Effect of pre-incision skin infiltration on post-hysterectomy pain--a double-blind randomized controlled trial

The analgesic efficacy of ultrasound-guided transversus abdominis plane block vs. local anesthetic infiltration technique in major gynecologic surgery: A randomized controlled trial

Background and Aim

Transversus abdominis plane (TAP) block and local anesthetic infiltration (LAI) technique are used as part of the multimodal analgesic regimen after abdominal surgery. Postoperative opioid consumption and analgesic efficacy was compared using TAP and LAI techniques in patients undergoing gynecologic surgery in a randomized, controlled clinical trial.

Material and Methods

Total of 135 patients scheduled for major gynecological surgeries were allocated into three groups: group T received bilateral TAP block with bupivacaine 0.25%; group I received LAI with 0.25% bupivacaine with epinephrine 5 μ/mL in the peritoneum and abdominal wall, and group C was control group. Anesthesia and postoperative analgesia were standardized. Outcome measures were cumulative and rescue tramadol consumption, numerical rating score (NRS) for pain and side effects in post-anesthesia care unit (PACU) at 4, 8, 12 hours postoperatively.

Results

Tramadol consumption, need for rescue analgesia, and NRS for pain between three groups at 4, 8, and 12 hours postoperatively had no statistically significant difference (P < 0.05). In PACU, median tramadol consumption used for rescue analgesia between group T (15 (15-30)) and group C (30 (15-45)) (P = 0.035), and between group T (15 (15-30)) and group I (30 (15-52)) was statistically significant (P = 0.034). In PACU, the percentage of patients having NRS >4 on movement in group C (72%) compared to group T (46.5%) and group I (46.5%) was significant (P = 0.034). No statistically significant difference was observed in the incidence of side effects among study groups (P > 0.05).

Conclusion

Except for the immediate postoperative period, neither TAP block nor LAI had added benefit to the multimodal analgesia regimen in patients undergoing gynecological surgeries.

Efficacy of acupuncture for pain relief in patients receiving extracorporeal shock wave lithotripsy: a meta-analysis of randomized controlled studies

Background

This meta-analysis aimed at investigating the efficacy of acupuncture for pain relief in patients receiving extracorporeal shock wave lithotripsy (ESWL).

Methods

Randomized controlled trials comparing the efficacy of acupuncture with conventional treatments were retrieved from major electronic databases (e.g., MEDLINE, EMBASE, and Cochrane Library) until August 28, 2022. The primary outcome was the response rate (i.e., rate of pain relief), while secondary outcomes included stone-free rate, satisfaction rate, duration of ESWL, peri-/post-procedural pain score, and risk of adverse events.

Results

Thirteen eligible studies involving 1,220 participants published between 1993 and 2022 were analyzed. Pooled results indicated that acupuncture had a better response rate compared to conventional treatments (RR = 1.17, 95% CI: 1.06-1.3, p = 0.003, seven trials, n = 832). Despite no difference in ESWL duration (MD = 0.02 min, 95% CI: -1.53 to 1.57, p = 0.98, three trials, n = 141), stone-free rate (RR = 1.11, 95% CI: 1-1.25, p = 0.06, six trials, n = 498), and satisfaction rate (RR = 1.51, 95% CI: 0.92-2.47, p = 0.1, three trials, n = 334) between the two groups, the acupuncture group had a lower risk of adverse events (RR = 0.51, 95% CI: 0.33-0.79, p = 0.003, five trials, n = 327), peri- (MD = -1.91 points, 94% CI: -3.53 to -0.28, p = 0.02, four trials, n = 258 patient) and post-procedural (MD = -1.07, 95% CI: -1.77 to -0.36, p = 0.003, four trials, n = 335) pain score.

Conclusion

The results of this meta-analysis showed that the use of acupuncture in patients receiving ESWL was associated with a higher pain relief rate and a lower risk of adverse events, suggesting feasibility of its use in this clinical setting.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42022356327.

