Total Dose Of Morphine Research Articles

The effectiveness of patient control analgesia in the treatment of acute traumatic pain in the emergency department

Pain seems to be one of the most frequent complaints in the emergency department, however pain control is often suboptimal as seen by many audits. We conducted a study to find out whether the use of patient control analgesia (PCA) is effective in controlling acute pain in the emergency department This was a randomized controlled trial conducted in the emergency departments of two tertiary centres over a period of 1 year. Patients were randomized into two groups. The study and the control groups were given analgesia through the PCA system and boluses of analgesia through titration method, respectively. Pain levels were measured using the Visual Analogue Scale at 15 min intervals. Any adverse events and total morphine dose for each group were recorded. Finally, within 24 h, these patients were given questionnaires regarding their experience with regards to pain relief encountered. A total of 47 patients were enrolled. The Visual Analogue Score change over 120 min for PCA and Morphine bolus groups were 5.921 [SD±1.656] and 4.834 (SD±1.797), respectively (P<0.001). However the total dosage of morphine consumed by both groups were statistically insignificant; PCA 7.95 mg (SD±2.44) versus bolus 8.10 (SD±0.99) (P=0.06). The satisfaction questionnaire also revealed that the PCA group of patients was more satisfied using this method of pain relief. PCA provides more effective pain relief and patient satisfaction when compared with the conventional method of bolus intravenous injection for the relief of traumatic pain in the emergency department setting.

Perioperative use of etoricoxib reduces pain and opioid side-effects after total abdominal hysterectomy: a double-blind, randomized, placebo-controlled phase III study

Objective:To evaluate the effects of two different doses of etoricoxib delivered perioperatively compared with placebo and standard pain management on pain at rest, pain with mobilization, and use of additional morphine/opioids postoperatively.Research design and methods:In this double-blind, placebo-controlled, randomized clinical trial, we evaluated postoperative pain following total abdominal hysterectomy over 5 days in patients receiving placebo or etoricoxib administered 90 min prior to surgery and continuing postoperatively. Patients were randomly assigned to receive either placebo (n = 144), etoricoxib 90 mg/day (n = 142), or etoricoxib 120 mg/day (n = 144). Average Pain Intensity at Rest over days 1–3 (0- to 10-point numerical rating scale [NRS]) was the primary efficacy endpoint. Secondary endpoints included Average Pain Intensity upon Sitting, Standing, and Walking over days 1–3 (0- to 10-point NRS) as well as Average Total Daily Dose of Morphine over days 1–3.Clinical trial registration:This trial is registered on www.clinicaltrials.gov (NCT00788710).Results:The least squares (LS) means (95% CI) for the primary endpoint were 3.26 (2.96, 3.55); 2.46 (2.16, 2.76); and 2.40 (2.11, 2.69) for placebo, etoricoxib 90 mg, and etoricoxib 120 mg, respectively, significantly different for both etoricoxib doses versus placebo (p < 0.001). Patients on etoricoxib 90 mg and 120 mg required ∼30% less morphine per day than those on placebo (p < 0.001), which led to more rapid bowel recovery in the active treatment groups by ∼10 hours vs. placebo. A greater proportion of patients on etoricoxib (10–30% greater than placebo) achieved mild levels of pain with movement, defined as pain ≤3/10.Limitations:A key limitation for this study was that movement-evoked pain measurements were not designated as primary endpoints.Conclusion:In patients undergoing total abdominal hysterectomy, etoricoxib 90 mg and 120 mg dosed preoperatively and then continued postoperatively significantly reduces both resting and movement-related pain, as well as reduced opioid (morphine) consumption that led to more rapid bowel recovery.

