The value of "multimodal" or "balanced analgesia" in postoperative pain treatment

[Perioperative pain therapy in interventions for elbow stiffness]

Conservative treatment and surgical release of a stiff elbow requires correct pain management which should be oriented to the individual needs of the patient. Regional anesthesia in combination with opioids is necessary postoperatively to obtain sufficient pain relief. There is a need for prospective randomized studies to develop an optimal pain therapy concept following operations for elbow stiffness.

Make a CHANGE: optimising communication and pain management decisions

The major objectives of the CHANGE PAIN International Advisory Board are to enhance understanding of chronic pain and to develop strategies for improving pain management. At its second meeting, in November 2009, evidence was presented that around one person in five in Europe and the USA experiences chronic pain, and the delay before referral to a pain specialist is often several years. Moreover, physicians' pharmacological approach to chronic pain is inconsistent, as evidenced by the huge variation in treatment between different European countries. It was agreed that efficient communication between physician and patient is essential for effective pain management, and that efficacy/side-effect balance is a key factor in choosing an analgesic agent. The multifactorial nature of chronic pain produces various physical and psychological symptoms, so the management of chronic pain should be tailored to the individual. Pharmacological therapy must be matched to the causative mechanisms responsible, or it is likely to prove ineffective and risk the development of a 'vicious circle'; doses are increased because of inadequate pain relief, but this increases side-effects so doses are reduced, pain relief is then inadequate, so doses are increased, and so on. Pain management decisions should not therefore be based solely on the severity of pain. Based on the concept of individual treatment targets (ITT), the CHANGE PAIN Scale was adopted - a simple, user-friendly assessment tool to improve communication between physician and patient. The 11-point NRS enables the patient to rate the current pain intensity and to set a realistic individual target level. On the reverse are six key parameters affecting the patient's quality of life; clinicians simply need to agree with patients whether improvement is needed in each one. Regular use can establish the efficacy and tolerability of pain management, and the rate of progress towards individual treatment targets.

Pain management in ferrets

The growing popularity of ferrets as pets has created the demand for advanced veterinary care for these patients. Pain is associated with a broad range of conditions, including acute or chronic inflammatory disease, neoplasia, and trauma, as well as iatrogenic causes, such as surgery and diagnostic procedures. Effective pain management requires knowledge and skills to assess pain, good understanding of the pathophysiology of pain, and general knowledge of pharmacologic and pharmacodynamic principles. Unfortunately, scientific studies on efficacy, pharmacokinetics, pharmacodynamics, and safety of analgesic drugs in the ferret are limited. However, basic rules on the treatment of pain and mechanisms of action, safety, and efficacy of analgesic drugs in other species can be adapted and applied to pain management in ferrets. This article aims to make an inventory of what is known on the recognition of pain in ferrets, what analgesic drugs are currently used in ferrets, and how they can be adopted in a patient-orientated pain management plan to provide effective pain relief while reducing and monitoring for unwanted side effects.

Multimodal analgesia with gabapentin, ketamine and dexamethasone in combination with paracetamol and ketorolac after hip arthroplasty: a preliminary study

BACKGROUND AND OBJECTIVE

It has been hypothesized that combinations of analgesics with different mechanisms of action may reduce or even prevent postoperative pain. We, therefore, investigated the analgesic effect of gabapentin, dexamethasone and low-dose ketamine in combination with paracetamol and ketorolac as compared with paracetamol and ketorolac alone after hip arthroplasty.

METHODS

In this double-blind study, 42 patients were randomly assigned to either a combination group [gabapentin 1200 mg+dexamethasone 8 mg+ketamine (0.15 mg kg(-1))+paracetamol 1 g+ketorolac 15 mg] or a control group (placebo+paracetamol 1 g+ketorolac 15 mg). The medication was given preoperatively except for ketorolac, which was given at the end of surgery. Postoperative pain treatment was paracetamol 1 gx3; ketorolac 15 mgx3; and patient-controlled intravenous morphine. Morphine consumption, pain intensity at rest and during mobilization, nausea and vomiting, sedation, dizziness, hallucination and consumption of ondansetron were recorded 2, 4 and 24 h after operation. A P value of less than 0.05 was considered statistically significant.

RESULTS

Morphine consumption was not significantly different between groups (P=0.085). Overall pain scores were improved in the combination group as compared with the control group both at rest (P=0.042) and during mobilization (P=0.027). In the combination group, individual pain score above 30 mm on a 100 mm visual analogue scale was almost eliminated. The incidence of side effects did not differ between the groups.

CONCLUSION

Preoperative gabapentin, dexamethasone and ketamine combined with paracetamol and ketorolac reduced overall pain scores in patients after hip arthroplasty as compared with paracetamol and ketorolac alone. Morphine consumption was not reduced.

Stability and compatibility of the mixture of tramadol, ketorolac, metoclopramide and ranitidine in a solution for intravenous perfusion

OBJECTIVE

To determine whether a mixture for intravenous perfusion containing tramadol (5 mg/ml), ranitidine (1.5 mg/ml), ketorolac (1.5 mg/ml) and metoclopramide (0.5 mg/ml) in a 0.9% sodium chlorides solution is compatible and stable at room temperature during a 48-hour period.

