d'Inconfort du Nouveau-Né score at two hours of age was significantly higher in the group that received paracetamol suppositories than in the placebo suppositories group (MD 1.00, 95% CI 0.60 to 1.40). In that study, when infants were subjected to a heel lance at two to three days of age, Bernese Pain Scale for Neonates scores were higher in the paracetamol group than in the placebo group, and infants spent a longer time crying (MD 19 seconds, 95% CI 14 to 24). For eye examinations, no significant reduction in PIPP scores in the first or last 45 seconds of eye examination was reported, nor at five minutes after the eye examination. In one study (n = 81), the PIPP score was significantly higher in the paracetamol group than in the 24% sucrose group (MD 3.90, 95% CI 2.92 to 4.88). In one study (n = 114) the PIPP score during eye examination was significantly lower in the paracetamol group than in the water group (MD -2.70, 95% CI -3.55 to 1.85). For postoperative care following major surgery, the total amount of morphine (µg/kg) administered over 48 hours was significantly less among infants assigned to the paracetamol group than to the morphine group (MD -157 µg/kg, 95% CI -27 to -288). No adverse events were noted in any study. The quality of evidence according to GRADE was low. The paucity and low quality of existing data do not provide sufficient evidence to establish the role of paracetamol in reducing the effects of painful procedures in neonates. Paracetamol given after assisted vaginal birth may increase the response to later painful exposures. Paracetamol may reduce the total need for morphine following major surgery, and for this aspect of paracetamol use, further research is needed.

Role of gabapentin in controlled hypotension for nasal surgeries

Background Providing bleeding control is critically important when microsurgical techniques are used. A mild bleeding can complicate the working in surgical field in nasal surgery so, a bloodless surgical field should be provided. For that purpose, the anesthesiologists should use controlled hypotension anesthetic technique. The aim of this study was to investigate the hypotensive and analgesic effects of gabapentin if combined with nitroglycerin infusion for conduction of hypotensive anesthesia in nasal surgeries. Patients and methods The present study was carried out at El-Zahraa hospital, Al Azhar University on 40 patients ASA I and II were randomly assigned into two equal groups (n=20). Gabapentin nitroglycerin (GN) group: patients received 1200 mg gabapentin orally 2 h preoperatively. Nitroglycerin placebo group (N): patients received placebo tablet orally 2 h preoperatively. Intravenous nitroglycerin infusion started and titrated for all 40 patients according to the target hypotensive condition (mean arterial pressure range between 55–65 mmHg and heart rate between 60–75 b/min). Intraoperative hemodynamic changes in the form of heart rate (HR) and mean arterial pressure (MAP) were recorded; the total nitroglycerin dose required was recorded; blood loss and quality of surgical field were assessed. Also, visual analog scale (VAS) for pain assessment and total amount of morphine used within 12 postoperative hours were detected for each group. Results The results showed that the heart rate and the mean arterial pressure were significantly lower in the GN group compared to N group. The total dose of intraoperative nitroglycerin was significantly lower in the GN group compared to N group. GN group provides the lower amount of blood loss and better surgical field exposure compared to N group. The visual analog scale (VAS) values was significantly lower at 30 min and 4 h post-operative while non-significant difference at 1 and 6 h postoperative in the GN group compared with N group. There was a significantly lower in the total morphine consumption for GN group compared to N group. Conclusion Preoperative oral gabapentin (1200 mg) augments the hypotensive effect of nitroglycerin as it provides dryness of surgical field associated with lower infusion rate of nitroglycerin. Also, it has better analgesic effect with lower narcotic consumption during controlled hypotensive anesthesia for nasal surgeries when compared to the administration of nitroglycerin alone.

Paracetamol (acetaminophen) for prevention or treatment of pain in newborns.