Morphine consumption is not modified in patients with severe pain and classified by the DN4 score as neuropathic

Neuropathic pain has been poorly investigated in the emergency department, although it is known to be less sensitive to opioids than other forms of pain. We tested the hypothesis that morphine requirements are increased in patients having severe pain classified as neuropathic using the DN4 score. We included adult patients with acute severe pain (visual analog scale ≥70), assessed using the DN4 score, and treated with intravenous morphine titration (bolus of 2 or 3 mg [body weight >60 kg] with 5-minute intervals between each bolus). Pain relief was defined as a visual analog scale 30 or less. Patients were divided into 2 groups: control group (DN4 score <4) and neuropathic pain group (DN4 score ≥4). The main outcome was the total dose of morphine administered. Data are mean±SD or median (interquartile range). Among the 239 patients included (mean age, 43+14 years), 35 patients (15%) had a DN4 score 4 or more. The main characteristics of the 2 groups were comparable. There were no significant differences between the 2 groups in morphine dose (0.16+0.09 vs 0.17+0.11 mg/kg, P=.32), number of boluses administered (3.5 [3-5] vs 3 [3-6], P=.97), proportion of patients with pain relief (75 vs 83%, P=.39), or morphine-related adverse effects (11% vs 3%, P=.14). In conclusion, morphine consumption was not significantly modified in patients having severe pain classified as neuropathic using the DN4 score as compared with a control group, suggesting that specific detection of neuropathic pain may not be useful in the emergency department.

Influence of esmolol on requirement of inhalational agent using entropy and assessment of its effect on immediate postoperative pain score

Background and Context:Beta-blockers have been used for attenuation of stress response, decreasing anaesthetic requirement and augmentation of the effect of opioids during general anaesthesia.Aims and Objectives:The present study aims to evaluate the influence of esmolol on the requirement of an inhalational agent while monitoring the depth of anaesthesia by entropy and also its effect on immediate postoperative pain score.Methods:Fifty American Society of Anaesthesiologists (ASA) I and II patients, between 25 and 65 years of age who underwent lower abdominal surgeries were randomly allocated to two groups: Group E and Group S of 25 patients each. Group E received esmolol infusion while Group S received the same volume of saline infusion. Demographic data, haemodynamics, amount of isoflurane used, end-tidal isoflurane concentration, postoperative pain score and total dose of morphine consumed in immediate postoperative period of 30 min were analyzed by using appropriate statistical tests. Value of P<0.05 was considered significant and P<0.001 as highly significant.Results:The two groups were comparable with respect to age, weight, ASA physical status, duration of surgery and amount of isoflurane used during anaesthesia. Assessment of postoperative pain was assessed by Visual Analogue Scale (VAS) which showed significant difference at 30 min. The total dose of morphine consumption was significantly less (P<0.05) in Group E for relief of postoperative pain.Conclusions:We conclude that in light of depth of anaesthesia monitor esmolol has no effect on requirement of isoflurane, but it decreases the postoperative pain as well as postoperative requirement of morphine without increasing the risk of awareness.

Role of postoperative continuous subfascial bupivacaine infusion after posterior cervical laminectomy: Randomized control study

IntroductionOne of the major drawbacks of posterior cervical decompression and rigid internal fixation is the severe postoperative neck pain created by extensive soft tissue and muscular dissection. The usual management of acute postsurgical pain consists of systemic opioids or non-steroidal anti-inflammatory drugs. Another satisfying method of postoperative pain relief is continuous local infusion of analgesic agents in posterior subfascial paravertebral space on both sides of the wound using epidural catheters.MethodsSixty patients scheduled for cervical laminectomy with fixation surgery via the posterior midline approach with postoperative epidural catheters placed subfascially on both sides of the wound. They were randomly divided into two groups, bupivacaine group with local infiltration of 0.5% bupivacaine at the rate 2 ml/h, and control group with saline infusion at a rate 2 ml/h. The patient controlled analgesia device (PCA) was given to all patients and set to deliver IV morphine in 1 mg boluses with a lock out at 10 min and a 4 h maximum 10 mg.ResultsThe visual analog score was statistically significant lower in bupivacaine group compared to control group during the first 60 h postoperatively. While in 66 and 72 h postoperatively there was no statistical significant difference was observed between the two groups. The total doses of morphine delivered by PCA in the three postoperative days were statistically significantly higher in control group than bupivacaine group. The incidence of side effects related to narcotics was higher in control than bupivacaine group.ConclusionBilateral subfascial continuous 0.5% bupivacaine infiltration through an ordinary epidural catheter at the rate 2 ml/h for three successive postoperative days is associated with better pain control, reduced narcotics, early ambulation and no serious side effects in the postoperative period in patients undergoing posterior cervical fixation.