METHODS

We tested the mixture for stability using the HPLC technique (high performance liquid chromatography), with parallel visual assessments of any changes in colour, appearance of precipitate or phase separation indicating incompatibilities between the components.

RESULTS

At the end of the trial, chromatography data showed a mean metoclopramide concentration between 100% and 105% of the initial level, while concentrations of tramadol, ketorolac and ranitidine were between 99% and 102% of initial levels. There was no evidence of incompatibility between the drugs at any time during the study period.

CONCLUSIONS

The combination is stable as a solution and its components are physically and chemically compatible in the concentrations used in the study, during at least 48 hours at room temperature.

Implementation of a standardized pain management in a pediatric surgery unit

Postoperative pain is still a major complication causing discomfort and significant suffering, especially for children. Therefore, every effort should be made to prevent pain and treat it effectively once it arises. Under-treatment of pediatric pain is often due to a lack of both knowledge about age-specific aspects of physiology and pharmacology and routine pain assessment. Factors for long term success require regularly assessing pain, as routinely as the other vital signs together with documentation of side effects. The fear of side effects mostly prevents the adequate usage of analgesics. Essential is selecting and establishing a simple concept for clinical routine involving a combination of non-pharmacological treatment strategies, non-opioid drugs, opioids and regional anesthesia.

Operative anesthesia and pain control

A comprehensive understanding of operative anesthesia and postoperative pain control is essential to the practicing colon and rectal surgeon. Most of the operations performed-particularly in the perineum-cause significant patient discomfort and often result in a lengthy recovery period. A variety of factors, including patient positioning in the operating room and patient expectations, influence the choice of operative anesthesia. Postoperatively numerous modalities and agents exist for pain control. With this variety of options at hand, surgeons should be educated and decisions should be individualized, with the ultimate goals of improving the patient experience and facilitating recovery.

A multi-center, randomized, double-blind placebo-controlled trial of intravenous-ibuprofen (IV-ibuprofen) for treatment of pain in post-operative orthopedic adult patients

Objective

To determine whether pre- and post-operative administration of intravenous ibuprofen (IV-ibuprofen) can significantly decrease pain and morphine use when compared with placebo in adult orthopedic surgical patients.

Design

This was a multi-center, randomized, double-blind placebo-controlled trial.

Setting

This study was completed at eight hospitals; six in the United States and two in South Africa.

Patients

A total of 185 adult patients undergoing elective orthopedic surgery.

Interventions

Patients were randomized to receive either 800 mg IV-ibuprofen or placebo every 6 hours, with the first dose administered pre-operatively. Additionally, all patients had access to intravenous morphine for rescue.

Outcome Measures

Efficacy of IV-ibuprofen was demonstrated by measuring the patient's self assessment of pain using a visual analog scale (VAS; assessed with movement and at rest) and a verbal response scale (VRS). Morphine consumption during the post-operative period was also assessed.

Results

In the immediate post-operative period, there was a 25.8% reduction in mean area under the curve-VAS assessed with movement (AUC-VASM) in patients receiving IV-ibuprofen (P < 0.001); a 31.8% reduction in mean AUC-VAS assessed at rest (AUC-VASR; P < 0.001) and a 20.2% reduction in mean VRS (P < 0.001) compared to those receiving placebo. Patients receiving IV-ibuprofen used 30.9% less morphine (P < 0.001) compared to those receiving placebo. Similar treatment emergent adverse events occurred in both study groups and there were no significant differences in the incidence of serious adverse events.

Conclusion

Pre- and post-operative administration of IV-ibuprofen significantly reduced both pain and morphine use in orthopedic surgery patients in this prospective randomized placebo-controlled trial.

Office based--is my anesthetic care any different? Assessment and management

Office-based anesthesia (OBA) is a unique and challenging venue, and, although the clinical outcomes have not been evaluated extensively, existing data indicate a need for increased regulation and additional education. Outcomes in OBA can be improved by education not only of anesthesiologists but also of surgeons, proceduralists, and nursing staff. Legislators must be educated so that appropriate regulations are instituted governing the practice of office-based surgery and the lay public must be educated to make wise, informed decisions about choice of surgery location. The leadership of societies, along with support from the membership, must play a key role in this educational process; only then can OBA become as safe as the anesthesia care in traditional venues.

Pharmacological treatment of chronic pain - the need for CHANGE

BACKGROUND

Although chronic pain affects around 20% of adults in Europe and the USA, there is substantial evidence that it is inadequately treated. In June 2009, an international group of pain specialists met in Brussels to identify the reasons for this and to achieve consensus on strategies for improving pain management.

SCOPE

Literature on chronic pain management was reviewed, and information presented to and discussed by a panel of experts.