Updates on Wound Infiltration Use for Postoperative Pain Management: A Narrative Review

Local anesthetic wound infiltration (WI) provides anesthesia for minor surgical procedures and improves postoperative analgesia as part of multimodal analgesia after general or regional anesthesia. Although pre-incisional block is preferable, in practice WI is usually done at the end of surgery. WI performed as a continuous modality reduces analgesics, prolongs the duration of analgesia, and enhances the patient’s mobilization in some cases. WI benefits are documented in open abdominal surgeries (Caesarean section, colorectal surgery, abdominal hysterectomy, herniorrhaphy), laparoscopic cholecystectomy, oncological breast surgeries, laminectomy, hallux valgus surgery, and radical prostatectomy. Surgical site infiltration requires knowledge of anatomy and the pain origin for a procedure, systematic extensive infiltration of local anesthetic in various tissue planes under direct visualization before wound closure or subcutaneously along the incision. Because the incidence of local anesthetic systemic toxicity is 11% after subcutaneous WI, appropriate local anesthetic dosing is crucial. The risk of wound infection is related to the infection incidence after each particular surgery. For WI to fully meet patient and physician expectations, mastery of the technique, patient education, appropriate local anesthetic dosing and management of the surgical wound with “aseptic, non-touch” technique are needed.

Effect of transcutaneous electrical nerve stimulation on quality of recovery and pain after abdominal hysterectomy

Background and Aims:

Transcutaneous electrical nerve stimulation (TENS) is a noninvasive complementary therapy for postoperative pain management. The effect of TENS on quality of recovery (QoR) and pain treatment in the early postoperative period is not well documented. The aim of this study was to evaluate the effect of TENS on postoperative QoR and pain in patients who had undergone a total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH + BSO).

Material and Methods:

Fifty-two patients were randomized into two groups: control (sham TENS treatment) and TENS (TENS treatment). QoR, dynamic pain, and static pain were evaluated after surgery.

Results:

The QoR score was significantly higher in the TENS group as compared with that in the control group (P = 0.029). Pain scores during coughing (dynamic pain) were significantly less in TENS group compared to control group (P <0.001). However, there was no between-group difference in pain scores at rest (static pain) or total analgesic consumption (P = 0.63 or P = 0.83, respectively).

Conclusion:

TENS may be a valuable tool to improve patients' QoR and dynamic pain scores after TAH + BSO.

The effectiveness of preemptive analgesia for relieving postoperative pain after video-assisted thoracoscopic surgery (VATS): a prospective, non-randomized controlled trial

Background

The effectiveness of preemptive analgesia (PA) for relieving postoperative pain and reducing the side effects of analgesics following video-assisted thoracoscopic surgery (VATS) has not yet been determined. This study intends to test the clinical application value of PA in the perioperative period of VATS.

Methods

From January 2018 to August 2018, we divided patients who underwent VATS in our hospital into a trial group (PA group) and a control group (traditional analgesia group, TA group). The PA group received a PA program, and the TA group was administered a conventional postoperative analgesia scheme. We compared the two groups according to the intensity of postoperative pain using the numeric rating scale (NRS), the incidence rate of analgesic drug-related adverse reactions, and the severity of stress-induced inflammation.

Results

One hundred five cases from the PA group, and 80 cases from the TA group were included in the analysis. There were no significant differences between the two groups in baseline characteristics (P>0.05). The PA group had a lower incidence rate of side effects from the analgesics compared to the TA group, and there was a statistical difference at 48 and 72 hours after surgery (P<0.05). The PA group had a slightly lower score than the TA group for postoperative resting pain. However, this difference was not statistically significant (P>0.05). The motion pain NRS score of the PA group was lower than the TA group, and although there were no significant differences at 4, 24, and 48 hours (P>0.05), there was a statistically significant difference at 72 hours (P<0.05). In the subset of patients with motion pain NRS ≥3 points, the PA group was marginally higher than the TA group at 4 hours (P>0.05) but was lower than the TA group at 24, 48, and 72 hours, with a statistically significant difference at 24 and 72 hours (P<0.05). There were no statistically significant differences in perioperative stress indexes between the two groups (P>0.05).

Conclusions

PA can relieve postoperative pain following VATS and reduce the incidence rate of analgesic drug-related adverse effects.