Intrathecal Morphine Pump for Neuropathic Cancer Pain

The WHO ladder has been the most widely used approach for management of Cancer Pain. However, oral medications alone may be inadequate, particularly in difficult to treat cancer pain syndromes. Neuropathic pain is one of these refractory syndromes. The role of opioids has always been controversial in pain of neuropathic origin. We report a case of a 61 year old female patient with endometrial carcinoma suffering from severe neuropathic pain in her left lower limb. The pain was refractory to highest tolerable doses of oral morphine and neuromodulator drugs, viz. gabapentin and pregabalin. We managed the patient successfully with intrathecal morphine pump reducing the total morphine dose and improving patient comfort and satisfaction. Intrathecal delivery of Morphine ensured better efficacy with fewer side effects.

Impact of treatment approach on maternal and neonatal outcome in pregnant opioid‐maintained women

The objective of this study is to compare maternal and neonatal outcome of opioid-dependent women maintained on buprenorphine or methadone throughout pregnancy in a randomized double-blind double-dummy clinical trial (CT) with a comparison group undergoing a structured standard protocol (SP) at the Medical University of Vienna, Austria. One hundred and fourteen subjects were included in the analysis, with 77 in SP (n = 51 methadone, n = 26 buprenorphine), and 37 in CT (n = 19 methadone, n = 18 buprenorphine), comparing maternal concomitant consumption during third trimester, demographic birth data, duration of treatment for neonatal abstinence syndrome (NAS), morphine dose for NAS treatment and length of hospital stay (LOS). Both study groups yielded healthy neonates with no significant demographic differences and equivalently low rates of positive maternal urine toxicologies. However, NAS parameters were significantly better in CT regarding total medication dose administered to neonates (p = 0.014) and LOS (p = 0.015). Superior results were achieved in buprenorphine compared with methadone-exposed neonates regarding gestational age at birth (p = 0.003), birth weight (p = 0.011), total morphine dose administered (p = 0.008), NAS treatment duration (p = 0.008) and LOS (p = 0.001). Comparably favorable outcome for mothers and infants and efficacy and safety of opioid medications were shown in both treatment approaches. Neonatal care could benefit from transferring successful CT procedures into clinical practice.

Dexmedetomidine

Dexmedetomidine (Precedex®), a pharmacologically active dextroisomer of medetomidine, is a selective α(2)-adrenergic receptor agonist. It is indicated in the US for the sedation of mechanically ventilated adult patients in an intensive care setting and in non-intubated adult patients prior to and/or during surgical and other procedures. This article reviews the pharmacological properties, therapeutic efficacy and tolerability of dexmedetomidine in randomized, double-blind, placebo-controlled, multicentre studies in these indications. Post-surgical patients in an intensive care setting receiving dexmedetomidine required less rescue sedation with intravenous propofol or intravenous midazolam to achieve and/or maintain optimal sedation during the assisted ventilation period than placebo recipients, according to two randomized, double-blind, multinational studies. Moreover, significantly more dexmedetomidine than placebo recipients acquired and/or maintained optimal sedation without rescue sedation. Sedation with dexmedetomidine was also effective in terms of the total dose of morphine administered, with dexmedetomidine recipients requiring less morphine than placebo recipients; with regard to patient management, dexmedetomidine recipients were calmer and easier to arouse and manage than placebo recipients. Intravenous dexmedetomidine was effective as a primary sedative in two randomized, double-blind, placebo-controlled, multicentre studies in adult patients undergoing awake fibre-optic intubation or a variety of diagnostic or surgical procedures requiring monitored anaesthesia care. In one study, significantly fewer dexmedetomidine than placebo recipients required rescue sedation with intravenous midazolam to achieve and/or maintain optimal sedation; conversely, in another study, rescue sedation with intravenous midazolam was not required by significantly more dexmedetomidine than placebo recipients. Primary sedation with intravenous dexmedetomidine was also effective in terms of the secondary efficacy endpoints, including the mean total dose of midazolam and fentanyl administered and the percentage of patients requiring further sedation (in addition to dexmedetomidine or placebo and midazolam), with, for the most part, significant between-group differences observed in favour of dexmedetomidine over placebo. In general, no significant differences were observed between the dexmedetomidine and placebo treatment groups in the anaesthesiologists' assessment of ease of intubation, haemodynamic stability, patient cooperation and/or respiratory stability. Intravenous dexmedetomidine is generally well tolerated when utilized in mechanically ventilated patients in an intensive care setting and for procedural sedation in non-intubated patients. Dexmedetomidine is associated with a lower rate of postoperative delirium than midazolam or propofol; it is not associated with respiratory depression. While dexmedetomidine is associated with hypotension and bradycardia, both usually resolve without intervention. Thus, intravenous dexmedetomidine provides a further option as a short-term (<24 hours) primary sedative in mechanically ventilated adult patients in an intensive care setting and in non-intubated adult patients prior to and/or during surgical and other procedures.

