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Salimi S, Taheri M, Khayat Kashani HR, Ghani F, Behnaz F, Ghasemi M. Evaluation of Intravenous Infusion of Ibuprofen with Paracetamol-Morphine in Pain and Satisfaction of Patients Undergoing Supratentorial Brain Surgery. Anesth Pain Med 2023; 13:e139758. [PMID: 38476989 PMCID: PMC10928444 DOI: 10.5812/aapm-139758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/19/2023] [Accepted: 10/14/2023] [Indexed: 03/14/2024] Open
Abstract
Background The pain experienced following supratentorial brain surgery is usually defined as moderate to severe. Therefore, pain-management approaches, including narcotics, are an integral part of treatment regimens that cause respiratory complications or seizures, and reducing this pain level and increasing patient satisfaction is vital. Methods This randomized, double-blind clinical trial study to evaluate the pain level and satisfaction in patients undergoing surgery for supratentorial brain neoplasms was performed on two groups with a sample size of 50 patients. In group I, after removal of the brain lesion (at the beginning of dura closure), 400 mg of ibuprofen solution was infused intravenously over 30 minutes. In group II, morphine 0.07 mg/kg intravenously with 1000 mg paracetamol was infused over 30 minutes. After injecting ibuprofen and paracetamol morphine, the patient's pain level and satisfaction with the process were checked. Results Patients' satisfaction score in the first 6 hours in the ibuprofen group was 1.67 ± 0.72, and in the other group was 2.27 ± 0.7, which was statistically different (P-value = 0.029). The mean of VAS in the first, second, third, and fourth hours was not statistically different. In the comparative analysis of the laboratory indicators of platelet function analysis in the two groups, none of the measured items had a significant difference between the two groups in the three measurement periods (P > 0.05). Conclusions Administration of ibuprofen led to pain relief and patient satisfaction comparable to morphine and paracetamol, and after the surgery for supratentorial brain tumors, ibuprofen did not affect the patients' blood clotting functions.
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Affiliation(s)
- Sohrab Salimi
- Department of Anesthesiology, Anesthesiology Research Center, Imam Hossein Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehrdad Taheri
- Department of Anesthesiology, Imam Hossein Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Reza Khayat Kashani
- Department of Neurosurgery, Imam Hossein Hospital, School of Medicine,Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farnazsadat Ghani
- Anesthesiology Research Center, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Faranak Behnaz
- Department of Anesthesiology, Shohada-e-Tajrish Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahshid Ghasemi
- Department of Anesthesiology, Akhtar Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Lai HC, Hsieh CB, Wong CS, Yeh CC, Wu ZF. Preincisional and postoperative epidural morphine, ropivacaine, ketamine, and naloxone treatment for postoperative pain management in upper abdominal surgery. ACTA ACUST UNITED AC 2016; 54:88-92. [DOI: 10.1016/j.aat.2016.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 10/03/2016] [Accepted: 10/05/2016] [Indexed: 11/28/2022]
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Perioperative Dextromethorphan as an Adjunct for Postoperative Pain: A Meta-analysis of Randomized Controlled Trials. Anesthesiology 2016; 124:696-705. [PMID: 26587683 DOI: 10.1097/aln.0000000000000950] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND N-methyl-D-aspartate receptor antagonists have been shown to reduce perioperative pain and opioid use. The authors performed a meta-analysis to determine whether the use of perioperative dextromethorphan lowers opioid consumption or pain scores. METHODS PubMed, Web of Science, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Pubget, and EMBASE were searched. Studies were included if they were randomized, double-blinded, placebo-controlled trials written in English, and performed on patients 12 yr or older. For comparison of opioid use, included studies tracked total consumption of IV or intramuscular opioids over 24 to 48 h. Pain score comparisons were performed at 1, 4 to 6, and 24 h postoperatively. Difference in means (MD) was used for effect size. RESULTS Forty studies were identified and 21 were eligible for one or more comparisons. In 848 patients from 14 trials, opioid consumption favored dextromethorphan (MD, -10.51 mg IV morphine equivalents; 95% CI, -16.48 to -4.53 mg; P = 0.0006). In 884 patients from 13 trials, pain at 1 h favored dextromethorphan (MD, -1.60; 95% CI, -1.89 to -1.31; P < 0.00001). In 950 patients from 13 trials, pain at 4 to 6 h favored dextromethorphan (MD, -0.89; 95% CI, -1.11 to -0.66; P < 0.00001). In 797 patients from 12 trials, pain at 24 h favored dextromethorphan (MD, -0.92; 95% CI, -1.24 to -0.60; P < 0.00001). CONCLUSION This meta-analysis suggests that dextromethorphan use perioperatively reduces the postoperative opioid consumption at 24 to 48 h and pain scores at 1, 4 to 6, and 24 h.
