Analgesic Efficacy and Adverse Effects of Meperidine in Managing Postoperative or Labor Pain: A Narrative Review of Randomized Controlled Trials

BACKGROUND

Meperidine, a synthetic opioid, has a rapid onset and short duration of action. Mounting evidence has challenged meperidine's analgesic benefits, and concerns have been raised about its safety profile. Despite recommendations to restrict the prescription of meperidine, the drug remains frequently used.

OBJECTIVES

The aim of this study was to evaluate the evidence regarding the efficacy and safety of meperidine for acute postoperative and labor pain.

STUDY DESIGN

This was a narrative review of the analgesic efficacy and side effects of meperidine compared to other analgesic drugs for acute postoperative and labor pain in adults.

SETTING

Randomized controlled trials that compared the analgesic efficacy and side effect profile of meperidine versus another analgesic drug in adult patients were evaluated.

METHODS

A systemized search of randomized controlled trials studying meperidine for acute postoperative or labor pain in the adult patient population from PubMed, Medline, and EMBASE was performed. Included studies reported on different routes of meperidine administration including intramuscular, intravenous, and patient-controlled analgesia in various surgical procedures such as abdominal surgery, Cesarean section, gynecological surgery, orthopedic surgery, cardiothoracic surgery, as well as for labor analgesia. Meperidine's analgesic efficacy and safety profile were compared to other opioids (morphine, tramadol, fentanyl, buprenorphine, nalbuphine, and pentazocine), nonsteroidal anti-inflammatory drugs (ketorolac, diclofenac, and indomethacin), dipyrone, ketamine, and bupivacaine.

RESULTS

A total of 62 randomized controlled trials published between 1972 and 2018 were reviewed. Meperidine had a similar or inferior analgesic efficacy compared to other analgesics for acute postoperative or labor pain. Meperidine was associated with more sedation and respiratory depression.

LIMITATIONS

The sample sizes of many clinical studies were small, and therefore probably insufficiently powered to detect differences in uncommon side effects, such as central nervous system toxicity. In addition, some of the included clinical studies were old.

CONCLUSION

Considering the availability of other effective analgesics with potentially fewer side effects, the use of meperidine for acute postoperative or labor pain should not be recommended.

KEY WORDS

Acute postoperative pain, adverse effects, labor analgesia, meperidine, pethidine.

Creation of a score to predict risk of high conscious sedation requirements in patients undergoing endoscopy

BACKGROUND AND AIMS

The administration of intravenous conscious sedation to patients undergoing GI endoscopy carries a risk of cardiopulmonary adverse events. Our study aim was to create a score that stratifies the risk of occurrence of either high-dose conscious sedation requirements or a failed procedure.

METHODS

Patients receiving endoscopy via endoscopist-directed conscious sedation were included. The primary outcome was occurrence of sedation failure, which was defined as one of the following: (1) high-dose sedation, (2) the need for benzodiazepine/narcotic reversal agents, (3) nurse-documented poor patient tolerance to the procedure, or (4) aborted procedure. High-dose sedation was defined as >10 mg of midazolam and/or >200 μg of fentanyl or the meperidine equivalent. Patients with sedation failure (n = 488) were matched to controls (n = 976) without a sedation failure by endoscopist and endoscopy date.

RESULTS

Significant associations with sedation failure were identified for age, sex, nonclonazepam benzodiazepine use, opioid use, and procedure type (EGD, colonoscopy, or both). Based on these 5 variables, we created the high conscious sedation requirements (HCSR) score, which predicted the risk of sedation failure with an area under the curve of 0.70. Compared with the patients with a risk score of 0, risk of a sedation failure was highest for patients with a score ≥3.5 (odds ratio, 17.31; P = 2 × 10^-14). Estimated area under the curve of the HCSR score was 0.68 (95% confidence interval, 0.63-0.72) in a validation series of 250 cases and 250 controls.

CONCLUSIONS

The HCSR risk score, based on 5 key patient and procedure characteristics, can function as a useful tool for physicians when discussing sedation options with patients before endoscopy.

Qualitative exploration of women's experiences of intramuscular pethidine or remifentanil patient-controlled analgesia for labour pain

OBJECTIVES

To explore women's experiences of remifentanil or pethidine for labour pain and infant feeding behaviours at 6weeks post partum.

DESIGN

Qualitative postnatal sub-study to the randomised controlled trial of remifentanil intravenous patient controlled analgesia (PCA) versus intramuscular pethidine for pain relief in labour (RESPITE). Semistructured telephone interviews were conducted at 6 weeks post partum, and thematic analysis was undertaken.