Multiple nerve blocks after video-assisted thoracic surgery (VATS)

Epidural analgesia and/or systemic narcotics are used for pain control after video-assisted thoracic surgery (VATS) lobectomy despite side effects. We report a video of a technique to safely place subpleural catheters in order to provide multiple nerve blocks and the results from our series comparing this technique to a standard post-operative analgesia protocol after VATS. At the end of the VATS wedge resection, two small incisions were made below and parallel to the position of the trocars, at the level of the anterior and posterior axillary line and an introducer was used to place a catheter subcutaneously. At this point, the introducer was curved, in a way to follow the anatomic shape of the costal margin of the patient, inserted into posterior incision and advanced in between the thoracic pleura and the ribs. Under direct vision from the thoracoscope and paying careful attention not to perforate the pleura, the guide was pushed toward the first rib by using a combination of blunt and hydro dissection. Once the guide reached the first rib, the introducer was removed and the catheter was left in place. We evaluated 64 patients (29 patient-controlled analgesia (PCA), 35 SC). Propensity weighting produced two matched groups for further analysis. Mean total morphine dose and mean total morphine dose/body mass index (BMI) were both significantly decreased in the SC group for the 0-24 h period only (mean total morphine 38.1 vs. 27.8; P = 0.024 and mean total morphine/BMI 1.15 vs 0.79; P = 0.024). Complication rates did not differ between groups. PCA narcotic analgesia with subpleural local anesthetic infusion provided similar pain control with less narcotic use in patients during the first 24 h after VATS lobectomy compared with PCA narcotic analgesia alone.

07 Incidence of peri-opiate nausea and vomiting in the pre-Hospital setting: an intermediate analysis

BackgroundIntravenous morphine is the preferred drug for the treatment of moderate to severe pain by paramedics. Nausea and vomiting are believed to be frequent side-effects and routine co-administration of metoclopramide...

02 Incidence of peri-opiate nausea and vomiting in the pre-hospital setting: an intermediate analysis

BackgroundIntravenous morphine is the preferred drug for the treatment of moderate to severe pain by paramedics. Nausea and vomiting are believed to be frequent side-effects and routine co-administration of metoclopramide...