Newborn infants have the ability to experience pain. Hospitalised infants are exposed to numerous painful procedures. Healthy newborns are exposed to pain if the birth process consists of assisted vaginal birth by vacuum extraction or by forceps and during blood sampling for newborn screening tests. To determine the efficacy and safety of paracetamol for the prevention or treatment of procedural/postoperative pain or pain associated with clinical conditions in neonates. To review the effects of various doses and routes of administration (enteral, intravenous or rectal) of paracetamol for the prevention or treatment of pain in neonates. We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 4), MEDLINE via PubMed (1966 to 9 May 2016), Embase (1980 to 9 May 2016), and CINAHL (1982 to 9 May 2016). We searched clinical trials' databases, Google Scholar, conference proceedings, and the reference lists of retrieved articles. We included randomised and quasi-randomised controlled trials of paracetamol for the prevention/treatment of pain in neonates (≤ 28 days of age). Two review authors independently extracted data from the articles using pre-designed forms. We used this form to decide trial inclusion/exclusion, to extract data from eligible trials and to request additional published information from authors of the original reports. We entered and cross-checked data using RevMan 5 software. When noted, we resolved differences by mutual discussion and consensus. We used the GRADE approach to assess the quality of evidence. We included nine trials with low risk of bias, which assessed paracetamol for the treatment of pain in 728 infants. Painful procedures studied included heel lance, assisted vaginal birth, eye examination for retinopathy of prematurity assessment and postoperative care. Results of individual studies could not be combined in meta-analyses as the painful conditions, the use of paracetamol and comparison interventions and the outcome measures differed. Paracetamol compared with water, cherry elixir or EMLA cream (eutectic mixture of lidocaine and prilocaine) did not significantly reduce pain following heel lance. The Premature Infant Pain Profile score (PIPP) within three minutes following lancing was higher in the paracetamol group than in the oral glucose group (mean difference (MD) 2.21, 95% confidence interval (CI) 0.72 to 3.70; one study, 38 infants). Paracetamol did not reduce "modified facies scores" after assisted vaginal birth (one study, 119 infants). In another study (n = 123), the Échelle de Douleur et d'Inconfort du Nouveau-Né score at two hours of age was significantly higher in the group that received paracetamol suppositories than in the placebo suppositories group (MD 1.00, 95% CI 0.60 to 1.40). In that study, when infants were subjected to a heel lance at two to three days of age, Bernese Pain Scale for Neonates scores were higher in the paracetamol group than in the placebo group, and infants spent a longer time crying (MD 19 seconds, 95% CI 14 to 24). For eye examinations, no significant reduction in PIPP scores in the first or last 45 seconds of eye examination was reported, nor at five minutes after the eye examination. In one study (n = 81), the PIPP score was significantly higher in the paracetamol group than in the 24% sucrose group (MD 3.90, 95% CI 2.92 to 4.88). In one study (n = 114) the PIPP score during eye examination was significantly lower in the paracetamol group than in the water group (MD -2.70, 95% CI -3.55 to 1.85). For postoperative care following major surgery, the total amount of morphine (µg/kg) administered over 48 hours was significantly less among infants assigned to the paracetamol group than to the morphine group (MD -157 µg/kg, 95% CI -27 to -288). No adverse events were noted in any study. The quality of evidence according to GRADE was low. The paucity and low quality of existing data do not provide sufficient evidence to establish the role of paracetamol in reducing the effects of painful procedures in neonates. Paracetamol given after assisted vaginal birth may increase the response to later painful exposures. Paracetamol may reduce the total need for morphine following major surgery, and for this aspect of paracetamol use, further research is needed.

Buprenorphine Versus Methadone for Opioid Dependence in Pregnancy.

To evaluate maternal and neonatal safety outcomes for methadone and buprenorphine in the obstetric population. A literature search of PubMed (1966 to March 2016) and EMBASE (1973 to March 2016) was completed using the search terms buprenorphine, methadone, pregnancy, opioid, and neonatal abstinence syndrome Priority was given to randomized controlled trials and trials directly comparing buprenorphine and methadone during pregnancy. The bibliographies were reviewed for other relevant articles. All human studies published in English, that compared methadone and buprenorphine use in pregnancy were evaluated. Because of the limited number of obstetric studies, only 5 critical studies were found. Buprenorphine significantly improved or had similar outcomes to methadone for development of neonatal abstinence syndrome (NAS), percentage of infants requiring treatment for NAS (20%-47% vs 45.5%-57%, respectively), total amount of morphine used to treat NAS (0.472-3.4 vs 1.862-10.4 mg, respectively), duration of NAS (4.1-5.6 vs 5.3-9.9 days, respectively), peak NAS (3.9-11 vs 4.9-12.8 score, respectively), infant hospital stay (6.8-10.6 vs 8.1-17.5 days, respectively), and gestational age at delivery (38.8-39.7 vs 37.9-38.8 weeks, respectively). No difference was found with other neonatal or maternal outcomes. Both methadone and buprenorphine are effective agents, with improved safety compared with continued nonmedical opioid use during pregnancy. There is evidence to suggest that buprenorphine should be considered as an equivalent option to methadone for use in pregnancy; however, larger studies are still needed to fully evaluate buprenorphine safety and advantages over methadone in the obstetric population.