FINDINGS

It was agreed that guidelines are not universally accepted by those involved in pain management, and pain treatment seems to be driven mainly by tradition and personal experience. Other factors include poor communication between patients and physicians, the side effects of analgesic drugs, and limited individualisation of therapy. Difficulty in maintaining the balance between adequate pain relief and acceptable tolerability, particularly with strong opioids, can lead to the establishment of a 'vicious circle' that alternates between lack of efficacy and unpleasant side effects, prompting discontinuation of treatment. The medical community's understanding of the physiological differences between nociceptive pain and neuropathic pain, which is often more severe and difficult to treat, could be improved. Increasing physicians' knowledge of the pharmacological options available to manage these different pain mechanisms offers the promise of better treatment decisions and more widespread adoption of a multi-mechanistic approach; this could involve loosely combining two substances from different drug classes, or administering an analgesic with two different mechanisms of action. In some circumstances, a single compound capable of addressing both nociceptive and neuropathic pain is desirable.

CONCLUSIONS

To improve patient outcomes, a thorough understanding of pain mechanisms, sensitisation and multi-mechanistic management is required. Universal, user-friendly educational tools are therefore required to familiarise physicians with these topics, and also to improve communication between physicians and their pain patients, so that realistic expectations of treatment can be established.

The determination and application of fixed-dose analgesic combinations for treating multimodal pain

When the pathophysiology of a medical condition is multimodal, ie, related to multiple physiological causes or mediated by multiple pathways, the optimal strategy can be to use a drug or a combination of drugs that contribute multiple mechanisms to the therapeutic endpoint. In such situations, a rational multimodal approach can also result in the fewest adverse effects. We discuss the quantitative analysis of multimodal action using the treatment of pain as a practical example and give examples of its application to some widely used analgesic drugs.

PERSPECTIVE

This article reviews the medical relevance of the quantitative evaluation of drug combinations, using pain and combinations of analgesics as specific examples. Such measure can help clinicians who seek to maximize therapeutic effect while simultaneously minimizing adverse effects.

The effect of intraarticular combinations of tramadol and ropivacaine with ketamine on postoperative pain after arthroscopic meniscectomy

INTRODUCTION

The purpose of this prospective randomized study was to evaluate the effects of intraarticular combinations of tramadol and ropivacaine with ketamine in postoperative pain control of patients undergoing arthroscopic meniscectomy.

MATERIALS AND METHODS

We randomly divided 80 patients into four groups to receive intraarticular 50 mg tramadol (Group T), 50 mg tramadol with 0.5 mg kg(-1) ketamine (Group TK), 75 mg ropivacaine (Group R), 75 mg ropivacaine with 0.5 mg kg(-1) ketamine (Group RK) in 20 ml normal saline at the end of surgery. Postoperative analgesia was provided with patient-controlled analgesia with morphine. Postoperative pain scores, total morphine consumption amount and side effects were recorded at intervals of 0, 1, 2, 4, 8, 12 and 24 h after the operation.

RESULTS

Pain scores were higher in Group T when compared with Group R and Group RK at second and fourth hours, also compared with Group RK at zeroth, first, second, fourth and eighth hours. Total morphine consumption amount was found to be higher in Group T when compared to Group TK at eighth and twelfth hours and Group RK at eighth hours (P < 0.05). Total morphine consumption was lowest in Group TK (P < 0.05). There were no significant differences among the study groups regarding side effects.

CONCLUSIONS

Administration of intraarticular tramadol-ketamine combination was found to be more effective in decreasing postoperative daily analgesic consumption.

Somatic paravertebral block decreases opioid requirements in children undergoing appendectomy

PURPOSE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

In children undergoing appendectomy, SPVB provides better pain relief than no block and reduces opioid requirements. Side effects were not statistically different between groups.

[Concepts for perioperative pain therapy. A critical stocktaking]

Despite numerous publications, new guidelines for the treatment of acute pain and efforts from a number of initiatives, there is still a tremendous need for improvement in postoperative pain therapy. One of the reasons for the shortcomings in the care of patients with postoperative pain is the lack of applicability of guidelines in daily clinical practice. Therefore, simple but effective and easy to implement concepts need to be developed. In the following review, different concepts that have been developed over recent years are presented and evaluated for their effectiveness. One of these is the notion of balanced analgesia, currently probably one of the most widely used perioperative therapy concepts. The idea of this concept is to reduce the doses of analgesics, e.g. opioids, through combinations of different classes of analgesics, thereby reducing their side effects. However, recent studies and essential meta-analyses indicate pitfalls using this concept. The pros and cons will be discussed and ideas on how to deal with balanced analgesia in daily practice will be given. Another pain concept of "procedure-specific postoperative pain therapy", is an appealing idea of an international initiative from surgeons and anaesthesiologists and an essential part of the German S3 guidelines for acute pain released last year. Critical evaluation of the available recommendations for procedure-specific analgesia together with the presentation of relatively simple but evidence-based algorithms for specific procedures may help to implement this concept in clinical routine.

Postoperative analgesic effect of preoperative intravenous flurbiprofen in arthroscopic rotator cuff repair

PURPOSE

This study was carried out to evaluate the postoperative analgesic effects of preoperative intravenous flurbiprofen in patients undergoing arthroscopic rotator cuff repair under general anesthesia.