Opioid Use in the Postoperative Arena: Global Reduction in Opioids After Surgery Through Enhanced Recovery and Gynecologic Surgery

Enhanced recovery programs aim to reduce surgical stress to improve the patient perioperative experience. Through a combination of multimodal analgesia and maintaining a physiological state, postoperative recovery is improved. Many analgesic adjuncts are available that improve postoperative pain control and limit opioid analgesia requirements. Adjuncts are often used in combination, but different interventions may be incorporated for patient-specific and procedure-specific needs. Postoperative pain control can be optimized by continuing nonopioid adjuncts, and prescribing opioid analgesia to address breakthrough pain. Prescribing practices should balance optimizing pain relief, minimizing the risk of chronic pain, while limiting the potential for opioid misuse.

Regional analgesia modalities in abdominal and lower limb surgery - comparison of efficacy

A significant component of all surgical procedures and postoperative treatment is pain management.Due to the physiological and psychological advantages of pain relief, it is one of the foremost indicators of quality of care. Today, there are various modalities of pain reduction, aimed to reduce patient discomfort andminimize side effects, which can be divided by therapeutic agents used (opioid or non-opioid), route of administration (intravenous, regional, oral, etc.) and modality (controlled by patients or "as needed"). Although opioids have proven to be very effective pain relief agents and are commonly used in postoperative analgesia, concerns about their side effects have spurred the development of modified, multimodal treatments that seek to minimize opioid use and associated drawbacks. Enhanced recovery protocols that emphasize sparing administration of opioids are growing in importance, andresulting in reduced length of hospital stay after abdominal and lower limb surgery. To further improve such protocols and optimize postoperative care for individual patient needs, it is imperative to fully assess the efficacy of available drugs and analgesia modalities.

Preemptive analgesia for postoperative hysterectomy pain control: systematic review and clinical practice guidelines

OBJECTIVE

The objective of the study was to investigate the effectiveness of preemptive analgesia at pain control in women undergoing total abdominal hysterectomy.

DATA SOURCES

Eligible studies, published through May 31, 2016, were retrieved through Medline, Cochrane Central Register for Controlled Trials, and Cochrane Database of Systematic Reviews.

STUDY ELIGIBILITY

We included randomized controlled trials with the primary outcome of pain control in women receiving a preemptive medication prior to total abdominal hysterectomy. Comparators were placebo, different doses of the same medication as intervention, or other nonnarcotic or narcotic medication.

STUDY APPRAISAL AND SYNTHESIS METHODS

Study data were extracted by one reviewer and confirmed by a second reviewer. For each outcome we graded the quality of the evidence. Studies were classified by the type of medication used and by outcome type.

RESULTS

Eighty-four trials met eligibility, with 69 included. Among nonnarcotic medications, paracetamol, gabapentin, and rofecoxib combined with gabapentin resulted in improvements in pain assessment compared with placebo and other nonnarcotic medications. Patient satisfaction was higher in patients who were given gabapentin combined with paracetamol compared with gabapentin alone. Use of preemptive paracetamol, gabapentin, bupivacaine, and phenothiazine resulted in less narcotic usage than placebo. All narcotics (ketamine, morphine, fentanyl) resulted in improved pain control compared with placebo. Narcotics had a greater reduction in pain assessment scores compared with nonnarcotics, and their use resulted in lower total narcotic usage.

CONCLUSION

Preemptive nonnarcotic and narcotic medications prior to abdominal hysterectomy decrease total narcotic requirements and improve patient postoperative pain assessment and satisfaction scores.

Effect of low-dose (single-dose) magnesium sulfate on postoperative analgesia in hysterectomy patients receiving balanced general anesthesia

Background and Aim. Aparallel, randomized, double blinded, placebo-controlled trial study was designed to assess the efficacy of single low dose of intravenous magnesium sulfate on post-total abdominal hysterectomy (TAH) pain relief under balanced general anesthesia. Subject and Methods. Forty women undergoing TAH surgery were assigned to two magnesium sulfate (N = 20) and normal saline (N = 20) groups randomly. The magnesium group received magnesium sulfate 50 mg·kg⁻¹ in 100 mL of normal saline solution i.v as single-dose, just 15 minutes before induction of anesthesia whereas patients in control group received 100 mL of 0.9% sodium chloride solution at the same time. The same balanced general anesthesia was induced for two groups. Pethidine consumption was recorded over 24 hours precisely as postoperative analgesic. Pain score was evaluated with Numeric Rating Scale (NRS) at 0, 6, 12, and 24 hours after the surgeries. Results. Postoperative pain score was lower in magnesium group at 6, 12, and 24 hours after the operations significantly (P < 0.05). Pethidine requirement was significantly lower in magnesium group throughout 24 hours after the surgeries (P = 0.0001). Conclusion. Single dose of magnesium sulfate during balanced general anesthesia could be considered as effective and safe method to reduce postoperative pain and opioid consumption after TAH.

