Dose-response study with indoprofen i.v. as an analgesic in postoperative pain

Management of Pain in the Critically Ill

Analgesia for critically ill patients can be provided most effectively by the use of modern techniques. Under standing of the anatomical pathways for nociceptive sig nal transmission allows the use of techniques that mod ulate or block nociceptive information at several levels (periphery, spinal cord, and systemic). A comprehen sive discussion of analgesic techniques at each level is presented. Formulation of a treatment plan is discussed. Several examples are presented to show the decision- making process for the use of modern analgesic tech niques in critically ill patients.

Characteristics and prediction of early pain after laparoscopic cholecystectomy

Small-scale studies have suggested a large inter-individual variation in early postoperative pain after laparoscopic cholecystectomy, emphasizing the need for improved analgesic treatment and valid predictors. We investigated prospectively the association between a preoperative nociceptive stimulus by ice water (cold pressor test), neuroticism, dyspepsia, patient history of biliary symptoms, intraoperative factors, and demographic information in 150 consecutive patients undergoing uncomplicated laparoscopic cholecystectomy for their influence on early postoperative pain. During the first postoperative week patients registered overall pain, incisional, visceral, and shoulder pain on a visual analogue scale and verbal rating scale, and daily analgesic requirements were noted. Throughout the first postoperative week overall pain showed a pronounced inter-individual variability. Incisional pain dominated in incidence and intensity compared with visceral pain, which in turn dominated over shoulder pain. In a multivariate analysis model, preoperative neuroticism, sensitivity to cold pressor-induced pain, and age were identified as independent risk factors for early postoperative pain. Our results suggest that future analgesic studies after laparoscopic cholecystectomy should focus on reduction of incisional pain.

Nonsteroidal anti-inflammatory drugs and bone metabolism in spinal fusion surgery: a pharmacological quandary

The use of nonsteroidal anti-inflammatory drugs (NSAIDs) is ubiquitous in contemporary medical practice and these agents are efficacious in a number of clinical contexts. In particular, NSAIDs have proven to be highly effective adjuncts in the amelioration of postoperative pain in the subset of patients undergoing spinal surgery requiring fusion. NSAIDs act through inhibition of cyclooxygenase enzymes and therefore diminish prostaglandin production. However, prostaglandins are intimately involved in the modulation of bone metabolism and the balance of data, from both clinical and laboratory contexts, indicate that prostaglandins preferentially favor bone anabolism. Most recently, limited emerging evidence suggests that NSAID administration in patients undergoing spinal fusion surgery may increase nonunion rates, which in turn, has important ramifications to the patient, their family and the entire medical system. Hence, disparate views have evolved regarding the use of NSAIDs in postoperative pain control in patients undergoing spinal surgery requiring fusion. NSAIDs have proven efficacy in the management of postoperative pain in these patients, however, this must be weighed against the risk of nonunion and its associated consequences. In this review, the role of prostaglandins in bone metabolism, the pharmacology of NSAIDs and the modulation of bone metabolism by NSAIDs are discussed. Additionally, the current evidence examining the use of NSAIDs in spinal surgery is presented. As rates of spinal surgery continue to rise, it is imperative that the apparent pharmacological quandary surrounding the administration of NSAIDs in patients undergoing spinal surgery requiring fusion be addressed, both to guide present clinical practice and to outline further directions for investigation.

A comparison of rectal indomethacin with placebo for pain relief following spinal surgery

Rectal indomethacin was compared with placebo in a randomised, double-blind study of 100 patients undergoing spinal surgery, in which postoperative pain scores, pethidine, diazepam and metoclopramide consumption, bleeding time, blood loss and oral fluid and food tolerance were measured. Side-effects of indomethacin and pethidine were compared in the two groups. In the indomethacin group, pain scores were significantly less for all measurements made during the first three postoperative days, pethidine and diazepam consumption were significantly less on all three days, bleeding time was significantly increased, although still within the clinically normal range, intraoperative and postoperative blood losses were not significantly affected, coagulation was not significantly impaired as assessed clinically, patients tolerated oral feeding significantly earlier, there was no significant increase in the incidence of gastro-intestinal side-effects except for diarrhoea, and there was no significant reduction in the incidence of side-effects associated with the use of pethidine.