METHODS

We studied 44 patients who underwent an elective arthroscopic rotator cuff repair in a prospective, randomized, and double-blind fashion. The patients were divided into two groups. Group A (n = 22) received lipid emulsion 0.1 ml kg(-1) as a placebo, and group B (n = 22) received flurbiprofen 1 mg kg(-1) before the surgery. Intralipid or flurbiprofen was given intravenously 5 min before the surgery. General anesthesia was maintained with sevoflurane and nitrous oxide, and 10 ml of 0.75% ropivacaine was administered intraarticularly at the end of the surgery. Postoperative analgesia was supplied with intravenous 0.1 mg buprenorphine according to the patient's demand. The effectiveness of flurbiprofen's analgesic effect was measured by a visual analog scale (VAS) and by the amount of buprenorphine consumption at 0.5, 1, 2, 4, 6, 12, and 24 h after the surgery. Time to the first analgesic was also recorded.

RESULTS

VAS in group B was significantly (P < 0.01) lower than that in group A during the first 6 h postoperatively. The amount of buprenorphine consumption in group B was also significantly (P < 0.01) less than that in group A within the first 2 h postoperatively. The time to first analgesic request in group B was significantly (P < 0.01) longer than that in group A.

CONCLUSION

These results show that preoperative intravenous flurbiprofen facilitates the analgesic effect in the early postoperative period after arthroscopic rotator cuff repair.

Potentiation of local anesthetic activity of neosaxitoxin with bupivacaine or epinephrine: development of a long-acting pain blocker

Local anesthetics effectively block and relieve pain, but with a relatively short duration of action, limiting its analgesic effectiveness. Therefore, a long-acting local anesthetic would improve the management of pain, but no such agent is yet available for clinical use. The aim of this study is to evaluate the potentiation of the anesthetic effect of neosaxitoxin, with bupivacaine or epinephrine in a randomized double-blind clinical trial. Ten healthy males were subcutaneously injected into the left and right forearms with a randomized pair of the following treatments: (i) bupivacaine (5 mg); (ii) neosaxitoxin (10 microg); (iii) neosaxitoxin (10 microg) plus bupivacaine (5 mg), and (iv) neosaxitoxin (10 microg) plus epinephrine (1:100.000), but all participant received all four formulations (in 2 ml; s.c.), with 1 month elapsing between the two round of experiments. A validated sensory and pain paradigm was used for evaluating the effect of the treatment 0-72 h after the injections, measuring sensory, pain, and mechanical touch perception threshold. The duration of the effect produced by combined treatments was longer than that by the single drugs. In conclusion, bupivacaine and epinephrine potentiate the local anesthetic effect of neosaxitoxin in humans when co-injected subcutaneously. The present results support the idea that neosaxitoxin is a new long-acting local pain blocker, with highly potential clinical use.

A randomized, multicentric, comparative evaluation of aceclofenac-paracetamol combination with aceclofenac alone in Indian patients with osteoarthritis flare-up

OBJECTIVE

To evaluate efficacy and safety of aceclofenac-paracetamol combination against aceclofenac alone in patients with osteoarthritis (OA) flare-up.

METHODS

This open, randomized, comparative, multicentric, 10-day study enrolled 199 patients (aceclofenac 100 mg + paracetamol 500 mg bid: 101; aceclofenac 100 mg, bid: 98) with painful OA flare-up. Primary efficacy parameters were pain intensity difference (PID), sum of PID (SPID), and peak PID over 4 h (0.5, 1, 2, 4 h) after first dose of study medication. Secondary efficacy measurements were mean pain intensity scores from day 1 to day 10, WOMAC scores, changes in baseline signs and symptoms, and patient's and investigator's overall efficacy assessment.

RESULTS

Both treatments showed significant improvement in their baseline values in all efficacy parameters. The combination was superior over monotherapy in terms of PID ( -0.54 vs -0.23, -1.23 vs -0.72, -1.73 vs -1.23 and -1.94 vs -1.43 at 0.5, 1, 2 and 4 h respectively), SPID ( -5.46 vs -3.63) and peak PID ( -2.08 vs -1.56; p < 0.05). At the end of therapy, both treatments were comparable (p > 0.05) with respect to average pain intensity from day 1 to day 10, changes in WOMAC scores and resolution of baseline signs and symptoms. The combination was significantly superior to monotherapy with respect to the patients' and investigators' overall efficacy assessments (p = 0.035 and p = 0.009 respectively).

CONCLUSION

The findings of this open-label, comparative study in Indian patients demonstrates that aceclofenac-paracetamol combination is effective and well tolerated in relieving OA flare-up pain. The combination showed rapid pain relief compared with monotherapy which is desirable by such patients and, hence, this combination can play an important role in the management of acute painful OA flare-up.

Consensus statement on the anticipation and prevention of acute postoperative pain: multidisciplinary RADAR approach

BACKGROUND

There has been considerable investment in efforts to improve postoperative pain management, including the introduction of acute pain teams. There have also been a number of guidelines published on postoperative pain management and there is widespread agreement on how pain should be practically managed. Despite these advances, there is no apparent improvement in the number of patients experiencing moderately severe or extreme pain after surgery. This highlights significant scope for improvement in acute postoperative pain management.