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Wu LY, Huang EYK, Tao PL. Coadministration of dextromethorphan during pregnancy and throughout lactation prevents morphine-induced hyperprolactinemia in female rats. Fertil Steril 2010; 93:1686-94. [DOI: 10.1016/j.fertnstert.2009.01.143] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Revised: 01/25/2009] [Accepted: 01/26/2009] [Indexed: 10/21/2022]
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Abstract
Surgery is a circumstance in which we know that we will cause pain. Although most of our perioperative pain management interventions are symptomatic, several strategies can reduce and even prevent pain in the perioperative setting. Because the physiologic mechanisms of postoperative pain are understood, it is possible to interrupt these mechanisms before the patient actually becomes symptomatic. This article reviews the literature and presents these strategies with the hope of implementation of the readers.
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Affiliation(s)
- Robert Hallivis
- Podiatric Surgery Section, Department of Orthopedics, INOVA Fairfax Hospital, Falls Church, VA 20042, USA
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Kawai M, Ando K, Matsumoto Y, Sakurada I, Hirota M, Nakamura H, Ohta A, Sudo M, Hattori K, Takashima T, Hizue M, Watanabe S, Fujita I, Mizutani M, Kawamura M. Discovery of (−)-6-[2-[4-(3-fluorophenyl)-4-hydroxy-1-piperidinyl]-1-hydroxyethyl]-3,4-dihydro-2(1H)-quinolinone—A potent NR2B-selective N-methyl d-aspartate (NMDA) antagonist for the treatment of pain. Bioorg Med Chem Lett 2007; 17:5558-62. [PMID: 17766106 DOI: 10.1016/j.bmcl.2007.08.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2007] [Revised: 07/18/2007] [Accepted: 08/09/2007] [Indexed: 11/22/2022]
Abstract
(-)-6-[2-[4-(3-Fluorophenyl)-4-hydroxy-1-piperidinyl]-1-hydroxyethyl]-3,4-dihydro-2(1H)-quinolinone was identified as an orally active NR2B-subunit selective N-methyl-d-aspartate (NMDA) receptor antagonist. It has very high selectivity for NR2B subunits containing NMDA receptors versus the HERG-channel inhibition (therapeutic index=4200 vs NR2B binding IC(50)). This compound has improved pharmacokinetic properties compared to the prototype CP-101,606.
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Affiliation(s)
- Makoto Kawai
- Discovery Chemistry, Pfizer Global Research & Development, Nagoya laboratories, 5-2 Taketoyo, Aichi 470-2393, Japan
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Lu CH, Liu JY, Lee MS, Borel CO, Yeh CC, Wong CS, Wu CT. Preoperative Cotreatment With Dextromethorphan and Ketorolac Provides an Enhancement of Pain Relief After Laparoscopic-assisted Vaginal Hysterectomy. Clin J Pain 2006; 22:799-804. [PMID: 17057562 DOI: 10.1097/01.ajp.0000210931.20322.da] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Both N-methyl-D-aspartate receptor antagonists and nonsteroidal anti-inflammatory drugs have been demonstrated to produce better postoperative pain relief. The concept of multimodal analgesia has also been used for clinical pain management. The aim of the present study was to examine the analgesic effect of preoperative cotreatment with dextromethorphan (DM) and ketorolac on postoperative pain management after laparoscopic-assisted vaginal hysterectomy (LAVH). METHODS Eighty ASA physical status I or II patients scheduled for LAVH were included and randomly assigned to 1 of 4 groups. Patients received intramuscular (IM) chorpheniramine 20 mg+ intravenous (IV) 2 mL of normal saline, IM DM 40 mg+IV 2 mL of normal saline, IM chorpheniramine 20 mg+IV 60 mg (2 mL) of ketorolac, and IM DM 40 mg+IV ketorolac 60 mg as the groups C, DM, Keto, and DM+Keto, respectively. All patients were given a patient-controlled analgesia (PCA) with morphine for pain relief postoperatively. Analgesic effects were evaluated using Visual Analog Scale pain scores at rest and during coughing, time to first PCA request for pain relief, total morphine consumption, bed rest time, and the time to first passage of flatus for 48 hours after surgery. RESULTS Patients in DM and Keto groups had significantly better pain relief than patients in group C. Patients in DM+Keto group exhibited the best postoperative pain relief among groups in the following several categories: time to first trigger of PCA, total morphine consumption, the worst Visual Analog Scale, bed rest time, and the time to first passage of flatus, demonstrating an enhanced effect between DM and ketorolac. Neither synergistic nor antagonistic interaction was observed between DM and ketorolac. DISCUSSION Preoperative treatment with both DM and ketorolac diminish postoperative pain. Our results suggest that the N-methyl-D-aspartate antagonist-DM and the nonsteroidal anti-inflammatory drugs-ketorolac cotreatment provide an enhancement of analgesia for postoperative pain management in patients after LAVH surgery.