Morphine Patient Controlled Analgesia for Postoperative Analgesia in Patients Who Have Transplanted Cadaver Donor Kidneys

Patients who have chronic renal disease present challenges to anesthesiologists because of the sequelae of the underlying disease. Postoperative pain is usually mild to moderate after renal transplantation and is a concern because of underlying co-morbidities and variable responses of the graft. Effective postoperative pain management contributes to a a successful outcome after renal transplantation. A retrospective study, based on the collected data from clinical process and registration of the acute pain unit. During 2007 and 2008, 124 patients were transplanted with cadaver donor kidneys. The final sample included 55 patients, namely 67% males and 33% females, whose ages range between 15 and 75 years (average, 47.23 years). Their American Society of Anesthesiologists physical status classification was 4 in 71% and 3 in 29%. Analgesia during surgery used a fentanyl, paracetamol and morphine protocol (n = 47) or fentanyl, paracetamol, morphine, and local anesthetic infiltration (n = 8). The postoperative pain was quantified using a numerical rating scale (0-4) with mean value of 1.07 on day 1, a mean value of 1 on day 2, and a mean value of 0.67 on day 3. Postoperative analgesia with morphine patient-controlled analgesia was used for every patient, combined with paracetamol in 89% of cases. The average number of bolus demands was 60 with 26.4 effective boluses, the mean total administered dose was 26.6 mg. The major side effects were constipation (18%), pruritus (14%), nausea (13%), and vomiting (1.8%). The following relations were significance: age and score of pain, pruritus and total dose of morphine, preoperative analgesia, and pain score on day 2. Our results suggest that analgesia with morphine patient-controlled analgesia was an effective method to achieve control of postoperative pain in this population with few side effects.

Assessment of the Degree of Satisfaction Among Living Kidney Donors

Background Organ donation during life is an act of great altruism, with unique family, social, economic, and psychological impacts. The group of anesthesiologists involved in this program sought to assess the degree of satisfaction among kidney donors between 2007 and 2008 and, in particular, with the anesthetic approach. Methods A telephone survey of kidney donors in 2007 and 2008 complemented a retrospective evaluation of the records of the Acute Pain Unit. Results Among 32 kidney donors, 2 were excluded as impossible to contact. Their mean age was 44.33 years including 60% women. The degree of relationship was fathers (43.3%), siblings (50%) or spouses (6.7%). Donors who underwent outpatient anesthesia were satisfied (40%) or very satisfied (60%) with the information received, all willing to repeat the experience of kidney donation. The positive aspects were: good reception (83.4%), help to a family member (30%), good information (13.3%), and confidence in the team (6.6%). No downside was mentioned by 50% of donors. Postoperative analgesia was performed using an epidural catheter (93.3%) or patient-controlled analgesia with morphine (6.7%) associated with intravenous paracetamol in all cases. With regard to analgesia using an epidural catheter, the mean total dose of morphine was 7.7 mg and 27.4 mg for 0.2% ropivacaine over an average of 3.32 days. Pain was assessed in the first 24 hours postoperatively using a scale ranging from 0 (no pain) to 4 (unbearable pain): 30% reported 0; 60% 1; and 10% 2. The complaints were pruritus (40%), nausea/vomiting (16.7%), constipation (6.7%) and/or urinary retention (3.3%). No donor showed an altered state of consciousness, motor block, or paresthesias. Conclusions Living kidney donors showed a high degree of overall satisfaction. The anesthesia consultation was extremely helpful with a positive impact on kidney donation. An epidural catheter for analgesia after surgery proved to be effective and appropriate for this type of procedure.

Surgical results of single-incision transumbilical laparoscopic Roux-en-Y gastric bypass