SCOPE

In January 2009, a multidisciplinary UK expert panel met to define and agree a practical framework to encourage implementation of the numerous guidelines and fundamentals of pain management at a local level. The panel recognised that to do this, there was a need to organise the information and guidelines into a simplified, accessible and easy-to-implement system based on their practical clinical experience. Given the volume of literature in this area, the Chair recommended that key international guidelines from professional bodies should be distributed and then reviewed during the meeting to form the basis of the framework. Consensus was reached by unanimous agreement of all ten participants.

FINDINGS

This report provides a framework for the key themes, including consensus recommendations based upon practical experience agreed during the meeting, with the aim of consolidating the key guidelines to provide a fundamental framework which is simple to teach and implement in all areas. Key priorities that emerged were: Responsibility, Anticipation, Discussion, Assessment and Response. This formed the basis of RADAR, a novel framework to help pain specialists educate the wider care team on understanding and prioritising the management of acute pain.

CONCLUSION

Acute postoperative pain can be more effectively managed if it is prioritised and anticipated by a well-informed care team who are educated with regard to appropriate analgesic options and understand what the long-term benefits of pain relief are. The principles of RADAR provide structure to help with training and implementation of good practice, to achieve effective postoperative pain management.

Apixaban or enoxaparin for thromboprophylaxis after knee replacement

BACKGROUND

The optimal strategy for thromboprophylaxis after major joint replacement has not been established. Low-molecular-weight heparins such as enoxaparin predominantly target factor Xa but to some extent also inhibit thrombin. Apixaban, a specific factor Xa inhibitor, may provide effective thromboprophylaxis with a low risk of bleeding and improved ease of use.

METHODS

In a double-blind, double-dummy study, we randomly assigned patients undergoing total knee replacement to receive 2.5 mg of apixaban orally twice daily or 30 mg of enoxaparin subcutaneously every 12 hours. Both medications were started 12 to 24 hours after surgery and continued for 10 to 14 days. Bilateral venography was then performed. The primary efficacy outcome was a composite of asymptomatic and symptomatic deep-vein thrombosis, nonfatal pulmonary embolism, and death from any cause during treatment. Patients were followed for 60 days after anticoagulation therapy was stopped.

RESULTS

A total of 3195 patients underwent randomization, with 1599 assigned to the apixaban group and 1596 to the enoxaparin group; 908 subjects were not eligible for the efficacy analysis. The overall rate of primary events was much lower than anticipated. The rate of the primary efficacy outcome was 9.0% with apixaban as compared with 8.8% with enoxaparin (relative risk, 1.02; 95% confidence interval, 0.78 to 1.32). The composite incidence of major bleeding and clinically relevant nonmajor bleeding was 2.9% with apixaban and 4.3% with enoxaparin (P=0.03).

CONCLUSIONS

As compared with enoxaparin for efficacy of thromboprophylaxis after knee replacement, apixaban did not meet the prespecified statistical criteria for noninferiority, but its use was associated with lower rates of clinically relevant bleeding and it had a similar adverse-event profile. (ClinicalTrials.gov number, NCT00371683.)

Multimodal analgesia for hip arthroplasty

Multimodal analgesia incorporates the use of analgesic adjuncts with different mechanisms of action to enhance postoperative pain management. Acetaminophen, anti-inflammatories, and gabapentinoids provide effective analgesia while reducing opioid requirements and opioid-related side effects. Intrathecal morphine and periarticular local anesthetic infiltration further enhance dynamic analgesia and improve postoperative mobilization. Epidural analgesia, peripheral nerve blocks, tramadol, ketamine, and/or clonidine can be added for improved benefit in opioid-tolerant individuals.

Repeated intraperitoneal instillation of levobupivacaine for the management of pain after laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy is the treatment of choice for symptomatic cholelithiasis. Postoperative pain, however, can prolong hospital stay and lead to increased morbidity. In the context of a multimodal approach to analgesia, intraperitoneal local anesthetic administration optimizes analgesia and facilitates early postoperative recovery, and it may be associated with a decreased risk of side effects.

METHODS

A total of 71 patients was randomized to receive either intraperitoneal analgesic (IPA group) or not (controls). At the completion of cholecystectomy, 10 mL of levobupivacaine 0.5% were infused intraperitoneally in the IPA group and 8 h postoperatively, whereas in the controls, 10 mL of 0.9% NaCl were administered in the corresponding points of time. Differences in pain scores between groups were the primary endpoints. Opioid consumption and adverse effects were the secondary endpoints.

RESULTS

The 2 groups were homogenous in respect to age, sex, body mass index (BMI), and duration of operation. No conversion, complication, or mortality was recorded. The IPA group had a lesser visual analog scale score at rest and at movement compared with controls at all points of time measured. Moreover, fentanyl consumption in the recovery room was significantly greater in the control group, and the consumption of meperidine and the percentage of the patients that requested rescue analgesia in the ward was significantly greater in the control group. Local analgesic intraperitoneal injection as well as parecoxib for postoperative analgesia had no significant adverse effects.