A study of the analgesic potency of indoprofen and pentazocine in postoperative pain

The relative potency of intravenous indoprofen and intramuscular pentazocine in postoperative pain was evaluated. Indoprofen was administered in 200- and 400-mg single doses and pentazocine was given in 15- and 30-mg doses. Pain was assessed at different time intervals, and additional medication consumption was recorded, as well as side effects and overall evaluations. An analysis of peak pain intensity difference (PID) has shown a significant dose-effect relationship for both drugs and a potency ratio of 1:7 between indoprofen and pentazocine (mg to mg). Based on the frequency of patients requiring remedication and those reporting total pain relief in at least one instance, the potency ratio of indoprofen:pentazocine was 1:13 and 1:10, respectively. The mean peak PID of the pooled data for both doses of each drug was significantly greater for indoprofen. Intravenous indoprofen 400 mg was ranked the most effective overall.

A controlled study on the effect of epidural analgesia with local anaesthetics and morphine on morbidity after abdominal surgery

A hundred patients scheduled for elective abdominal surgery were randomized to either general anaesthesia (low-dose fentanyl) and systemic morphine for postoperative pain or combined general anaesthesia and epidural analgesia with etidocaine 1.5% intraoperatively (T4-S5) and bupivacaine 0.5% 5 ml/4 h for 24 h and morphine 4 mg/12 h for 72 h. Postoperative pain was better controlled by the epidural regimen (P less than 0.0001). We found no significant reduction in postoperative mortality (6% to 2%), pneumonia (28% to 20%), cardiac dysrhythmia (10% to 5%) and wound complications (14% to 11%) by the epidural analgesic regimen. The incidence of deep venous thrombosis (125I-fibrinogen scan) was 32% after general anaesthesia and low-dose heparin and 34% after epidural analgesia with no prophylactic antithrombotic treatment (P greater than 0.9). Postoperative weight loss and decrease in serum-albumin and serum-transferrin, as well as the reduction in haemoglobin and the need for postoperative transfusions, were similar in the two groups. Convalescence, as assessed by postoperative fatigue, restoration of bowel function (flatus, bowel movement and food intake) and the time until the patients were self-aided at their preoperative level, was not reduced by epidural analgesia. Since 50% of the patients in each group suffered from one or more of the above-mentioned postoperative complications, this epidural regimen was not effective in reducing postoperative morbidity after major abdominal surgery despite the achievement of adequate pain relief.

Administration of ketoprofen suppositories for out-patient post-operative analgesia

A double-blind, randomized, placebo-controlled study was carried out to assess the efficacy of ketoprofen suppositories as a post-operative analgesic in out-patients undergoing extirpation surgery. Thirty patients received 2 X 100 mg ketoprofen suppositories, and 30 patients received placebo suppositories 1-hour pre-operatively. Patients received no premedication and the anaesthetic used was intravenous diazepam and ketamine administered by intravenous drip according to the patient's need. Subjective symptoms of pain were evaluated 15, 30, 60 and 90 minutes post-operatively. None of the patients who received ketoprofen complained of post-operative pain, whereas the patients on placebo showed varying degrees of pain. The only side-effects recorded were nausea and vomiting both in ketoprofen and placebo-treated patients and these were probably related to the anaesthetic.

Indoprofen and pentazocine in post-traumatic pain. A double-blind, parallel-group comparative trial

In a double-blind, randomized, parallel-group study involving sixty patients with severe pain due to fractures, the analgesic activity of indoprofen and pentazocine was evaluated. Each patient received one of the following treatments in random order: indoprofen 400 mg i.v., pentazocine 30 mg i.v., placebo. The analgesic effect was measured by rating the intensity of pain before treatment and after 1/2, 1, 2, 4 and 6 hours. Patients' final opinions on efficacy were assessed on the basis of categoric and visual analogue scales. Highly significant differences were found between the active drugs and placebo for all variables analyzed. Indoprofen was significantly superior to pentazocine when assessed through variables measuring total analgesic effects. Since both drugs were well tolerated, i.v. indoprofen appears to offer an effective and safe alternative to narcotic analgesics in acute pain due to fractures.