BackgroundConventional laparoscopic Roux-en-Y gastric bypass (LRYGB) has been the reference standard for bariatric surgery but requires 5–7 trocar incisions. We have developed a new procedure—single-incision transumbilical LRYGB (SITU-LRYGB)—that results in minimal scarring and is more cosmetically acceptable. To compare the surgical results and patient satisfaction between 5-port LRYGB and the novel SITU-LRYGB at a university hospital. MethodsWe performed 5-port or SITU-LRYGB on 140 morbidly obese patients; the patients chose the operation method. We used a novel liver traction method and omega-umbilicoplasty specifically designed for SITU-LRYGB. ResultsBefore surgery, the patients in the 5-port surgery group were more obese than those in the SITU group (120.8 kg versus 108.9 kg, P = .013). The rate of hypertension was also greater in the former group. The operative time was longer for SITU-LRYGB (101.1 versus 81.1 min, P = .001) without increased intraoperative complications. The total morphine dose for the SITU group seemed to be greater but the difference was not statistically significant. No difference in complications was observed. Postoperatively, the percentage of excess body weight lost the SITU and 5-port surgery groups was 21.2% and 20.9%, 40.4% and 39.4%, 55.0% and 55.2%, 64.8% and 75.2%, and 75.4% and 78.2% at 1, 3, 6, 9, and 12 months, respectively. The SITU-LRYGB patients reported greater satisfaction related to scarring than those who had undergone 5-port surgery (score 4.57 versus 3.96, respectively, P = .005). No patient died. ConclusionCompared with conventional LRYGB, SITU-LRYGB resulted in acceptable complications, the same recovery, comparative weight loss, and better patient satisfaction related to scarring.

The effect of adding intrathecal magnesium sulphate to morphine-fentanyl spinal analgesia after thoracic surgery. A prospective, double-blind, placebo-controlled research study

Background We investigated whether intrathecally magnesium sulphate added to morphine and fentanyl reduces patients’ postoperative analgesia requirements and prolongs spinal opioid analgesia after thoracotomy. Methods In a single-center, prospective, placebo-controlled, double-blind trial, we enrolled 58 adult patients undergoing elective posterolateral thoracotomy. Patients were randomized to receive either 25 μg of fentanyl citrate (0.5 mL) + 300 μg of morphine + 1.0 mL of preservative-free 0.9% sodium chloride (Group S) or 25 μg of fentanyl citrate (0.5 mL) + 300 μg of morphine + 50 mg of magnesium sulphate 5% (1.0 mL) (Group MgSO 4) for intrathecal analgesia. Opioid consumption and postoperative pain were assessed for 36 hours. Results VAS pain scores at rest and on coughing were similar in all groups. The total 36-h intravenous morphine requirements were significantly lower in group MgSO 4 (14 [9.50–26.50] mg vs. 33 [30–41] mg, p < 0.001); i.e. 57% less for the group MgSO 4. The total dose of intravenous morphine administered during titration was significantly lower in this group (4 [2–8] mg vs. 8 [6–10] mg, p = 0.001). Morphine consumption was significantly lower in the group MgSO 4 at intervals 0–12, 12–24 and 24–36 h. The number of patients requiring titration was significantly lower in group MgSO 4 (68% vs. 96%, p = 0.001). There is no difference in opioid side effects. No patient experienced side effects resulting from lumbar puncture, or neurological deficit or signs of systemic magnesium toxicity. Conclusion We found that in patients undergoing pulmonary resection with elective posterolateral thoracotomy, magnesium sulphate (50 mg), when added to spinal morphine analgesia reduces postoperative morphine requirements, the number of patients requiring morphine titration without increasing opioid side effects.

Comparison of the efficacy of parecoxib versus ketorolac combined with morphine on patient-controlled analgesia for post-cesarean delivery pain management

we compared the clinical efficacy and safety between a new injectable cyclooxygenase-2 selective inhibitor, parecoxib, and an old nonselective, ketorolac combined with morphine in patient-controlled analgesia (PCA) for management of post-cesarean delivery pain. in this randomized, open-label study, 66 parturients undergoing cesarean section were divided into two groups: In Group P the patients received an initial intravenous bolus of 40mg parecoxib as a loading dose post-operatively and then two bolus doses of 20mg parecoxib were subsequently given at intervals of 24h. Morphine was basically used in PCA manner during the 3-day study course; and in Group K patients received an intravenous loading bolus of 30mg ketorolac post-operatively and then 90mg ketorolac combined with morphine in PCA fashion throughout the study course. Efficacy was evaluated by Verbal ranking scale (0-10) for pain intensity, Ramsay sedation score (1-6), profile of mood state (0-3) and quality of sleep (0-3), and patient satisfaction (0-4) with the analgesia. Efficacy evaluations and adverse effects were recorded every 24h and at 72h after initial loading boluses. The duration of hospital stay and total dose of morphine used throughout the study were also recorded. there were no significant differences of sedation scale, mood state, quality of sleep and satisfaction between two groups, except patients of Group P had a lower pain scores than those of the Group K at 24h (3.1, range 0-5 vs. 4.3, range 0-8, p = 0.005) and 72h (1.1, range 0-3 vs. 1.9, range 0-4, p = 0.005). Moreover, there were also no significant differences in the duration of hospital stay, but there was a lower total morphine requirement (22% reduction) in Group P in comparison with Group K (43.5 ± 19.2 vs. 55.5 ± 21.5, p = 0.02). Regarding adverse effects, there were no statistical differences between two groups. we noted that parecoxib with PCA morphine can be used for post-cesarean delivery analgesia with the same efficacy as ketorolac for an opioid-sparing effect.