SETTING

Women recruited to the RESPITE trial from seven UK hospitals.

PARTICIPANTS

Eighty women consented and 49 (30 remifentanil group and 19 pethidine group) completed the interview.

RESULTS

Eight themes emerged which encompassed women's antenatal plans for pain management (Birth Expectations) through to their future preferences for pain relief (Reflections for Future Choices). Many women who used remifentanil felt it provided effective pain relief (Effectiveness of Pain Relief), whereas women in the pethidine group expressed more mixed views. Both groups described side effects, with women using pethidine frequently reporting nausea (Negative Physiological Responses) and women using remifentanil describing more cognitive effects (Cognitive Effects). Some women who used remifentanil reported restricted movements due to technical aspects of drug administration and fear of analgesia running out (Issues with Drug Administration). Women described how remifentanil enabled them to maintain their ability to stay focused during the birth (Enabling a Sense of Control). There was little difference in reported breastfeeding initiation and continuation between pethidine and remifentanil groups (Impact on Infant Behaviour and Breastfeeding).

CONCLUSIONS

Qualitative insights from a follow-up study to a trial which explored experiences of intravenous remifentanil PCA with intramuscular pethidine injection found that remifentanil appeared to provide effective pain relief while allowing women to remain alert and focused during labour, although as with pethidine, some side effects were noted. Overall, there was little difference in reported breastfeeding initiation and duration between the two groups.

TRIAL REGISTRATION NUMBER

ISRCTN29654603.

Pethidine in Low Doses versus Dipyrone for Pain Relief in Labor: A Randomized Controlled Trial

OBJECTIVE

 To compare low doses of pethidine with dipyrone in labor analgesia.

METHODS

 In a randomized prospective study conducted by Universidade de Fortaleza, in the state of Ceará, Brazil, between May and December 2016, 200 full-term parturients, with very painful uterine contractions and exhibiting uterine cervix dilatation ≥ 5 cm, were selected to receive a single intravenous dose of either 0.25 mg/kg of pethidine (n = 100) or of 25 mg/kg of dipyrone (n = 100). Pain was assessed using the visual analogue scale. The data were analyzed using the Student t-test, the chi-square test and the likelihood ratio.

RESULTS

 There was a significant improvement in pain in 35% of the parturients. Both drugs presented a similar analgesic effect 1 hour after the intervention (p = 0.692). There was no analgesic effect during the evaluation of the second hour after the intervention with pethidine or dipyrone. There were no adverse effects, such as maternal drowsiness, nausea or vomiting, related to the drugs used.

CONCLUSION

 Pethidine in low doses and dipyrone presented equivalent analgesia during labor.

PUBLIC REGISTRY OF CLINICAL TRIALS

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Sedation of children undergoing dental treatment

BACKGROUND

Children's fear about dental treatment may lead to behaviour management problems for the dentist, which can be a barrier to the successful dental treatment of children. Sedation can be used to relieve anxiety and manage behaviour in children undergoing dental treatment. There is a need to determine from published research which agents, dosages and regimens are effective. This is the second update of the Cochrane Review first published in 2005 and previously updated in 2012.

OBJECTIVES

To evaluate the efficacy and relative efficacy of conscious sedation agents and dosages for behaviour management in paediatric dentistry.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 22 February 2018); the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 1) in the Cochrane Library (searched 22 February 2018); MEDLINE Ovid (1946 to 22 February 2018); and Embase Ovid (1980 to 22 February 2018). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Studies were selected if they met the following criteria: randomised controlled trials of conscious sedation comparing two or more drugs/techniques/placebo undertaken by the dentist or one of the dental team in children up to 16 years of age. We excluded cross-over trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted, in duplicate, information regarding methods, participants, interventions, outcome measures and results. Where information in trial reports was unclear or incomplete authors of trials were contacted. Trials were assessed for risk of bias. Cochrane statistical guidelines were followed.

MAIN RESULTS

We included 50 studies with a total of 3704 participants. Forty studies (81%) were at high risk of bias, nine (18%) were at unclear risk of bias, with just one assessed as at low risk of bias. There were 34 different sedatives used with or without inhalational nitrous oxide. Dosages, mode of administration and time of administration varied widely. Studies were grouped into placebo-controlled, dosage and head-to-head comparisons. Meta-analysis of the available data for the primary outcome (behaviour) was possible for studies investigating oral midazolam versus placebo only. There is moderate-certainty evidence from six small clinically heterogeneous studies at high or unclear risk of bias, that the use of oral midazolam in doses between 0.25 mg/kg to 1 mg/kg is associated with more co-operative behaviour compared to placebo; standardized mean difference (SMD) favoured midazolam (SMD 1.96, 95% confidence interval (CI) 1.59 to 2.33, P < 0.0001, I2 = 90%; 6 studies; 202 participants). It was not possible to draw conclusions regarding the secondary outcomes due to inconsistent or inadequate reporting or both.