Mice with neuropathic pain exhibit morphine tolerance due to a decrease in the morphine concentration in the brain

The chronic administration of morphine to patients with neuropathic pain results in the development of a gradual tolerance to morphine. Although the detailed mechanism of this effect has not yet been elucidated, one of the known causes is a decrease in μ-opioid receptor function with regard to the active metabolite of morphine, M-6-G(morphine-6-glucuronide), in the ventrotegmental area of the midbrain. In this study, the relationship between the concentration of morphine in the brain and its analgesic effect was examined after the administration of morphine in the presence of neuropathic pain. Morphine was orally administered to mice with neuropathic pain, and the relationship between morphine's analgesic effect and its concentration in the brain was analysed. In addition, the expression levels of the conjugation enzyme, UGT2B (uridine diphosphate glucuronosyltransferase), which has morphine as its substrate, and P-gp, which is a transporter involved in morphine excretion, were examined. In mice with neuropathic pain, the concentration of morphine in the brain was significantly decreased, and a correlation was found between this decrease and the decrease in the analgesic effect. It was considered possible that this decrease in the brain morphine concentration may be due to an increase in the expression level of P-gp in the small intestine and to an increase in the expression level and binding activity of UGT2B in the liver. The results of this study suggest the possibility that a sufficient analgesic effect may not be obtained when morphine is administered in the presence of neuropathic pain due to a decrease in the total amount of morphine and M-6-G that reach the brain.

Postoperative Etoricoxib versus Ketoprofen Administration for Pain Management after Total Knee Arthroplasty: A Randomized, Double-Blind Controlled Study

Objective. This randomized double-blind study compared the analgesic efficacy and tolerability of etoricoxib versus ketoprofen in 165 patients with elective total primary knee arthroplasty. Methods. After ethical committee approval, 165 patients were randomized in 3 groups: the etoricoxib group (E) receiving etoricoxib 120 mg/day, at the end of surgery and in the first postoperative day; the ketoprofen group (K) receiving ketoprofen 2 pills of 100 mg/day, the first at the end of surgery and then 1 pill every 12 hours in the surgery day and the first postoperative day; the placebo group (P). All groups received postoperatively the same analgesia protocol when NRS is over 3 with IV Perfalgan and morphine. The effectiveness was evaluated by the time from the initiation of spinal anesthesia until the first analgesic dose, the total amount of morphine administered in the surgery day and the first postoperative day, and the frequency of patients with side effects and necessary amount of adjuvant medication. Results. The baseline demographic characteristics were similar among the 3 groups. In both study days etoricoxib provided an analgesic effect superior to placebo and to ketoprofen, the total administered morphine being significantly lower in etoricoxib group. There were no statistically significant differences between groups regarding the side effects.

Buprenorphine and Naloxone Compared With Methadone Treatment in Pregnancy

OBJECTIVE: To compare neonatal abstinence syndrome prevalence and characteristics among neonates born to women prescribed buprenorphine and naloxone compared with methadone during pregnancy. METHODS: Retrospective cohort analysis of mother– neonate dyads treated with either buprenorphine and naloxone or methadone during pregnancy. Primary neonatal outcomes included diagnosis of neonatal abstinence syndrome, neonatal abstinence syndrome peak scores, total amount of morphine used to treat neonatal abstinence syndrome (mg), and duration of treatment for neonatal abstinence syndrome (days). Secondary outcomes included head circumference, birth weight, length, preterm birth, neonatal intensive care unit admission, Apgar scores, and overall length of hospitalization. RESULTS: From January 1, 2011, to November 30, 2013, we identified 62 mother–neonate dyads, 31 treated with methadone and 31 treated with buprenorphine and naloxone. Sixteen neonates (51.6%) in the methadone group were diagnosed with neonatal abstinence syndrome compared with eight (25.1%) in the buprenorphine and naloxone group (adjusted odds ratio 2.55, 95% confidence interval [CI] 1.31–4.98, P5.01). The buprenorphine and naloxone-exposed neonates had lower peak neonatal abstinence syndrome scores (9.064.4 compared with 10.763.7, multivariate-adjusted mean difference522.77, 95% CI 24.99 to 20.56, P5.02) and shorter overall hospitalization (5.665.0 compared with 9.867.4 days, multivariate-adjusted mean difference523.90, 95% CI, 27.13 to 20.67, P5.02). We found no other differences in primary or secondary outcomes. CONCLUSION: In a cohort of pregnant patients treated with either methadone or buprenorphine and naloxone in pregnancy, newborns exposed to maternal buprenorphine and naloxone had less frequent neonatal abstinence syndrome. Additionally, neonates exposed to buprenorphine and naloxone had shorter overall hospitalization lengths.