Postoperative pain control

The effective relief of pain is of the utmost importance to anyone treating patients undergoing surgery. Pain relief has significant physiological benefits; hence, monitoring of pain relief is increasingly becoming an important postoperative quality measure. The goal for postoperative pain management is to reduce or eliminate pain and discomfort with a minimum of side effects. Various agents (opioid vs. nonopioid), routes (oral, intravenous, neuraxial, regional) and modes (patient controlled vs. "as needed") for the treatment of postoperative pain exist. Although traditionally the mainstay of postoperative analgesia is opioid based, increasingly more evidence exists to support a multimodal approach with the intent to reduce opioid side effects (such as nausea and ileus) and improve pain scores. Enhanced recovery protocols to reduce length of stay in colorectal surgery are becoming more prevalent and include multimodal opioid sparing regimens as a critical component. Familiarity with the efficacy of available agents and routes of administration is important to tailor the postoperative regimen to the needs of the individual patient.

The pharmacokinetics and safety of an intraoperative bupivacaine-collagen implant (XaraColl(®)) for postoperative analgesia in women following total abdominal hysterectomy

Background

XaraColl^®, a collagen-based intraoperative implant that delivers bupivacaine to the site of surgical trauma, is under development for postoperative analgesia. We examined the pharmacokinetics, safety and efficacy of XaraColl following implantation in women undergoing total abdominal hysterectomy.

Methods

Three XaraColl implants, each containing 50 mg bupivacaine hydrochloride, were implanted in 12 women undergoing total abdominal hysterectomy for a benign condition. Serum samples were obtained through 96 hours for pharmacokinetic analysis. Patients received acetaminophen 1000 mg every 6 hours, diclofenac 50 mg every 8 hours, and were given access to intravenous morphine for breakthrough pain via patient-controlled analgesia during the first 24 hours. Pain intensity was assessed at regular intervals using a 100 mm visual analog scale. Safety was assessed through 30 days.

Results

The pharmacokinetic profile displayed a double peak in bupivacaine concentration with the second peak occurring up to 24 hours after the first and at a generally higher concentration. The time to maximum concentration (t_max) varied from 0.5 to 24 hours (median 12 hours) according to which peak predominated. The mean maximum concentration (C_max) was 0.22 μg/mL and the maximum individual C_max was 0.44 μg/mL, which are well below the established systemic toxicity threshold. Morphine use was generally low (mean 16.8 mg; median 6.5 mg) and compared favorably with institutional experience. At 6 hours post-surgery, 11 patients recorded pain scores ≤ 20 mm, 6 recorded ≤ 10 mm, and 2 reported no pain. Scores continued to decline throughout the study. The product was considered safe and well tolerated.

Conclusion

XaraColl exhibits a biphasic and sustained release profile that may provide a significant advance over standard wound infiltration. Considering the encouraging results from this study alongside those from other randomized controlled efficacy trials, XaraColl should be further evaluated as a postoperative analgesic in large, double-blind efficacy trials.

A randomized, multicenter, pilot study comparing the efficacy and safety of a bupivacaine-collagen implant (XaraColl(®)) with the ON-Q PainBuster(®) Post-op Pain Relief System following open gynecological surgery

Background

XaraColl^®, a collagen-based intraoperative implant that delivers bupivacaine to the site of surgical trauma, is under development for postoperative analgesia. We compared the efficacy and safety of XaraColl for the prevention of postsurgical pain versus a slow postoperative perfusion of bupivacaine to the wound environment via the ON-Q PainBuster^® Post-op Pain Relief System (ON-Q).

Methods

We randomized 27 women undergoing open gynecological surgery to receive either three XaraColl implants (each containing 50 mg bupivacaine hydrochloride) or ON-Q (900 mg bupivacaine hydrochloride perfused over 72 hours) in a 1:1 ratio. Following surgery, patients had access to intravenous morphine via a patient-controlled analgesia pump as rescue analgesia for the first 24 hours and to oral opioid medication thereafter. Total use of opioid analgesia was compared through 24, 48, 72, and 96 hours after surgery. Patients also evaluated overall pain control over the 96-hour period using a five-point numeric rating scale. Safety was assessed for 30 days after surgery.