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Affiliation(s)
- Chueng-He Lu
- Department of Anesthesiology, Tri-Service General Hospital and, National Defense Medical Center, no. 325, Section 2, Chenggung Road, Neihu 114, Taipei, Taiwan, Republic of China
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Dextromethorphan premedication reduced postoperative analgesic consumption in patients after oral surgery. ACTA ACUST UNITED AC 2006; 102:591-5. [PMID: 17052633 DOI: 10.1016/j.tripleo.2005.10.060] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2005] [Revised: 10/18/2005] [Accepted: 10/24/2005] [Indexed: 11/29/2022]
Abstract
OBJECTIVE N-methyl-D-aspartate (NMDA) receptor antagonist premedication reduces postoperative pain. In this study, we examined if NMDA antagonist premedication might reduce postoperative pain after oral surgery, testing dextromethorphen. STUDY DESIGN One hundred eleven patients undergoing mandibular third molar extraction under local anesthesia were included. Patients were randomly allocated into 3 groups. Group A (n = 37), B (n = 38), and C (n = 36) patients were emphasis-placed on dextromethorphan 30 mg, diclofenac 25 mg, or placebo orally before surgery, respectively. Postoperatively, patients were allowed to use oral diclofenac, 25 mg, for postoperative pain relief. Postoperative pain was evaluated the 1st, 7th, and 14th day after surgery, respectively, by using a visual analog scale (VAS) and the number of diclofenac consumed. VAS score and the number of diclofenac consumption were compared among the groups. RESULTS VAS score was similar among the 3 groups during the study period. Total postoperative diclofenac consumption was significantly less in group A than in group C (P < 0.05). CONCLUSION Dextromethorphan premedication reduced postoperative analgesic consumption after oral surgery.
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Duedahl TH, Rømsing J, Møiniche S, Dahl JB. A qualitative systematic review of peri-operative dextromethorphan in post-operative pain. Acta Anaesthesiol Scand 2006; 50:1-13. [PMID: 16451144 DOI: 10.1111/j.1399-6576.2006.00900.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND The N-methyl-D-aspartate (NMDA) receptor antagonist, dextromethorphan (DM), has received interest as an adjunctive agent in post-operative pain management. Clinical trials have been contradictory. This systematic review aims to evaluate the available literature examining the analgesic efficacy of DM in post-operative patients. METHODS Twenty-eight randomized, double-blind, clinical studies, with 40 comparisons, including a variety of dosing regimens comparing DM treatment with placebo, were included. Meta-analysis was intended but deemed to be inappropriate because of the substantial difference in methodology and reporting between trials. The outcome measures (pain scores at rest, time to first analgesic request and supplemental analgesic consumption) were evaluated qualitatively by significant difference (P<0.05) as reported in the original investigations. RESULTS DM did not reduce the post-operative pain score with a clinically significant magnitude. The time to first analgesic request was significantly prolonged in most comparisons with DM. Significant decreases in supplemental opioid consumption were observed in the majority of parenteral DM studies and in about one-half of the oral studies. The decreases were of questionable clinical importance in most comparisons, although a relationship between a decrease in opioid consumption and opioid-related side-effects was established in some studies. CONCLUSION Based on the studies available, DM has the potential to be a safe adjunctive agent to opioid analgesia in post-operative pain management, but the consistency of the potential opioid-sparing and pain-reducing effect must be questioned. Consequently, it is not possible to recommend dose regimens or routine clinical use of DM in post-operative pain. The route of administration may be important for the beneficial effect.
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Affiliation(s)
- T H Duedahl
- Department of Pharmaceutics, The Danish University of Pharmaceutical Sciences, Copenhagen, and Department of Anaesthesiology, Glostrup University Hospital, Denmark.