Postoperative efficacies of femoral nerve catheters sited using ultrasound combined with neurostimulation compared with neurostimulation alone for total knee arthroplasty

Neurostimulation is commonly used to perform femoral nerve block. Ultrasound can be used to identify nerve structures and guide needle placement. The aim of this study was to compare postoperative analgesic efficiency when femoral nerve catheters were sited using ultrasound (in-plane approach) combined with neurostimulation or neurostimulation alone, for total knee arthroplasty. Ninety-three patients were enrolled in this prospective, randomized, blind study to receive a continuous femoral nerve block performed using conventional neurostimulation or ultrasound guidance combined with neurostimulation. The primary endpoint was the postoperative 48 h total local anaesthetic consumption. Other outcomes included visual analogue scale scores at rest, after 12, 24 and 48 h; total oral opioid dose; onset time of femoral block; procedural time; knee flexion and complications. Results are expressed with medians (25-75th percentiles), mean ± SD and n (%), as appropriate. The onset time of sensory and motor block was faster in the ultrasound group [11 (6-17) min] than in the conventional group [16 (11-23) min, P = 0.009]. Total local anaesthetic dose was reduced [299 ± 45 vs. 333 ± 48 ml, (difference = 34.0 ml, 95% confidence interval 15.6-52.5 ml), P = 0.0003] and the time to the first analgesic request was lengthened [11 (7-13) vs. 7 (4-12) h, P = 0.034] in the ultrasound group. Visual analogue scale scores at 12, 24 and 48 h were lower in the ultrasound group as well as visual analogue scale scores during knee flexion at 48 h [14.5 (11.0-23.0) vs. 28.5 (21.0-43.5) mm, P < 0.0001]. Total oral morphine doses were 20 (0-40) vs. 40 (20-60) mg (P = 0.0065). Durations of hospital stay were comparable in both groups. Continuous perineural femoral catheter placement using ultrasound combined with neurostimulation and an in-plane approach reduces total doses of local anaesthetic, morphine consumption and improves postoperative pain management by comparison with neurostimulation alone.

A Retrospective Audit of three Different Regional Anaesthetic Techniques for Circumcision in Children

Postoperative analgesia for male circumcision surgery has been traditionally provided by a landmark-based dorsal penile nerve block (DPNB-LM) or by caudal epidural analgesia (CEA). In this study we report on a retrospective analysis of the effectiveness and safety of CEA, DPNB-LM and ultrasound-guided dorsal penile nerve block (DPNB-US) in our institution over a six-year period. Information was gathered from each patient's medical record. A total of 216 circumcisions were performed on patients aged from five months to 15 years. One hundred and fifteen patients received CEA, 46 DPNB-LM and 55 DPNB-US. Patients in the DPNB-LM group required rescue morphine administration in the recovery unit more frequently (30.4%) than either the DPNB-US (3.5%) or CEA groups (3.6%). Similarly, the DPNB-LM group required a larger total dose of morphine, and had longer recovery ward stays than CEA or DPNB-US groups. Time to first analgesia was greatest for the CEA group while there was no significant difference between time to first analgesia for DPNB-LM and DPNB-US. Sixty-three percent of patients in the DPNB-LM group, 1.7% of CEA and 5.5% of the DPNB-US required intraoperative opiates (P < 0.0001). There was no difference in time to hospital discharge.