Results

XaraColl was non-inferior to ON-Q in total use of opioid analgesia for the first 24, 48, 72, and 96 hours after surgery, with a statistical trend towards reduced opioid use in favor of XaraColl over 24, 48, and 72 hours (P = 0.067, 0.100, and 0.089, respectively). The time to first use of opioid analgesia was also significantly delayed in patients treated with XaraColl (P = 0.024). There was no significant difference between groups in patients’ evaluation of pain control or their satisfaction with the treatment in general. Both treatments were considered safe and well tolerated.

Conclusion

Despite using only 17% of the ON-Q dose, XaraColl is as effective as ON-Q in providing postoperative analgesia for 4 days after open gynecological surgery. These preliminary findings suggest that XaraColl offers great potential for the management of postoperative pain and warrants further definitive studies.

[Efficacy of a continuous infusion of local anesthetic into the surgical wound for pain relief after abdominal hysterectomy]

OBJECTIVE

To assess the quality of postoperative analgesia provided by intravenous administration of paracetamol and ketorolac plus morphine in bolus doses with or without continuous infusion of local anesthetic into the surgical wound after abdominal hysterectomy. Patient satisfaction was included among the outcomes assessed.

MATERIAL AND METHODS

Prospective pilot study in ASA 1-2 patients randomized to 2 groups: women in the subcutaneous catheter group received intravenous analgesics plus a continuous infusion (2 mL/h) of 0.25% bupivacaine whereas women in the control group received only the intravenous analgesics. The outcome measures were pain intensity assessed on a verbal numerical scale at rest and with movement, morphine requirements in the first 48 hours after surgery, and complications related to the drugs used or the technique.

RESULTS

Twenty-six patients were enrolled; 10 were randomized to the catheter group and 16 to the control group. Statistically significant between-group differences in pain both at rest and with movement were found while the women were in the postoperative recovery unit. Postoperative pain with movement was also significantly different at 24 hours (P<.004) and 48 hours (P<.02). Similarly, mean (SD) morphine requirements in the recovery unit were significantly greater in the control group, at 8 (2.27) mg, compared with 3.20 (1.79) mg in the catheter group (P<.002). Walking began earlier in the catheter group. No differences were found in the incidences of complications.

CONCLUSIONS

Postoperative pain is effectively relieved by continuous infusion of local anesthetic into the surgical wound after abdominal hysterectomy. This technique provides good analgesia with less morphine consumption and scarce adverse effects. Patient satisfaction and the sense of receiving quality pain management are high.

Influence of uterine exteriorization versus in situ repair on post-Cesarean maternal pain: a randomized trial

BACKGROUND

This study was done to compare post-cesarean delivery pain associated with routine exteriorization of the uterus versus in situ uterine repair in the puerperium.

METHODS

This prospective study included 206 women who underwent cesarean delivery under general anesthesia and who were randomly assigned to two groups based on the site of uterine repair: exteriorized uterine repair (102 women) versus in situ uterine repair (104 women). Exclusion criteria were neuraxial blockade and patient refusal to participate. Visceral and incisional pain was assessed on the first and second postoperative nights using a visual analog score of 0-100 mm.

RESULTS

There were no significant differences between the groups in maternal age, weight, gestational age, race, preoperative hemoglobin or gravidity. All subjects underwent general anesthesia and had a low transverse incision of the uterus. Exteriorization was associated with higher postoperative visceral pain scores: first night 66.7 vs. 43.5 (P<0.001); second night 44.6 vs. 23.9 (P<0.001). The incidence of postoperative fever and wound infection, postoperative hemoglobin and duration of hospital stay were similar between groups.

CONCLUSION

Exteriorization of the uterus for repair of the uterine incision increases the first- and second-night postoperative pain significantly in women undergoing cesarean section.

Preoperative analgesia with local lidocaine infiltration for abdominal hysterectomy pain management

OBJECTIVE

To evaluate the impact of preemptive local analgesia at the incision site in reducing pain in women undergoing abdominal hysterectomy for a benign myomatous uterus.