CONCLUSION

Our study showed that 2 separate doses of intraperitoneally administered levobupivacaine significantly decreased postoperative pain and the need for opioids compared with placebo. This technique is simple, safe, and without adverse effects.

Epidural ropivacaine concentrations for intraoperative analgesia during major upper abdominal surgery: a prospective, randomized, double-blinded, placebo-controlled study

BACKGROUND

The postoperative beneficial effects of thoracic epidural analgesia (TEA) within various clinical pathways are well documented. However, intraoperative data are lacking on the effect of different epidurally administered concentrations of local anesthetics on inhaled anesthetic, fluid and vasopressor requirement, and hemodynamic changes. We performed this study among patients undergoing major upper abdominal surgery under combined TEA and general anesthesia.

METHODS

Forty-five patients undergoing major upper abdominal surgery were randomly assigned to one of three treatment groups receiving intraoperative TEA with either 10 mL of 0.5% (Group 1) or 0.2% (Group 2) ropivacaine (both with 0.5 microg/mL sufentanil supplement), or 10 mL saline (Group 3) every 60 min. Anesthesia was maintained with desflurane in nitrous oxide (60%) initiated at an age-adapted 1 minimum alveolar concentration (MAC) until incision. Desflurane administration was then titrated to maintain an anesthetic level between 50 and 55, as assessed by continuous Bispectral Index monitoring and the common clinical signs (PRST score). Lack of intraoperative analgesia, as defined by an increase in pulse rate, sweating, and tearing (PRST) score >2 or an increase of mean arterial blood pressure (MAP) >20% of baseline, was treated by readjusting the end-tidal concentration of desflurane toward 1 MAC, and above this level by additional rescue i.v. remifentanil infusion. Hypotension, as defined as a decrease in MAP >20% of baseline, was treated by reducing the end-tidal desflurane concentration to a Bispectral Index level of 50-55 and below that with crystalloid or norepinephrine infusion, depending on central venous pressure.

RESULTS

End-tidal desflurane concentration could be significantly reduced in Group 1 to 0.7 +/- 0.1 MAC (P < 0.001) and to 0.8 +/- 0.1 MAC (P < 0.001) in Group 2, but not in Group 3. Significant hypotension occurred within 20 min in all patients of Groups 1 and 2 (MAP from 80 +/- 10 to 56 +/- 5) (Group 1), 78 +/- 18 to 58 +/- 7 mm Hg (Group 2), P < 0.01, whereas MAP remained unchanged in Group 3 (74 +/- 12 to 83 +/- 15 mm Hg, P = 0.42). Heart rate did not change significantly over time within any of the groups. Furthermore, groups did not differ significantly regarding i.v. fluid and norepinephrine requirement. Patients in Group 3 received more remifentanil throughout the surgical procedure (7.2 +/- 4.9 mg x kg(-1) x h(-1)) when compared with Group 2 (1.6 +/- 2.2 mg x kg(-1) x h(-1)), P < 0.01. Remifentanil infusion among patients receiving ropivacaine 0.5% was not necessary at any time.

CONCLUSION

Epidural administration of 0.5% ropivacaine leads to a more pronounced sparing effect on desflurane concentration for an adequate anesthetic depth when compared with a 0.2% concentration of ropivacaine at comparable levels of vasopressor support and i.v. fluid requirement.

Analgesic efficacy of perioperative use of vedaprofen, tramadol or their combination in cats undergoing ovariohysterectomy

The analgesic efficacy of tramadol and/or vedaprofen was evaluated in cats submitted for elective ovariohysterectomy, using a randomised double blind placebo controlled design. Forty adult female cats (3.0+/-0.32kg; 1.8+/-0.7 years) were distributed into four groups. Vedaprofen PO (0.5mg/kg), tramadol SC (2mg/kg), both, or placebo was administered 1h before surgery and every 24 and 8h, respectively, for 72h after surgery. Pain score evaluated by interactive visual analogue and composite pain score and hyperalgesia by the von Frey filament test were recorded at 1, 2, 4, 6, 8, 12, 24, 28, 32, 48, 52, 56, 72, 96h and on the 7th day after surgery. Animals treated with combined vedaprofen and tramadol treatment did not need rescue analgesia, did not develop hyperalgesia, and their serum cortisol concentrations and pain scores were lower than placebo until 24 and 72h after surgery, respectively. Combined vedaprofen and tramadol treatment provided more effective postoperative analgesia and prevented hyperalgesia than when used on their own. Multimodal technique is a superior method of treating pain after feline ovariohysterectomy. This work also provides evidence for the benefits of analgesia for up to 3 days following ovariohysterectomy.