Paracetamol (acetaminophen) for prevention or treatment of pain in newborns.

Paracetamol (acetaminophen) for prevention or treatment of pain in newborns.

Application of continuous thoracic paravertebral nerve block guided by nerve stimulator on postoperative pain relief for nephrectomy

To evaluate the effects of continuous paravertebral nerve block after nephrectomy. 60 cases receiving simple nephrectomy,American Society of Anesthesiologists(ASA) grading status I or II, aged from 30 to 65 years, weighing from 45 to 80 kg, male or female, were randomly divided into 2 groups: control group (CEA group ) and continuous paravertebral nerve block group (PVB group ), 30 patients in each one. Both groups were performed with 0.2% ropivacaine 250 ml in continuous infusion, assisted with intravenous morphine patient-controlled analgesia. The blood gas was examined in 6, 12, 24 and 48 h postoperatively, and the VAS scores of quiet state and motion state were assessed.In 48 h postoperation, the total amount of morphine was calculated and the complications cases were recorded. Compared with the CEA group, PaO2 in PVB group increased and PaCO2 declined significantly. There was no difference of VAS score under quiet state, but under the motion state the VAS scores declined significantly, the total amount of morphine reduced[ (5.2 ± 1.2) vs (13.9 ± 1.6) mg) ], the cases of nausea, vomiting, pruritus , orthostatic hypotension decreased and the postoperative first anal exhaust time interval shortened (P < 0.05). Compared with CEA, postoperative administration of PVB for open nephrectomy results in lowering morphine dose as well as side effect related with the use of morphine.

P39: Predictive value of meconium concentrations of buprenorphine and methadone in neonatal abstinence syndrome (NAS)

Introduction Buprenorphine (BPN) and methadone (MTD) are two drugs authorized during pregnancy for opioid-dependence treatment. Substitution by MTD or BPN reduce fetal heroin exposure, obstetric complications, and neonatal morbidity and mortality (OFDT, 2003; Lejeune, 2004). Few days after birth newborns exposed in utero to MTD or BPN may suffered of neonatal abstinence syndrome (NAS), consisting in hyperirritability, gastrointestinal dysfunction, respiratory distress, and neurovegetative dysregulations and sometimes convulsions. NAS is treated with morphine, depending of the intensity of the symptoms (measured with Lipsitz scale). Previous studies show that maternal buprenorphine or methadone dose does not predict the severity or duration of NAS. Aim Meconium, the first neonatal feces, could represent the cumulative exposure to drugs in utero all along the gestation. A cohort of 80 opioid-dependent women and their newborn was enrolled for an inter-regional clinical assay managed by Caen university hospital. We assayed in meconium MTD and BPN concentrations, their metabolites and other drugs, and try to correlate them as prognostic factors of time, severity and duration of NAS. Methods 10 women treated with buprenorphine, 12 with methadone, and their newborns were currently included. NAS was followed by repeated Lipsitz scores (positive when >4). Meconium sample preparation included deproteinization followed by solidphase extraction (SPE) with Strata XC ® column. BPN, MTD with their main metabolites norbuprenorphine and EDDP, and morphine were quantified by a liquid chromatography - tandem mass spectrometry (LC-MS/MS) method, developed and validated for this study. Separation was done with a Macherey-Nagel Nucleodur Polartec ® (150 mm x 2,1 mm, 5 μm) column using 10mM ammonium formiate, 0,2 % formic acid and acetonitrile, 0,1 % formic acid as mobile phases at a flow rate of 0,35 mL/min in a gradient mode. The analytes were identified and quantified by LC-MS/MS on an ABSciex ® QTRAP3200 instrument with a TurboIon-Spray source operating in positive mode. Total time for each chromatograph was 15 min. Correlations were determined between meconium concentrations and 3 parameters: NAS onset, peak NAS score, and total amount of morphine used for NAS treatment. Other illicit substances and drugs which may have an impact on NAS are screened in maternal and newborn urines. Results For MTD mean meconium concentrations were 4200 ng/g, for EDDP 11700 ng/g (with a mean ratio MTD/EDDP = 0.42). EDDP meconium concentration and methadone/EDDP ratio were correlated with the peak NAS score (p=0.034 and p=0.029 respectively), and with the total amount of morphine used for NAS treatment (p=0.020 and p=0.013). There was no correlation with MTD meconium concentrations. Results are unavailable for buprenorphine at this time. Urine drug screens revealed frequently tobacco, opiates, cannabis, cocaine, hydroxyzine and benzodiazepines, confirming drugs of abuse are commonly used in opioid-dependent pregnant women. Conclusion These results show that measurement of meconium concentrations of EDDP and methadone/EDDP ratio may help clinicians to predict the severity of NAS, and so adapt earlier treatment with morphine. These preliminary results must be confirmed on large cohorts, higher than 30 newborns per group, including buprenorphine results.