STUDY DESIGN

In this prospective, randomized, double-blinded, placebo-controlled study, 20 mL of 1% lidocaine or 0.9% saline was injected at the abdominal incision site prior to the performance of the hysterectomy. Thirty-two women were enrolled in the study, 16 received preemptive analgesia while 14 were treated by placebo; 2 were excluded. All operations were performed under general anesthesia. The standard postoperative pain treatment consisted of oral analgesia with ibuprofen (400 mg) in liquid-filled capsules. Morphine (10 mg) was used for rescue analgesia. Pain intensity was self-evaluated with the use of a 100 mm visual analog scale.

RESULTS

Compared to the placebo group, women who received preemptive analgesia with lidocaine 1% perceived a significant reduction in postoperative pain in the first hours after surgery (2 h: 50.1+/-27.9 versus 70.6+/-22.6, p=0.043; 5 h: 42.5+/-25.2 versus 64.6+/-28.3, p=0.043; 8 h: 31.2+/-22.4 versus 53.3+/-30.3, p=0.031).

CONCLUSION

Preemptive analgesia with lidocaine 1% is a simple, cheap and efficient mode to reduce pain in the first hours after hysterectomy.

Expression of granulocyte colony-stimulating factor is induced in injured rat carotid arteries and mediates vascular smooth muscle cell migration

Granulocyte colony-stimulating factor (G-CSF) is a lineage-restricted hematopoietic growth factor that stimulates proliferation and maturation of hematopoietic progenitors and is a known powerful mobilizer of bone marrow-derived stem cells. Very little has been reported on G-CSF expression and modulation of vascular smooth muscle cell (VSMC) activation. The purpose of this study was to characterize the expression and effects of G-CSF on primary human VSMC and balloon angioplasty-injured rat carotid arteries. In cultured human VSMC, G-CSF mRNA and protein expression are induced by several cytokines, with the most potent being fetal calf serum and T-lymphocyte-conditioned media. G-CSF is not expressed in naive rat carotid arteries but is induced in neointimal SMC in carotid arteries subject to balloon angioplasty. G-CSF is chemotactic for human VSMC. There is a significant difference between unstimulated cells and those treated with G-CSF at 100 and 1,000 pg/ml (P < 0.01 and 0.05 for 3 experiments). G-CSF also activates the GTPase Rac1, a regulator of cellular migration in VSMC. Inhibition of Rac1 inhibits G-CSF-driven VSMC migration. Important signal transduction protein kinases, including p44/42 MAPK, Akt, and S6 kinase, are also activated in response to G-CSF. This is the first report describing the expression of G-CSF in injured arteries and the multiple effects of G-CSF on VSMC activation. Together, our data suggest that G-CSF is an important mediator of inflammatory cell-VSMC communication and VSMC autocrine activation and may be an important mediator of the VSMC response to injury.

Efficacy of preemptive analgesia for wound pain after laparoscopic operations in infertile women: a randomised, double-blind and placebo control study

OBJECTIVE

To compare preemptive analgesia and preclosure analgesia in reducing wound pain after laparoscopic operation.

DESIGN

Randomised, double-blind and placebo control.

SETTING

University referral centre.

POPULATION

Infertile women undergoing diagnostic laparoscopy with or without additional procedures.

METHODS

One hundred and forty-four women were randomised to receive 10 mL of 1% lignocaine at the surgical sites before incision and 10 mL of normal saline before closure of incision (the preemptive group), saline before incision and lignocaine before closure of incision (the preclosure group) and saline at the surgical sites both before incision and closure of incision (the placebo group).

MAIN OUTCOME MEASURES

Post-operative wound pain measured by linear visual analogue scale and amount of analgesic use.

RESULTS

The women in the preclosure group had significantly lower pain scores at 2, 4 and 24 hours than those in the placebo group, whereas the women in the preemptive group only showed significantly lower pain scores at 2 hours than the placebo group. The pain score at 24 hours in the preclosure group was significantly lower than that in the preemptive group. There was no significant difference in the post-operative analgesic requirement among the three groups.

CONCLUSION

The preclosure analgesia is better than preemptive analgesia and no analgesia in reducing post-operative wound pain.