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Duedahl TH, Dirks J, Petersen KB, Romsing J, Larsen NE, Dahl JB. Intravenous dextromethorphan to human volunteers: relationship between pharmacokinetics and anti-hyperalgesic effect. Pain 2005; 113:360-368. [PMID: 15661445 DOI: 10.1016/j.pain.2004.11.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2004] [Revised: 10/22/2004] [Accepted: 11/22/2004] [Indexed: 11/19/2022]
Abstract
The aim of this study was to investigate the effect of dextromethorphan (DM) 0.5 mg/kg administered intravenously (i.v.) on hyperalgesia and pain after a tissue injury in human volunteers, and to describe the relationship between pharmacokinetic and pharmacodynamic data. The heat-capsaicin sensitisation model, a well-established experimental hyperalgesia model was induced in 24 healthy, male volunteers aged 21-35 years. The subjects received i.v. DM 0.5 mg/kg or isotonic saline on two separate study sessions. The primary outcome measure from 0 to 3 h was reduction in area of established secondary hyperalgesia. Secondary outcome measures were reduction in area of secondary hyperalgesia in response to brief thermal stimulation, heat pain detection thresholds and painfulness after tonic heat pain. Blood samples were collected throughout the study to describe the relationship between pharmacokinetic and pharmacodynamic data. Intravenous DM 0.5 mg/kg significantly reduced areas of established secondary hyperalgesia with an average of 39% (P<0.05). Development of secondary hyperalgesia was substantially prevented by DM (P<0.05). No significant effect was seen on either heat pain detection thresholds or after tonic heat pain. The pharmacokinetic-pharmacodynamic relationship showed a large inter-subject variation with a mean delay in effect of nearly 2 h in relation to peak serum concentration. The results strongly indicate that DM is an anti-hyperalgesic drug. The delay in effect may be explained by several mechanisms and suggests that timing of DM administration is an essential factor for using the drug in clinical settings.
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Affiliation(s)
- Tina H Duedahl
- The Danish University of Pharmaceutical Sciences, Copenhagen, Denmark Department of Anesthesiology and Intensive Care Medicine, Herlev University Hospital, Herlev, Denmark The Pharmacological Laboratory, Glostrup University Hospital, Glostrup, Denmark Department of Anesthesiology, Glostrup University Hospital, Glostrup, Denmark
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11
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Yeh CC, Jao SW, Huh BK, Wong CS, Yang CP, White WD, Wu CT. Preincisional Dextromethorphan Combined with Thoracic Epidural Anesthesia and Analgesia Improves Postoperative Pain and Bowel Function in Patients Undergoing Colonic Surgery. Anesth Analg 2005; 100:1384-1389. [PMID: 15845691 DOI: 10.1213/01.ane.0000148687.51613.b5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Colonic surgery is associated with severe postoperative pain and postoperative ileus, which contribute to delayed hospital discharge. In previous studies, we demonstrated that IM dextromethorphan (DM) provided preemptive analgesia and improved postoperative pain. The benefit of thoracic epidural anesthesia (TEA) and postoperative epidural analgesia on postoperative pain was well demonstrated. The goal of this study was to investigate the effect of preincisional IM DM combined with intraoperative TEA and postoperative patient-controlled epidural analgesia (PCEA) on pain and bowel function after colonic surgery. Patients were randomized into 3 equal groups to receive: 1) chlorpheniramine maleate (CPM) 20 mg and general anesthesia (CPM-GA); 2) CPM 20 mg and GA combined with TEA (CPM-TEA); or 3) DM 40 mg (containing 20 mg of CPM) and GA combined with TEA (DM-TEA). The CPM, DM, and TEA with lidocaine were administered after GA induction via an IM injection and 30 min before the skin incision. All patients received postoperative PCEA for pain control. Analgesic effects were evaluated for 72 h after surgery using visual analog scale pain scores at rest and moving, time to first PCEA request for pain relief, total PCEA consumption, and the time to first passage of flatus. Statistically significant improvement of postoperative pain and bowel function was observed in the following order: DM-TEA > CPM-TEA > CPM-GA. Compared with the CPM-TEA group, the DM-TEA group averaged 1.6 points lower on first-hour pain scores, 40 min longer to first PCEA request, 15.8 mL less PCEA drug over 72 h, and 14.7 h earlier bowel function (all P < 0.01). We conclude that the combination of preincisional DM (40 mg IM), intraoperative TEA, and postoperative PCEA enhances analgesia and facilitates recovery of bowel function, suggesting possible synergistic interaction with local anesthetics and opioids.
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Affiliation(s)
- Chun-Chang Yeh
- Departments of *Anesthesiology and †Surgery, Tri-Service General Hospital, and National Defense Medical Center, Taipei, Taiwan, Republic of China; and ‡Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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Ong CKS, Lirk P, Seymour RA, Jenkins BJ. The efficacy of preemptive analgesia for acute postoperative pain management: a meta-analysis. Anesth Analg 2005; 100:757-773. [PMID: 15728066 DOI: 10.1213/01.ane.0000144428.98767.0e] [Citation(s) in RCA: 464] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Whether preemptive analgesic interventions are more effective than conventional regimens in managing acute postoperative pain remains controversial. We systematically searched for randomized controlled trials that specifically compared preoperative analgesic interventions with similar postoperative analgesic interventions via the same route. The retrieved reports were stratified according to five types of analgesic interventions: epidural analgesia, local anesthetic wound infiltration, systemic N-methyl-d-aspartic acid (NMDA) receptor antagonists, systemic nonsteroidal antiinflammatory drugs (NSAIDs), and systemic opioids. The primary outcome measures analyzed were the pain intensity scores, supplemental analgesic consumption, and time to first analgesic consumption. Sixty-six studies with data from 3261 patients were analyzed. Data were combined by using a fixed-effect model, and the effect size index (ES) used was the standardized mean difference. When the data from all three outcome measures were combined, the ES was most pronounced for preemptive administration of epidural analgesia (ES, 0.38; 95% confidence interval [CI], 0.28-0.47), local anesthetic wound infiltration (ES, 0.29; 95% CI, 0.17-0.40), and NSAID administration (ES, 0.39; 95% CI, 0.27-0.48). Whereas preemptive epidural analgesia resulted in consistent improvements in all three outcome variables, preemptive local anesthetic wound infiltration and NSAID administration improved analgesic consumption and time to first rescue analgesic request, but not postoperative pain scores. The least proof of efficacy was found in the case of systemic NMDA antagonist (ES, 0.09; 95% CI, -0.03 to 0.22) and opioid (ES, -0.10; 95% CI, -0.26 to 0.07) administration, and the results remain equivocal.