Impact of Ultrasound-Guided Femoral Nerve Blocks in the Pediatric Emergency Department

The objective of this study was to compare the duration of analgesia, need for analgesic medications, and pain-related nursing interventions in patients who did and did not receive ultrasound-guided femoral nerve blocks for femur fracture pain. This is a retrospective, preimplementation and postimplementation cohort study. An emergency department log of patients receiving femoral nerve blocks for femur fracture pain was compared with a similar cohort of patients with femur fractures who did not receive nerve blocks. The primary outcome is time from initial pain treatment until the next dose of analgesic. Data were analyzed using Kaplan-Meier methods. Secondary outcomes include number of doses of pain medication, total amount of morphine given, and number of pain-related nursing interventions. Data were analyzed with the Mann-Whitney U test. Eighty-one patients met inclusion/exclusion criteria: 50 in the preimplementation cohort and 31 in the postimplementation group. The median times until next dose of analgesic medication were 2.2 hours (interquartile range [IQR], 1.2-3.4 hours) in the preimplementation group and 6.1 hours (IQR, 3.8-9.5 hours) in the postimplementation group (P < 0.001). The median numbers of doses of pain medication were 0.3 per hour (IQR, 0.25-0.5 per hour) in the preimplementation group and 0.15 per hour (IQR, 0.07-0.3 per hour) in the postimplementation group. The median total doses of morphine were 14.8 µg/kg per hour (IQR, 9.4-19.2 µg/kg per hour) in the preimplementation group and 6.5 µg/kg per hour (IQR, 0-12.2 µg/kg per hour) in the postimplementation group (P = 0.01). The median numbers of nursing interventions were 0.4 per hour (IQR, 0.25-0.5 per hour) in the preimplementation group and 0.15 per hour (IQR, 0.1-0.2 per hour) in the postimplementation group (P < 0.001). Patients who received ultrasound-guided femoral nerve block for femur fracture pain had longer duration of analgesia, required fewer doses of analgesic medications, and needed fewer nursing interventions than those receiving systemic analgesic medication alone.

The relationship between maternal methadone dose at delivery and neonatal outcome: Methodological and design considerations

Compared to untreated opioid dependence, methadone maintenance treatment of opioid-dependent pregnant women has been found to be associated with better maternal and neonatal outcomes. Secondary analysis of data from 73 maternal and neonatal participants in the MOTHER study (H. E. Jones et al., New England Journal of Medicine, 2010) found no relationship between maternal methadone dose at delivery and any of 9 neonatal outcomes — peak neonatal abstinence syndrome (NAS) score, total amount of morphine needed to treat NAS, duration of neonatal hospital stay, duration of treatment for NAS, estimated gestational age at delivery, Apgar score at 5min, and neonatal head circumference, length, and weight at birth. These results are consistent with a recent systematic review and meta-analysis (B. J. Cleary et al., Addiction, 2010) and extend findings to outcomes other than NAS. Methodological and design issues that might have adversely impacted the ability of researchers to establish the existence or non-existence of these relationships are considered.