[Pain therapy for the lower extremities]

Pain therapy after surgical procedures of the lower extremity is an important goal, whereas insufficient analgesia leads to an essential reduction of the patient's mobility and convalescence. If possible, regional anaesthetic and intrathecal procedures for pre-, intra- and postoperative analgesia should be used. Systemic analgesics should not be used preoperatively, whereas non-opioids and opioids are recommended postoperatively. Surgical options that adequately reduce pain are intra-articular injection of local anaesthetics alone or in combination with opioids and cooling and physiotherapeutic treatment regimens after joint procedures. There is no scientific rationale as an argument for inserting drains. The surgical approach depends more on the individual patient's anatomical characteristics. Whereas the regional analgesic regimen is more effective than systemic therapy, sufficient tools for pain reduction during surgical procedures of the lower extremity are at the orthopaedic surgeon's disposal, too.

A comparative study on the analgesic effect of continuous intraarticular infusion with ropivacaine, ropivacaine/fentanyl and ropivacaine/fentanyl/ketorolac after arthroscopic shoulder surgery

BACKGROUND

Arthroscopic shoulder surgery can result in severe postoperative pain. A variety of methods have been used to control pain in postoperative period and the results are variable. The purpose of this study was to compare the relative analgesic efficacies of the postoperative intraarticular infusion of ropivacaine, ropivacaine/fentanyl, and ropivacaine/fentanyl/ketorolac after arthroscopic shoulder surgery.

METHODS

Thirty patients undergoing arthroscopic shoulder surgery under general anesthesia were randomly assigned to three groups. At the end of surgery, 0.5% ropivacaine 20 ml was infused into the articular space and a continuous infusion catheter was inserted into intraarticular operated site. After surgery, continuous infusion of 0.5% ropivacaine 100 ml (Group 1, n = 10), 0.5% ropivacaine 100 ml including fentanyl 10 microg/kg (Group 2, n = 10), or 0.5% ropivacaine 100 ml including fentanyl 10 microgram/kg and ketorolac 150 mg (Group 3, n = 10) was started through catheter at rate of 2 ml/hr with bolus dose of 0.5 ml with a lock out time of 15 minutes for 2 days. The level of pain was assessed using a visual analogue scale (VAS) postoperative 2, 6, 12, 24 and 48 hours and the amounts of supplemental analgesics were recorded.

RESULTS

The VAS was significantly lower after 2, 6, 12 hours in Group 2 than in Group 1. In Group 3, the VAS was significantly lower all hours than in the other two groups.

CONCLUSIONS

The combination of fentanyl and ketorolac with ropivacaine did provide better postoperative analgesia than the other groups after arthroscopic shoulder surgery.

Analgesic management of an eight-year-old Springer Spaniel after amputation of a thoracic limb

Analgesic agents were administered perioperatively to an eight-year-old Springer Spaniel undergoing amputation of its right thoracic limb. The amputation was carried out due to a painful, infiltrative and poorly differentiated sarcoma involving the nerves of the brachial plexus. A combination of pre-emptive and multimodal perioperative analgesic strategies was used; including intravenous (IV) infusions of fentanyl, morphine, lidocaine and ketamine.

Effects of Carprofen and Morphine on the Minimum Alveolar Concentration of Isoflurane in Dogs

The minimum alveolar concentration (MAC) of isoflurane in dogs was determined following carprofen (2.2 mg/kg per os) alone, morphine (1 mg/kg intravenously) alone, carprofen and morphine, and no drug control in eight healthy adult dogs. Isoflurane MAC following administration of morphine alone (0.81%±0.18%) or carprofen and morphine (0.68%±0.31%) was significantly less than the control MAC (1.24%±0.15%). Isoflurane MAC after carprofen alone (1.13%±0.13%) was not significantly different from the control value. Results indicated that administration of morphine alone or in combination with carprofen significantly reduced the MAC of isoflurane in dogs. The isoflurane MAC reduction was additive between the effects of carprofen and morphine.

[Physico-chemical stability and sterility of non-opioid analgesics in solution]

OBJECTIVES

The combination of non-opioid analgesic drugs (P: paracetamol, K: ketoprofen and N: nefopam) is currently recommended for postoperative pain control. In practice, these analgesics are often administered in the same solution. We investigated the chemical stability and sterility of three mixtures of analgesics (P+K, P+N and K+N).

METHODS

For each mixture, concentrations of active principles were measured using high-performance liquid chromatography over 24 hours. These mixtures were cultured for microbiological colonization.

RESULTS

Our study demonstrated chemical and bacteriologic stability of these three mixtures over a 24-hour period. The results allow the use of P+K, P+N and K+N in the same ready to use solution.

[Postoperative analgesia with continuous intra-articular infusion of ropivacaine following trapeziectomy]

OBJECTIVES

A pilot study was implemented to evaluate the efficacy of patient controlled analgesia (PCA) with continuous intra-articular infusion of ropivacaine following trapeziectomy with ligament reconstruction and tendon interposition.

METHODS

Twelve patients were prospectively included. A catheter was placed into the trapezium void and connected to a PCA pump set on a continuous intra-articular infusion rate of ropivacaine: 2mg/ml. Patients were allowed to deliver additional boluses when analgesia was incomplete.

RESULTS

Pain was evaluated less than 3/10 (Numeric Scale Evaluation) by 92% of the patients during the first 48 h. No toxicity of the local anaesthetic nor catheter-related complication were reported.