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Affiliation(s)
- Cliff K-S Ong
- *Department of Oral & Maxillofacial Surgery, Faculty of Dentistry, National University of Singapore; †Department of Anesthesiology & Critical Care Medicine, Faculty of Medicine, Medical University of Innsbruck, Innsbruck, Austria; ‡Department of Restorative Dentistry, Faculty of Dentistry, University of Newcastle upon Tyne, Newcastle upon Tyne, United Kingdom; and §Department of Anaesthetics and Intensive Care Medicine, College of Medicine, University of Wales, United Kingdom
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Wu CT, Borel CO, Lee MS, Yu JC, Liou HS, Yi HD, Yang CP. The Interaction Effect of Perioperative Cotreatment with Dextromethorphan and Intravenous Lidocaine on Pain Relief and Recovery of Bowel Function After Laparoscopic Cholecystectomy. Anesth Analg 2005; 100:448-453. [PMID: 15673874 DOI: 10.1213/01.ane.0000142551.92340.cc] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Both dextromethorphan (DM) and IV lidocaine improve postoperative pain relief. In the present study, we evaluated the interaction of DM and IV lidocaine on pain management after laparoscopic cholecystectomy (LC). One-hundred ASA physical status I or II patients scheduled for LC were randomized into four equal groups to receive either: (a) chlorpheniramine maleate (CPM) intramuscular injection (IM) 20 mg and IV normal saline (N/S) (group C); (b) DM 40 mg IM and IV N/S (group DM); (c) CPM 20 mg IM and IV lidocaine 3 mg . kg(-1) . h(-1) (group L); or (d) DM 40 mg IM and IV lidocaine (group DM+L). All treatments were administered 30 min before skin incision. Analgesic effects were evaluated using visual analog scale pain scores at rest and during coughing, time to meperidine request, total meperidine consumption, and the time to first passage of flatus after surgery. Patients of the DM+L group exhibited the best pain relief and fastest recovery of bowel function among groups. Patients in the DM and L groups had significantly better pain relief than those in the C group. The results showed an additional effect on pain relief and a synergistic effect on recovery of bowel function when DM was combined with IV lidocaine after LC.
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Affiliation(s)
- Ching-Tang Wu
- Department of *Anesthesiology and †General Surgery, Tri-Service General Hospital; ‡Department of Public Health, National Defense Medical Center, National Defense University, Taipei; Division of §Obstetrics and Gynecology and ∥Anesthesiology, Armed Forces Taoyuan General Hospital, Taiwan, Republic of China; and ¶Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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Abstract
Perioperative analgesia for thoracotomy has evolved in concert with increasing knowledge of the impact of pain on recovery, the origin of this pain, and new methods for treating it. Thoracic surgery is one of the few areas where there is more general agreement between surgeons and anesthesiologists as to the importance of aggressive pain management, often with an indwelling epidural catheter left in place until after thoracostomy tube removal. The reasons for this agreement is that it has become increasingly clear to both specialties that pain puts patients with decreased pulmonary reserve who undergo thoracotomy at greater risk for morbidity. Future studies need to examine drugs or drug combinations that can lead to further reductions in the often intense pain that patients receiving aggressive epidural analgesia still experience. Studies directed at finding interventions capable of reducing the rate of long-term postthoracotomy pain still need to be performed.
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Affiliation(s)
- E Andrew Ochroch
- Department of Anesthesia, University of Pennsylvania Health System, 3400 Spruce Street, 680 Dulles Building, Philadelphia, PA 19104, USA.