AUTHORS' CONCLUSIONS

There is some moderate-certainty evidence that oral midazolam is an effective sedative agent for children undergoing dental treatment. There is a need for further well-designed and well-reported clinical trials to evaluate other potential sedation agents. Further recommendations for future research are described and it is suggested that future trials evaluate experimental regimens in comparison with oral midazolam or inhaled nitrous oxide.

A Retrospective Study of Dosing Weight and Outcomes for One Pediatric Dental Sedation Regimen

Purpose: The purpose of this study was to assess the use of a dosing scalar for association with the success of procedural sedation in pediatric dentistry. Methods: This cross-sectional, retrospective study assessed healthy two- to 12-year-olds who received an elixir of midazolam (0.3 mg/kg), meperidine (1.5 mg/kg), and hydroxyzine (1.0 mg/kg). The scaled body weight (SBW) for each patient was determined using the 50th percentile weight-for-age from the 2000 Centers for Disease Control and Prevention (CDC) growth chart. Children under the 50th percentile were dosed at their actual weight. Children weighing over the 50th percentile received a dose that was reduced to the 50th percentile weight-for-age. Statistical analysis evaluated sedation success, measured by the Houpt scale. Lean body weight (LBW) and ideal body weight (IBW) were calculated to compare SBW with other available dosing scalars. Results: The sample consisted of 427 children. The success was 73.8 percent. There was no significant difference in sedation success by dose delivered. The calculated LBW and IBW were significantly greater than the SBW (P<.001, P<.001). Conclusions: Sedation success was not affected by use of a scalar that reduced dosing weight to the 2000 CDC growth chart's 50th percentile weight-for-age.

Intravenous remifentanil patient-controlled analgesia versus intramuscular pethidine for pain relief in labour (RESPITE): an open-label, multicentre, randomised controlled trial

BACKGROUND

About a third of women receiving pethidine for labour pain subsequently require an epidural, which provides effective pain relief but increases the risk of instrumental vaginal delivery. Remifentanil patient-controlled analgesia (PCA) in labour is an alternative to pethidine, but is not widely used. We aimed to evaluate epidural analgesia progression among women using remifentanil PCA compared with pethidine.

METHODS

We did an open-label, multicentre, randomised controlled trial in 14 UK maternity units. We included women aged 16 years or older, beyond 37 weeks' gestation, in labour with a singleton cephalic presentation, and who requested opioid pain relief. We randomly assigned eligible participants (1:1) to either the intravenous remifentanil PCA group (40 μg bolus on demand with a 2 min lockout) or the intramuscular pethidine group (100 mg every 4 h, up to 400 mg in 24 h), using a web-based or telephone randomisation service with a minimisation algorithm for parity, maternal age, ethnicity, and mode of labour onset. Because of the differences in routes of drug administration, study participants and health-care providers were not masked to the group allocation. The primary outcome was the proportion of women who received epidural analgesia after enrolment for pain relief in labour. Primary analyses were unadjusted and analysed by the intention-to-treat principle. This study is registered with the ISRCTN registry, number ISRCTN29654603.

FINDINGS

Between May 13, 2014, and Sept 2, 2016, 201 women were randomly assigned to the remifentanil PCA group and 200 to the pethidine group. One participant in the pethidine group withdrew consent, leaving 199 for analyses. The proportions of epidural conversion were 19% (39 of 201) in the remifentanil PCA group and 41% (81 of 199) in the pethidine group (risk ratio 0·48, 95% CI 0·34-0·66; p<0·0001). There were no serious adverse events or drug reactions directly attributable to either analgesic during the study.

INTERPRETATION

Intravenous remifentanil PCA halved the proportion of epidural conversions compared with intramuscular pethidine. This finding challenges routine pethidine use as standard of care in labour.

FUNDING

National Institute for Health Research Clinician Scientist Award.

Parenteral opioids for maternal pain management in labour

BACKGROUND

Parenteral opioids (intramuscular and intravenous drugs including patient-controlled analgesia) are used for pain relief in labour in many countries throughout the world. This review is an update of a review first published in 2010.