CONCLUSION

This preliminary study showed continuous basal and bolus infusion of ropivacaine through a single catheter placed into the trapezium void to provide an excellent postoperative pain control and to be related to a high patient's satisfaction level.

Intra-articular sufentanil in multimodal analgesic management after outpatient arthroscopic anterior cruciate ligament reconstruction: a prospective, randomized, double-blinded study

PURPOSE

This prospective, randomized, blinded study was designed to evaluate the effectiveness of intra-articular sufentanil, ropivacaine, and clonidine compared with that of ropivacaine and clonidine without sufentanil on postoperative pain after arthroscopic reconstruction of the anterior cruciate ligament of the knee.

METHODS

One hundred twenty patients were enrolled and randomly divided into 2 groups. At the end of the operation, the surgeon injected 20 mL of a solution containing 5 microg sufentanil, 100 mg ropivacaine, and 1 microg/kg clonidine in the knees of patients in group A whereas the surgeon injected the same solution without sufentanil in group B. During the postoperative period and for the first 24 hours, we recorded pain intensity using a visual analog scale.

RESULTS

All patients were discharged after a few hours with well-controlled pain. Pain scores were low in both groups both before and after discharge. We did not show any difference in pain scores at any time point. During the first postoperative hour, patients in group B required more rescue analgesic drugs (P < .05).

CONCLUSIONS

In our patients the addition of sufentanil in the intra-articular solution did not provide better control of pain.

LEVEL OF EVIDENCE

Level I, therapeutic randomized controlled trial.

Preemptive analgesia with local lidocaine infiltration for single-level open disc operation

To evaluate the impact of preemptive local analgesia at the incision site for postoperative pain in patients undergoing disc operation. In this prospective, randomized, double-blinded, placebo-controlled study 166 patients were assigned to either lidocaine (n = 83) or placebo (n = 83) groups. The incision site was infiltrated with either 20 mL of 2% lidocaine and 0.9% saline in lidocaine group or 0.9% saline before the incision. Morphine (5 mg) was used for postoperative pain treatment. Postoperative pain was measured with Visual Analog Scale (VAS) in 6, 12, 24 and 48 h. Data were analyzed with SPSS software, using Chi-square and t-tests. The groups were matched for age, sex, type of operation, mean length of hospital stay and mean length of operation. Statistical analysis revealed no significant difference in visual analog scores of pain severity at 6, 12, 24 and 48 h after surgery between lidocaine and placebo groups (6 h: 38.22 +/- 26.87 vs. 34.52 +/- 24.43, p = 0.35; 12 h: 33.26 +/- 28.83 vs. 28.01 +/- 24.71, p = 0.20; 24 h: 26.71 +/- 23.31 vs. 22.85 +/- 22.48, p = 0.27; 48 h 16.35 +/- 10.16 vs. 15.23 +/- 8.90 p = 0.45). The amount of narcotics used post operatively had no meaningful difference in the groups (lidocaine 10.07 +/- 8.24 mg vs. placebo 10.54 +/- 9.31 mg p = 0.73). Preemptive analgesia with lidocaine 2% used subcutaneously before skin incision has no effect in reducing postoperative pain, narcotics demand and duration of hospital stay.

Perspective on pain management in the 21st century

Pain is a predictable consequence of surgery or trauma. Untreated, it is associated with significant physiologic, emotional, mental, and economic consequences. Despite the vast amount of current knowledge, uncontrolled postoperative pain is reported by approximately 50% of patients. Thus, techniques for effective acute pain management (APM) represent unmet educational needs. The significance of this unmet need is reflected in the number of journal and textbook publications dedicated to disseminating research, evidence-based guidelines, and clinical information. Acknowledging the importance of APM, health care accrediting agencies and professional societies have become increasingly focused on ensuring that patients receive prompt and acceptable pain relief.

Understanding addiction: the orthopedic surgical perspective to a significant problem

The realm of addiction and addiction medicine is one in which physicians receive little formal training, particularly in surgical subspecialties. This article presents an overview of addiction medicine and treatment, concentrating on the neurophysiology, psychological aspects, and terminology. Assessment tools and objective findings for recognizing addiction in patients in pain are discussed, as is the management of acute pain and perioperative considerations for patients who are undergoing opioid treatment programs.

Multimodal analgesia without parenteral narcotics for total knee arthroplasty

Use of parenteral narcotics after total knee arthroplasty is considered by most orthopedic surgeons to be the standard of care. This study tested the hypothesis that a multimodal oral pain medication protocol could control pain and minimize complications of parenteral narcotics. Postoperative oral analgesia was augmented with either continuous epidural infusion or continuous femoral infusion using ropivacaine only. Seventy patients had total knee arthroplasty with a protocol that included preemptive oral analgesics, epidural anesthesia, pericapsular analgesic injection, and postoperative analgesia without parenteral opioids. The average daily pain score was less than 4 out of 10, nausea occurred in 15 patients (21%), emesis in 1 patient (1.4%), and there were no severe complications. This study proved the hypothesis that pain after total knee arthroplasty could be effectively managed without routine use of parenteral opioids.