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Kukanich B, Papich MG. Plasma profile and pharmacokinetics of dextromethorphan after intravenous and oral administration in healthy dogs. J Vet Pharmacol Ther 2004; 27:337-41. [PMID: 15500572 DOI: 10.1111/j.1365-2885.2004.00608.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Dextromethorphan is an N-methyl-D-aspartate (NMDA) noncompetitive antagonist which has been used as an antitussive, analgesic adjunct, probe drug, experimentally to attenuate acute opiate and ethanol withdrawal, and as an anticonvulsant. A metabolite of dextromethorphan, dextrorphan, has been shown to behave pharmacodynamically in a similar manner to dextromethorphan. The pharmacokinetics of dextromethorphan were examined in six healthy dogs following intravenous (2.2 mg/kg) and oral (5 mg/kg) administration in a randomized crossover design. Dextromethorphan behaved in a similar manner to other NMDA antagonists upon injection causing muscle rigidity, ataxia to recumbency, sedation, urination, and ptyalism which resolved within 90 min. One dog repeatedly vomited upon oral administration and was excluded from oral analysis. Mean +/- SD values for half-life, apparent volume of distribution, and clearance after i.v. administration were 2.0 +/-0.6 h, 5.1 +/- 2.6 L/kg, and 33.8 +/- 16.5 mL/min/kg. Oral bioavailability was 11% as calculated from naive pooled data. Free dextrorphan was not detected in any plasma sample, however enzymatic treatment of plasma with glucuronidase released both dextromethorphan and dextrorphan indicating that conjugation is a metabolic route. The short half-life, rapid clearance, and poor bioavailability of dextromethorphan limit its potential use as a chronic orally administered therapeutic.
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Affiliation(s)
- B Kukanich
- Department of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, 4700 Hillsborough Street, Raleigh, NC 27606, USA.
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Yeh CC, Wu CT, Lee MS, Yu JC, Yang CP, Lu CH, Wong CS. Analgesic effects of preincisional administration of dextromethorphan and tenoxicam following laparoscopic cholecystectomy. Acta Anaesthesiol Scand 2004; 48:1049-53. [PMID: 15315625 DOI: 10.1111/j.1399-6576.2004.00455.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pre-incisional treatment with either N-methyl-D-aspartate (NMDA) receptor antagonists or non-steroidal anti-inflammatory drugs (NSAIDs) improves postoperative pain relief. This study examines the effect on postlaparoscopic cholecystectomy (LC) pain of a combination of dextromethorphan (DM), a NMDA-receptor antagonist, and tenoxicam, a NSAID, given preoperatively. METHODS Eighty-eight ASA I or II patients scheduled for LC were entered into a randomized, double-blind study and randomly allocated to one of four groups. Controls received 20 mg (4 ml) of chlorpheniramine maleate (CPM) IM and 4 ml of normal saline (N/S) IV. Group DM received 40 mg of DM (containing 20 mg of CPM) IM and 4 ml of N/S IV. Group T were given CPM 20 mg IM, and tenoxicam 40 mg (4 ml) IV. Group DM + T were given DM 40 mg (containing 20 mg of CPM) IM, and tenoxicam 40 mg IV. All treatments were given 30 min before skin incision. Analgesic effects were evaluated by Visual Analog Scale (VAS) pain scores at rest and during coughing, at 1, 2, 4, 12, 24 and 48 h after surgery. The time to the first request for meperidine for pain relief, and total meperidine consumption, were recorded for 48 h after surgery. RESULTS Compared to controls, patients given DM and DM + T first requested meperidine significantly later, had lower meperidine consumption, made fewer requests for meperidine, and had lower pain scores. There were significant differences between the DM + T and T groups at 2 and 4 h in both resting and incident VAS pain scores, the incidence of meperidine requests and the time to first meperidine injection. There were significant differences between groups DM and T at 1 h for resting pain and at 2 and 4 h for incident pain. Except for a significant difference in the incident pain score 1 h after surgery, there were no other differences in pain scores between the DM and DM + T groups. Neither synergistic nor antagonistic interaction was observed between DM and tenoxicam. CONCLUSIONS The results suggest that pretreatment with DM, but not tenoxicam, provides significant pre-emptive analgesia for postoperative pain management in patients after LC surgery. Combining DM and tenoxicam also gives good pain relief.