OBJECTIVES

To assess the effectiveness, safety and acceptability to women of different types, doses and modes of administration of parenteral opioid analgesia in labour. A second objective is to assess the effects of opioids in labour on the baby in terms of safety, condition at birth and early feeding.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (11 May 2017) and reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials examining the use of intramuscular or intravenous opioids (including patient-controlled analgesia) for women in labour. Cluster-randomised trials were also eligible for inclusion, although none were identified. We did not include quasi-randomised trials. We looked at studies comparing an opioid with another opioid, placebo, no treatment, other non-pharmacological interventions (transcutaneous electrical nerve stimulation (TENS)) or inhaled analgesia.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of each evidence synthesis using the GRADE approach.

MAIN RESULTS

We included 70 studies that compared an opioid with placebo or no treatment, another opioid administered intramuscularly or intravenously or compared with TENS applied to the back. Sixty-one studies involving more than 8000 women contributed data to the review and these studies reported on 34 different comparisons; for many comparisons and outcomes only one study contributed data. All of the studies were conducted in hospital settings, on healthy women with uncomplicated pregnancies at 37 to 42 weeks' gestation. We excluded studies focusing on women with pre-eclampsia or pre-existing conditions or with a compromised fetus. Overall, the evidence was graded as low- or very low-quality regarding the analgesic effect of opioids and satisfaction with analgesia; evidence was downgraded because of study design limitations, and many of the studies were underpowered to detect differences between groups and so effect estimates were imprecise. Due to the large number of different comparisons, it was not possible to present GRADE findings for every comparison.For the comparison of intramuscular pethidine (50 mg/100 mg) versus placebo, no clear differences were found in maternal satisfaction with analgesia measured during labour (number of women satisfied or very satisfied after 30 minutes: 50 women; 1 trial; risk ratio (RR) 7.00, 95% confidence interval (CI) 0.38 to 128.87, very low-quality evidence), or number of women requesting an epidural (50 women; 1 trial; RR 0.50, 95% CI 0.14 to 1.78; very low-quality evidence). Pain scores (reduction in visual analogue scale (VAS) score of at least 40 mm: 50 women; 1 trial; RR 25, 95% CI 1.56 to 400, low-quality evidence) and pain measured in labour (women reporting pain relief to be "good" or "fair" within one hour of administration: 116 women; 1 trial; RR 1.75, 95% CI 1.24 to 2.47, low-quality evidence) were both reduced in the pethidine group, and fewer women requested any additional analgesia (50 women; 1 trial; RR 0.71, 95% CI 0.54 to 0.94, low-quality evidence).There was limited information on adverse effects and harm to women and babies. There were few results that clearly showed that one opioid was more effective than another. Overall, findings indicated that parenteral opioids provided some pain relief and moderate satisfaction with analgesia in labour. Opioid drugs were associated with maternal nausea, vomiting and drowsiness, although different opioid drugs were associated with different adverse effects. There was no clear evidence of adverse effects of opioids on the newborn. We did not have sufficient evidence to assess which opioid drug provided the best pain relief with the least adverse effects.

AUTHORS' CONCLUSIONS

Though most evidence is of low- or very-low quality, for healthy women with an uncomplicated pregnancy who are giving birth at 37 to 42 weeks, parenteral opioids appear to provide some relief from pain in labour but are associated with drowsiness, nausea, and vomiting in the woman. Effects on the newborn are unclear. Maternal satisfaction with opioid analgesia was largely unreported. The review needs to be examined alongside related Cochrane reviews. More research is needed to determine which analgesic intervention is most effective, and provides greatest satisfaction to women with acceptable adverse effects for mothers and their newborn.

Pharmacokinetics of meperidine (pethidine) in rabbit oral fluid: correlation with plasma concentrations after controlled administration

Oral fluid assays for quantifying drugs are useful in forensic toxicology and drug monitoring. Compared with blood and urine specimens, oral fluid collection is simple, non-invasive, and more difficult to adulterate. Therefore, we investigated whether meperidine and its metabolites could be detected in oral fluid and whether there was a predictable relationship between oral fluid and plasma concentrations. Male New Zealand white rabbits (n = 10) were administered meperidine hydrochloride (20 mg/kg, intravenous). Then, plasma and oral fluid were collected at various time points up to 10 h after administration. We developed a simple and sensitive gas chromatography-mass spectrometry method for the determination of meperidine and normeperidine in oral fluid and plasma. We estimated the apparent pharmacokinetic parameters for meperidine in oral fluid and plasma and determined the ratio and correlation between oral fluid and plasma concentrations. The results demonstrate that this method has excellent specificity, linearity, precision, and recovery. Meperidine and normeperidine were detected in both body fluids; meperidine was the most abundant analyte in oral fluid. The oral fluid-to-plasma drug concentration ratios did not differ significantly over time (p > 0.05). In addition, oral fluid and plasma levels of meperidine and normeperidine were significantly correlated over time (r = 0.713 and 0.725, respectively; p < 0.05). These results provide context for interpreting meperidine and metabolite concentrations in oral fluid and support the utility of oral fluid as an alternative matrix in clinical and forensic testing.

