The Effect of Adding Lidocaine to Patient Controlled Analgesia with Morphine on Pain Intensity after Caesarean Section with Spinal Anesthesia: A Double-Blind, Randomized, Clinical Trial

The Assessment of Marcaine Versus Meperidine for Spinal Anesthesia in Anorectal Surgery: A Randomized Clinical Trial

Background

Spinal anesthesia (SA) for the surgical management of chronic anal fissures is favored by surgeons as it provides an early return to daily activities; however, the agents applied for SA to achieve the best outcomes with minimized adverse effects are a matter of debate.

Objectives

This study aimed to assess the utility of Marcaine versus meperidine for SA induction of anoderm surgery.

Methods

This randomized clinical trial (RCT) was conducted on 138 patients with chronic anal fissures who were candidates for surgical management in 2020. The patients were randomly assigned to two groups of SA using 2.5 mL of hyperbaric Marcaine 0.5% (n = 69) or 1 mg/kg of meperidine (n = 69). Pain severity (measured via Numerical Rating Scale (NRS)), anal sphincter tone manometry (measured at baseline and the end of the sphincterotomy), and drug-related adverse effects were compared between the groups.

Results

Both agents led to significant pain relief within 24 hours after SA (P < 0.05); nevertheless, pain severity was remarkably lower in meperidine-treated patients in different measurements performed during the first 24 hours after SA (P < 0.05). The sphincteric tone significantly decreased in both groups (P < 0.001), while the postoperative tone was significantly less in the Marcaine-treated patients (65.22 ± 3.02 versus 46.04 ± 1.97, P < 0.001). The two groups did not differ regarding the adverse effects (P > 0.05).

Conclusions

Meperidine for SA in anal fissure surgical management was relatively superior to Marcaine, as postoperative pain control was remarkably better achieved with meperidine. However, anal sphincter tone reached a normal range in Marcaine-treated cases, and the average tone in those anesthetized with meperidine was slightly above the normal limits.

Post-cesarean section analgesia

Worldwide, the most performed surgical intervention is cesarean section. Hence, post-cesarean pain is a common problem with significant health and economic impact on the individual patient and society. Adequate treatment of post-cesarean pain is necessary to facilitate enhanced recovery, improve neonatal outcome by improving breastfeeding success and bonding between mother and child, and reduce pain-induced side effects. Therefore, optimal pain relief is important, but in the obstetric population, this is often complex due to the interplay of mother and neonate. To facilitate recovery and temper the side effects of potent analgesic drugs such as opioids, multimodal analgesia is currently advocated, and clear international guidelines and recommendations have recently been described. In the present overview, we will discuss the most recent guidelines and evaluate various analgesic interventions.

Comparison of an ephedrine infusion with lidocaine %5 for prevention of hypotension during spinal anesthesia in cesarean section

Background

Spinal anesthesia is the method of choice for cesarean section and in most cases causes hypotension.

Objective

The aim of this study was to treat hypotension by ephedrine in order to prevent maternal and fetal complications, and also to determine the effective amount of ephedrine for reducing arterial hypertension in order to prevent its complications, including cardiac arrhythmias.

Method

This cross-sectional descriptive study was conducted on 131 patients. Mean arterial blood pressure (MAP) of the candidates for cesarean section in the supine position was measured and recorded as mean baseline blood pressure. 75 mg of lidocaine (5%) was used as spinal anesthesia, following which the average blood pressure was measured every 1 min. In the event of a decrease in the mean arterial blood pressure of at least 20% of the mean baseline blood pressure, ephedrine 0.1/mg/kg was injected intravenously and after 1 min of MAP was measured.

Result

The prevalence of hypotension was 89.30%. 25.60% of patients with hypotension had 30–34.99% reduction in MAP compared to baseline MAP. 12% patients had 40% drop in their MAP. 4 min following spinal anesthesia, the incidence of hypotension reduced by 20%. The average dose of ephedrine required to reduce the incidence of hypotension was 20.5 mg.

Conclusion

Reduction in MAP following spinal anesthesia using lidocaine is common. Ephedrine at the dose of 20 mg is effective to reduce the incidence of perioperative hypotension.

•

Spinal anesthesia is the method of choice for cesarean section and in most cases causes hypotension.

•

Arterial blood pressure drop after spinal anesthesia is very common in cesarean section.

•

With lidocaine 5% and in most cases ephedrine is approximately 20 mg treated during the operation.