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MESH Headings
- Adult
- Aged
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/adverse effects
- Analgesics, Opioid/therapeutic use
- Anesthesia, General
- Anti-Inflammatory Agents, Non-Steroidal/administration & dosage
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Chlorpheniramine/therapeutic use
- Cholecystectomy, Laparoscopic
- Dextromethorphan/administration & dosage
- Dextromethorphan/therapeutic use
- Double-Blind Method
- Female
- Histamine H1 Antagonists/therapeutic use
- Humans
- Injections, Intravenous
- Male
- Meperidine/administration & dosage
- Meperidine/adverse effects
- Meperidine/therapeutic use
- Middle Aged
- Pain Measurement
- Pain, Postoperative/drug therapy
- Pain, Postoperative/prevention & control
- Piroxicam/administration & dosage
- Piroxicam/analogs & derivatives
- Piroxicam/therapeutic use
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Affiliation(s)
- C-C Yeh
- Department of Anesthesiology, Tri-Service General Hospital, Taipei, Taiwan
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McCartney CJL, Sinha A, Katz J. A Qualitative Systematic Review of the Role of N-Methyl-d-Aspartate Receptor Antagonists in Preventive Analgesia. Anesth Analg 2004; 98:1385-400, table of contents. [PMID: 15105220 DOI: 10.1213/01.ane.0000108501.57073.38] [Citation(s) in RCA: 242] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
UNLABELLED We evaluated in a qualitative systematic review the effect of N-methyl-D-aspartate (NMDA) receptor antagonists on reducing postoperative pain and analgesic consumption beyond the clinical duration of action of the target drug (preventive analgesia). Randomized trials examining the use of an NMDA antagonist in the perioperative period were sought by using a MEDLINE (1966-2003) and EMBASE (1985-2003) search. Reference sections of relevant articles were reviewed, and additional articles were obtained if they evaluated postoperative analgesia after the administration of NMDA antagonists. The primary outcome was a reduction in pain, analgesic consumption, or both in a time period beyond five half-lives of the drug under examination. Secondary outcomes included time to first analgesic request and adverse effects. Forty articles met the inclusion criteria (24 ketamine, 12 dextromethorphan, and 4 magnesium). The evidence in favor of preventive analgesia was strongest in the case of dextromethorphan and ketamine, with 67% and 58%, respectively, of studies demonstrating a reduction in pain, analgesic consumption, or both beyond the clinical duration of action of the drug concerned. None of the four studies examining magnesium demonstrated preventive analgesia. IMPLICATIONS We evaluated, in a qualitative systematic review, the effect of N-methyl D-aspartate antagonists on reducing postoperative pain and analgesic consumption beyond the clinical duration of action of the target drug (preventive analgesia). Dextromethorphan and ketamine were found to have significant immediate and preventive analgesic benefit in 67% and 58% of studies, respectively.
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Affiliation(s)
- Colin J L McCartney
- Department of Anesthesia and Pain Management, Toronto Western Hospital and University of Toronto, Ontario, Canada.
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18
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Wiech K, Kiefer RT, Töpfner S, Preissl H, Braun C, Unertl K, Flor H, Birbaumer N. A Placebo-Controlled Randomized Crossover Trial of the N-Methyl-d-Aspartic Acid Receptor Antagonist, Memantine, in Patients with Chronic Phantom Limb Pain. Anesth Analg 2004; 98:408-413. [PMID: 14742379 DOI: 10.1213/01.ane.0000096002.53818.bd] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED In the present study we investigated the effect of the N-methyl-D-aspartic acid (NMDA) receptor antagonist memantine (30 mg/d) on the intensity of chronic phantom limb pain (PLP) and cortical reorganization. In 8 patients with chronic PLP, memantine was tested in a placebo-controlled double-blinded crossover trial of 4 wk duration per trial. The intensity of PLP was rated hourly by the patients on a visual analog scale during baseline and both treatment periods. At the same time points, the functional organization of the primary somatosensory cortex (SI) was determined by neuromagnetic source imaging. In comparison to baseline and placebo, the NMDA receptor antagonist had no effect on the intensity of chronic PLP. In none of the periods were significant changes in the functional organization of SI observed. Although the conclusions regarding the clinical effect are limited because of the small sample size, the data indicate that in the studied dosage the NMDA receptor antagonist memantine is ineffective in the treatment of chronic PLP and is also ineffective for the reduction of associated neural plasticity in the primary SI. IMPLICATIONS NMDA receptors play a substantial role in central nervous system changes underlying neuropathic pain. In a placebo-controlled double-blinded study we tested the effect of 30 mg memantine on chronic phantom limb pain and pain-associated cortical reorganization.