Influence of Mu-Opioid Receptor Variant on Morphine Use and Self-Rated Pain Following Abdominal Hysterectomy

A common variant in the mu-opioid receptor gene (OPRM1) has been associated with response to opioid analgesia. Our previous data revealed significantly higher amounts of morphine self-administered by patients carrying the 118G allele compared to those with the 118A allele after elective cesarean section. In this study, the association of this genetic variation with pressure pain, postoperative pain scores, and amount of morphine used was investigated in 973 patients undergoing scheduled total hysterectomy under general anesthesia. Preoperative pressure pain threshold and tolerance were also measured for most patients. For pressure pain, OPRM1 genotype was not significantly associated with either pain threshold or pain tolerance. Statistically significant associations were found for postoperative pain and the total amount of morphine used, with the GG group reporting higher pain scores and using the most morphine. When analysis was stratified by ethnic group, differences in weight-adjusted morphine for the 3 genotypic groups were also significant for the Chinese and Asian Indians. These results extend our previous finding on the association of higher self-reported pain and morphine use for acute postoperative pain with OPRM1 118G to patients who had total hysterectomy under general anesthesia. PerspectiveIn a large cohort of patients undergoing hysterectomy, we found large variability in the self-rated pain scores and the amount of morphine required for pain relief. Both are associated with OPRM1 genotypes and preoperative experimental pressure pain threshold. Experimental pressure pain tolerance is also associated with postoperative pain.

Cigarette smoking in opioid-dependent pregnant women: Neonatal and maternal outcomes

BackgroundThe relationship between cigarette smoking and neonatal and maternal clinical outcomes among opioid-agonist-treated pregnant patients is sparse. Objectives(1) Is smoking measured at study entry related to neonatal and maternal outcomes in pregnant women receiving opioid-agonist medication? (2) Is it more informative to use a multi-item measure of smoking dependence or a single-item measure of daily smoking? (3) Is the relationship between smoking at study entry and outcomes different between methadone and buprenorphine? MethodsSecondary analyses examined the ability of the tobacco dependence screener (TDS) and self-reported past 30-day daily average number of cigarettes smoked, both measured at study entry, to predict 12 neonatal and 9 maternal outcomes in 131 opioid-agonist-maintained pregnant participants. ResultsPast 30-day daily average number of cigarettes smoked was significantly positively associated with total amount of morphine (mg) needed to treat neonatal abstinence syndrome (NAS), Adjusted Odds Ratio (AOR)=1.06 (95% CI: 1.02, 1.09), number of days medicated for NAS, AOR=1.04 (95% CI: 1.01, 1.06), neonatal length of hospital stay in days, AOR=1.03 (95% CI: 1.01, 1.05), and negatively associated with 1-AOR=.995 (95% CI: .991,.999) and 5-min Apgar scores, AOR=.996 (95% CI: .994,.998). Simple effect tests of the two significant TDS×medication condition effects found TDS was unrelated to non-normal presentation and amount of voucher money earned in the methadone [AORs=.90 (95% CI: .74, 1.08, p>.24) and 1.0 (95% CI: .97, 1.03, p>.9)] but significant in the buprenorphine condition [AORs=1.57 (95% CI: 1.01, 2.45, p<.05) and 1.08 (95% CI: 1.04, 1.12, p<.01)]. ConclusionsRegardless of prenatal methadone or buprenorphine exposure, heavier cigarette smoking was associated with more compromised birth outcomes.

Randomized Clinical Trial of Transversus Abdominis Plane Block Versus Placebo Control in Live-Donor Nephrectomy

Laparoscopic surgery reduces pain after donor nephrectomy; however, most patients still require a significant amount of postoperative parenteral opiate analgesia. Therefore, there is a need to investigate techniques that might further reduce postoperative pain. This study assessed the safety and efficacy of using a transversus abdominis plane (TAP) block in a randomized, double-blind, placebo-controlled trial. Forty-six patients were analyzed in the trial and were randomized to undergo the TAP block procedure with either bupivacaine (n=24) or saline placebo (Control n=22) injected into the muscle plane. Prefilled syringes were dispensed with the group allocation concealed to maintain blinding. After surgery, the amount of morphine, level of pain, and measures of recovery were recorded. The amount of morphine used 6 hr after surgery was significantly lower in patients receiving TAP block with bupivacaine compared with the control (presented as mean [SD], 12.4 [8.4] vs. 21.2 [14.0] mg; P=0.015). However, the total amount of morphine used was similar in both groups 45.6 [31.4] vs. 52.7 [28.8] mg; P=0.771. Patients in the bupivacaine group experienced significantly less pain on postoperative days 1 (score, 19 [15] vs. 37 [20]; P=0.003) and 2 (score, 11 [10] vs. 19 [13]; P=0.031). Recovery and postoperative hospital stay were similar in both groups. There were no complications associated with the procedure. The TAP block procedure is beneficial in reducing postoperative pain and early morphine requirements in laparoscopic live-donor nephrectomy.