Continuous Intravenous Morphine Infusion for Postoperative Analgesia Following Posterior Spinal Fusion for Idiopathic Scoliosis

A retrospective study of postoperative pain management. Evaluate the efficacy and safety of continuous intravenous morphine infusion for postoperative pain management in patients with idiopathic scoliosis (IS) undergoing posterior spinal fusion (PSF) and segmental spinal instrumentation (SSI). Postoperative pain is a common problem following surgery for IS. There are no published reports regarding the use of a continuous intravenous morphine infusion for this patient population. We retrospectively reviewed data regarding 339 consecutive patients with IS who underwent PSF and SSI between 1992 and 2006. All patients received intrathecal morphine after the induction of general anesthesia. Following surgery, preordered morphine infusion (0.01 mg/kg/h) was started at first reported pain. The infusion rate was titrated based on vital signs, visual analog scale (VAS) pain scores (0-10), and clinical status. It was continued until patients were able to take oral analgesics. We reviewed intrathecal morphine dosage, VAS pain scores through the third postoperative day, interval to start of morphine infusion, total morphine requirements in the first 48 hours, and any adverse reactions (nausea/vomiting, pruritus, respiratory depression, and pediatric intensive care unit admission). Mean intrathecal morphine dose was 15.5 +/- 3.9 microg/kg and mean interval to start of the intravenous morphine infusion was 17.5 +/- 5 hours. Mean VAS pain scores were 3.1, 4.5, 4.5, and 4.6 at 12 hours, 1, 2, and 3 days after surgery, respectively.The total mean morphine dose in the first 48 hours postoperatively was 0.03 +/- 0.01 mg/kg/h. Total morphine received was 1.44 +/- 0.5 mg/kg. Nausea/vomiting and pruritus, related to the morphine infusion occurred in 45 patients (13.3%) and 14 patients (4.1%), respectively. No patients had respiratory depression or required Pediatric Intensive Care Unit admission. A low frequency of adverse events and a mean postoperative VAS pain score of 5 or less demonstrate that a continuous postoperative morphine infusion is a safe and effective method of pain management in patients with IS following PSF and SSI.

Somatic paravertebral block decreases opioid requirements in children undergoing appendectomy

Somatic paravertebral block (SPVB) appears to provide effective and prolonged nerve block in children; however, study of its use in this population is limited. We compared SPVB with no block in children undergoing appendectomy. Thirty-six children aged 3-16 yr undergoing open appendectomy were involved in this prospective randomized controlled study. Anesthesia was induced with propofol and maintained with isoflurane in N(2)O/oxygen. All subjects received fentanyl, acetaminophen and ketorolac during anesthesia. Group I (SPVB) subjects received a right SPVB at T(11), T(12), and L(1) using 0.2% ropivacaine 0.25 mL.kg(-1) with epinephrine 1:200,000 preoperatively. Group II (Control) had only bandaids applied to skin. Both groups were given morphine 0.05 mg.kg(-1) iv every 2 hr if pain scores reached 5/10 on a visual analogue scale. Acetaminophen was administered postoperatively every 6 hr to both groups. Time to first dose of morphine, total dose of morphine in 24 hr, and any adverse effects up to 24 hr after surgery were recorded. Group I (SPVB) subjects required significantly less morphine than Group II (Control) patients (0.12 +/- 0.07 vs 0.34 +/- 0.15 mg.kg(-1), respectively; P < 0.001), and time to their first dose was significantly longer (7.1 +/- 4.4 vs 2.5 +/- 1.6 hr, respectively; P < 0.001). Incidence of vomiting was 11% with Group I and 27% with Group II (P = 0.21). No other adverse effects were observed in either group. In children undergoing appendectomy, SPVB provides better pain relief than no block and reduces opioid requirements. Side effects were not statistically different between groups.