Analgesic efficacy of continuous delivery of bupivacaine by an elastomeric balloon infusor after abdominal hysterectomy: a prospective randomised controlled trial

OBJECTIVE

To investigate the analgesic efficacy and morphine-sparing effect of continuous bupivacaine wound infiltration after abdominal hysterectomy.

DESIGN

Prospective, randomised controlled trial.

SAMPLE

Fifty-two female ASA I or II patients were enrolled with 26 patients in each of the study and control groups.

METHODS

The study group received 0.5% bupivacaine infusion into the incisional (Pfannenstiel) wound via an elastomeric infusor at 2 mL/hr for 48 hours postoperatively plus morphine via a patient controlled analgesia (PCA) pump. The control group had only PCA morphine.

RESULTS

There were no significant differences in the visual analogue scores (VAS) for pain nor PCA morphine usage for 48 hours postoperatively

CONCLUSION

That continuous infusion of the incisional wound with 0.5% bupivacaine did not confer additional analgesia over PCA morphine after abdominal hysterectomy

The analgesic effects of intraperitoneal and incisional bupivacaine with epinephrine after total abdominal hysterectomy

The objective of our study was to see if incisional and intraperitoneal bupivacaine with epinephrine produces analgesia after total abdominal hysterectomy. Forty-six ASA physical status I and II patients received a standardized anesthetic, patient-controlled analgesia (PCA) morphine, and rectal paracetamol 1 g every 6 h. Patients were randomized to receive 50 mL of bupivacaine 0.25% with epinephrine 5 microg/mL or 50 mL of normal saline. Thirty milliliters and 20 mL of treatment solution were administered into the peritoneum and incision, respectively, before wound closure. Seventeen and 16 patients in the Placebo and Bupivacaine groups, respectively, completed the study. The reasons for withdrawal were PCA malfunction, PCA discontinued too early, nausea, chest infection, intraabdominal drain insertion, and protocol violation. There were no significant differences between the Bupivacaine and Placebo groups in age, height, weight, or duration of surgery. Pain on movement was significantly more intense in the Placebo group than in the Bupivacaine group on awakening. Morphine consumption (interquartile range) over 24 h was 62 mg (53-85 mg) in the Placebo group compared with 44 mg (33-56 mg) in the Bupivacaine group (P < 0.01). This significant difference was attributable to the larger morphine consumption in the Placebo group in the first 4 postoperative h. We conclude that a combination of intraperitoneal and incisional bupivacaine with epinephrine provides significant morphine-sparing analgesia for 4 h after total abdominal hysterectomy.

IMPLICATIONS

A combination of intraperitoneal and incisional bupivacaine with epinephrine may be recommended because it provides significant morphine-sparing analgesia for 4 h after total abdominal hysterectomy.

A randomized trial of postoperative wound irrigation with local anesthetic for pain after cesarean delivery

OBJECTIVE

The purpose of this study was to investigate the efficacy of continuous local anesthetic infusion system for pain control after cesarean delivery.

STUDY DESIGN

This was a randomized prospective double-blind study. Patients who underwent cesarean delivery had a pain system implanted subcutaneously after closure of the fascia. Patients were randomized to receive an infusion of either 0.25% bupivacaine (n = 20) or normal saline solution (n = 16) into the wound for 48 hours. Postoperative pain (determined with a visual analog scale) and postoperative morphine use were assessed at 12, 24, and 48 hours.

RESULTS

There were no significant differences in patient demographics or visual analog pain scores at any time interval between the bupivacaine versus the placebo group. However, narcotic requirements to produce this amount of pain relief were significantly less in patients who received bupivacaine infusion rather than normal saline solution at all time intervals.

CONCLUSION

The continuous local anesthetic infusion system appears to be effective in reducing postoperative morphine use after cesarean delivery.

Pre-emptive analgesia: an unsolved problem

Preemptive analgesia studies have provided mixed results, some showing benefit and others no benefit, whereas others have shown small differences that are probably not clinically useful. There is no consensus yet about whether preemptive analgesia is a clinically useful tool. This review examines the mechanisms of preemptive analgesia before surveying the recent literature. A new definition of preemptive analgesia is proposed that accommodates the need for a broader definition. Recently published trials confirm that confusion exists about what preemptive analgesia is, how to distinguish it from simple analgesia, and how to design trials that truly assess preemptive analgesia, defined as analgesia that is capable of modifying the central excitatory responses.