Endogenous opiates and behavior: 2019

This paper is the forty-second consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2019 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

PROSPECT guideline for elective caesarean section: updated systematic review and procedure-specific postoperative pain management recommendations

Caesarean section is associated with moderate‐to‐severe postoperative pain, which can influence postoperative recovery and patient satisfaction as well as breastfeeding success and mother‐child bonding. The aim of this systematic review was to update the available literature and develop recommendations for optimal pain management after elective caesarean section under neuraxial anaesthesia. A systematic review utilising procedure‐specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language between 1 May 2014 and 22 October 2020 evaluating the effects of analgesic, anaesthetic and surgical interventions were retrieved from MEDLINE, Embase and Cochrane databases. Studies evaluating pain management for emergency or unplanned operative deliveries or caesarean section performed under general anaesthesia were excluded. A total of 145 studies met the inclusion criteria. For patients undergoing elective caesarean section performed under neuraxial anaesthesia, recommendations include intrathecal morphine 50–100 µg or diamorphine 300 µg administered pre‐operatively; paracetamol; non‐steroidal anti‐inflammatory drugs; and intravenous dexamethasone administered after delivery. If intrathecal opioid was not administered, single‐injection local anaesthetic wound infiltration; continuous wound local anaesthetic infusion; and/or fascial plane blocks such as transversus abdominis plane or quadratus lumborum blocks are recommended. The postoperative regimen should include regular paracetamol and non‐steroidal anti‐inflammatory drugs with opioids used for rescue. The surgical technique should include a Joel‐Cohen incision; non‐closure of the peritoneum; and abdominal binders. Transcutaneous electrical nerve stimulation could be used as analgesic adjunct. Some of the interventions, although effective, carry risks, and consequentially were omitted from the recommendations. Some interventions were not recommended due to insufficient, inconsistent or lack of evidence. Of note, these recommendations may not be applicable to unplanned deliveries or caesarean section performed under general anaesthesia.

Neonatal effect of remifentanil in cesarean section with general anesthesia: A protocol of systematic review and meta-analysis

BACKGROUND

Although several previous studies have reported the efficacy of remifentanil in cesarean section (CS) under general anesthesia, no study has specifically addressed its neonatal effect (NE) in CS under general anesthesia systematically. Thus, this study will systematically investigate the NE of remifentanil in CS under general anesthesia.

METHODS

Electronic databases including MEDLINE, EMBASE, Cochrane Library, Web of Science, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure will be systematically retrieved with the assistance of a specialist librarian to check randomized controlled trials reporting NE in CS under general anesthesia. We will retrieve all electronic databases from their initial time to March 20, 2020 without restrictions of language. All process of study selection, data extraction, and risk of bias evaluation will be carried out by 2 independent authors. We will invite another senior expert to solve the problems that arise between 2 authors. Data will be pooled and analyzed using RevMan V.5.3 software.

RESULTS

Outcomes consist of assessment of neonatal adaptation, requirements for postoperative respiratory support of neonates, systolic and diastolic noninvasive blood pressure, mean blood pressure, heart rate, electrocardiography, umbilical cord blood gas analysis, and adverse events.

CONCLUSION

This study will present evidence of the NE of remifentanil in CS under general anesthesia. This information may inform benefits of intervention to guide the usage of remifentanil in CS under general anesthesia.

STUDY REGISTRATION

INPLASY202040028.

The Effect of Adding Low-Dose Naloxone to Intrathecal Morphine on Postoperative Pain and Morphine Related Side Effects after Cesarean Section: A Double-Blind, Randomized, Clinical Trial

BACKGROUND:

Nowadays, spinal anaesthesia is a suitable choice for most elective and emergency cesarean section (C-section) deliveries.

AIM:

This study aimed to determine the effect of adding low-dose naloxone to intrathecal morphine on postoperative pain and morphine related side effects after C-section.

MATERIAL AND METHODS:

In the present double-blind, randomised clinical trial, 70 women aged over 18 years, who were candidates for elective medical C-section under spinal anaesthesia were selected and randomly assigned to either the study group or the control group. For spinal anaesthesia, 10 mg of Bupivacaine plus 100 μg of morphine was administered for all patients. However, patients in the study group received 20 µg of naloxone intrathecally; but the patients in the control group only received normal saline as a placebo. After surgery, patient-controlled analgesia (PCA) pump with paracetamol (Apotel®) was connected to each patient. The intensity of postoperative pain in the patients was evaluated and recorded using Visual Acuity Screening (VAS) at 2, 4, 6 and 24 hours after the surgery. The patients were also examined for postoperative nausea and pruritus.

RESULTS:

Regardless of the groups to which the patients were assigned, a significant difference in pain intensity was observed during the study period (time effect; p < 0.001). Although the intensity of pain was lower in the study group, the difference was not statistically significant (group effect; p = 0.84). Also, there was no group time interaction between pain intensity and the times studied (p = 0.61). The incidence rates of postoperative nausea and pruritus were significantly lower in the study group compared to the control group (p < 0.001).

CONCLUSION:

According to the results of this study, adding low dose naloxone to intrathecal morphine did not significantly change postoperative pain intensity in the patients undergone elective C-section using spinal anaesthesia; however, significantly decreased the severity of postoperative nausea and pruritus.