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Affiliation(s)
- Katja Wiech
- *Institute of Medical Psychology and Behavioral Neurobiology and the †Department of Anesthesiology and Intensive Care Medicine, University of Tübingen, Tübingen, Germany, the ‡Department of Neuropsychology, University of Heidelberg, Central Institute of Mental Health, Mannheim, Germany, and the §Center for Cognitive Neuroscience, University of Trento, Trento, Italy
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19
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Abstract
BACKGROUND Many previous studies have suggested a role for the N-methyl-D-aspartate (NMDA) receptor antagonists ketamine and magnesium in decreasing postoperative pain and analgesic requirements in adults, but none has investigated these medications in children. METHODS This randomized, double-blind, placebo-controlled study evaluated the effects of ketamine and magnesium in children undergoing tonsillectomy. Eighty patients, aged 3-12 years, were randomly assigned to four groups. Patients received either ketamine 0.15 mg.kg-1, magnesium sulphate 30 mg.kg-1, ketamine 0.15 mg.kg-1 plus magnesium sulphate 30 mg.kg-1, or placebo intravenously 5 min prior to the start of surgery. Intraoperative analgesia was standardized, and included fentanyl and dexamethasone. RESULTS There were no differences among the groups with respect to pain assessment postoperatively. Compared with placebo, the treatment groups did not require less fentanyl in the postanaesthesia recovery room or consume less codeine in the first 24-h postoperatively. There was no evidence of synergism between ketamine and magnesium. There were no differences among the groups in the incidence of nausea, vomiting, sedation, bleeding, or dreaming postoperatively. CONCLUSION This study did not demonstrate a decrease in pain or analgesic consumption in children undergoing tonsillectomy when pretreated with a small dose of ketamine and/or magnesium.
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Affiliation(s)
- Jennifer E O'Flaherty
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA 22908-0710, USA.
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20
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Scientific surgery. Br J Surg 2002. [DOI: 10.1046/j.1365-2168.2000.01549.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Evidence from the last several decades indicates that the excitatory amino acid glutamate plays a significant role in nociceptive processing. Glutamate and glutamate receptors are located in areas of the brain, spinal cord and periphery that are involved in pain sensation and transmission. Glutamate acts at several types of receptors, including ionotropic (directly coupled to ion channels) and metabotropic (directly coupled to intracellular second messengers). Ionotropic receptors include those selectively activated by N-methyl-D-aspartate, alpha-amino-3-hydroxy-5-methylisoxazole-4-propionic acid and kainate. Metabotropic glutamate receptors are classified into 3 groups based on sequence homology, signal transduction mechanisms and receptor pharmacology. Glutamate also interacts with the opioid system, and intrathecal or systemic coadministration of glutamate receptor antagonists with opioids may enhance analgesia while reducing the development of opioid tolerance and dependence. The actions of glutamate in the brain seem to be more complex. Activation of glutamate receptors in some brain areas seems to be pronociceptive (e.g. thalamus, trigeminal nucleus), although activation of glutamate receptors in other brain areas seems to be antinociceptive (e.g. periaqueductal grey, ventrolateral medulla). Application of glutamate, or agonists selective for one of the several types of glutamate receptor, to the spinal cord or periphery induces nociceptive behaviours. Inhibition of glutamate release, or of glutamate receptors, in the spinal cord or periphery attenuates both acute and chronic pain in animal models. Similar benefits have been seen in studies involving humans (both patients and volunteers); however, results have been inconsistent. More research is needed to clearly define the role of existing treatment options and explore the possibilities for future drug development.
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Affiliation(s)
- M E Fundytus
- Department of Oncology, McGill University, Montreal, Quebec, Canada.
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Wong CS, Wu CT, Yu JC, Yeh CC, Lee MM, Tao PL. Preincisional dextromethorphan decreases postoperative pain and opioid requirement after modified radical mastectomy. Can J Anaesth 1999; 46:1122-6. [PMID: 10608204 DOI: 10.1007/bf03015519] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To examine whether preincisional dextromethorphan (DM) improved analgesia after modified radical mastectomy (MRM). METHODS Sixty patients (ASA I-II) scheduled for MRM were included and randomly allocated into two groups. Patients in the treatment group (DM) received 40 mg DM and 20 mg chlorpheniramine maleate (CPM) i.m., and those in the control group received 20 mg CPM i.m. alone 30 min before skin incision. Meperidine, 1 mg x kg(-1) i.m., was given for postoperative pain relief as required. The time to first meperidine injection, total meperidine consumption, worst pain score, bed-rest time, and side effects were recorded every 24 hr for 48 hr after surgery by a resident anesthesiologist on a double-blind basis. RESULTS A longer time to first meperidine injection (19.2 +/- 1.6 vs 1.5 +/- 0.23 hr, P < 0.001) and lower meperidine consumption (0[10] vs 75[50] mg, median [interquartile range], P < 0.001) were observed in the DM group than in the control group. The bed-rest time was shorter in the DM than in the control group (18.0[4] vs 23.0[19] hr, P < 0.001). No difference was noted in worst VAS pain score. Meperidine-related side effects (nausea, vomiting, pruritus, dizziness, headache) were more frequent in the control (10/30) than in the DM group (3/30, P < 0.05). The number of patients who required meperidine injection for pain relief was lower in the DM (7/30) than in the control group (25/30, P < 0.005). No DM- or CPM-associated side effects were observed. CONCLUSION Preincisional IM. DM treatment decreased postoperative pain and opioid requirement after MRM surgery.
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Affiliation(s)
- C S Wong
- Department of Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
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