Opioid Consumption in Hospitals of the Friuli-Venezia Giulia Region: A Four-Year Retrospective Study

Aims and background

Opioid consumption for analgesic purposes is considered an important indicator of the quality of cancer pain treatment. Italy's consumption ranks among the lowest in economically developed countries. A lack of systematic education of health care professionals regarding pain control and a sort of “opiophobia” induced by measures designed to control the improper use of drugs have been indicated as possible reasons for this trend. The aim of this study was firstly to evaluate the level of opioid consumption at inpatient institutions (where opioid prescription rules have never been subjected to any restriction) and secondly to survey the attitude of the physicians working in general hospitals and specialized oncology institutions (oncology centers and hospices) towards opioid administration.

Methods

The authors performed a four-year survey (1996–1999) on the consumption of major opioids (morphine, meperidine, buprenorphine, transdermal fentanyl) among all the inpatient institutions (six regional/provincial hospitals, eleven district hospitals, the Aviano Oncology Institute and two hospices) of the Friuli-Venezia Giulia region in North-Eastern Italy. To facilitate data interpretation, all the opioids were converted to milligrams equivalent of oral morphine (mg OME). Data on the number of days of hospitalization of oncological patients in every institution were also collected.

Results

The overall consumption of opioids was 9,299,177 mg OME (83.3%) and 1,845,060 mg OME (16.7%) in general hospitals and specialized oncology institutions, respectively. Overall, the number of days of hospitalization of oncological patients was 1,121,142 (87%) and 167,665 (13%) in general hospitals and specialized oncology institutions, respectively. The ratio between the total dosage of mg OME administered and the total number of hospitalization days in general hospitals and specialized oncology institutions was 8.29 mg OME/day and 11 mg OME/day, respectively.

Conclusions

Our data show that in specialized oncology institutions, opioid consumption was proportionally higher than in general hospitals. This result indicates the attitude of the physicians of these institutions towards opioid administration, probably due to the training received on cancer pain treatment, and emphasizes the need to educate all health care workers involved in the management of cancer patients.

[Safety of gastroenterologist-directed propofol administration for endoscopic procedures: 10-year experience in a private clinic in Lima, Peru]

OBJECTIVE

To evaluate safety of propofol combined with Meperidine and Midazolam in colonoscopies, upper endoscopies (EGD) and Endoscopic Ultrasound (EUS) administered by a nurse supervised by a trained gastroenterologist. To compare the required doses of propofol among older and younger than 75 years old.

MATERIALS AND METHODS

Retrospective descriptive study including patients 18 years of age and older who received propofol for EGD, colonoscopy (or EGD + colonoscopy) and EUS. The patients were given a baseline dose of Meperidine (25 mg) and Midazolam (1-3 mg) intravenously (IV). After 2-3 minutes, they received an IV bolus of propofol between 10-30 mg. Repeat boluses of 10-20 mg were administered at intervals no lesser than 60 seconds during the procedure, as needed according to patient`s tolerance to the procedure.

RESULTS

Between September 2006 and September 2016, 9,704 procedures were performed, of which 1,598 were EGD, 3,065 colonoscopies, 2,492 EGD + colonoscopies and 57 EUS. There were 3,912 women (59.1%), and the average age was 57.1 ± 14.6 years. Eight hundred eighty (12.5%) were older than 75 years. The average dose of propofol for all the procedures was 83.2 ± 48.1 mg, for EGD and colonoscopy was 59.7 ± 36.2 mg and 77.2 ± 41 mg respectively. The average dose used in patients >75 years for EGD was 47.5 ± 37.8 mg, for colonoscopies 58.3 ± 33.4 mg and for EGD + colonoscopies was 78.7 ± 42.7 mg compared to patients <75 years in whom the average dose for EGD was 61.1 ± 35.8 mg (p<0.05), in colonoscopies was 80.5 ± 41.3 mg (p<0.05) and in EGD + colonoscopies 105.9 ± 50.2 mg (p<0.05). There were no sedation-related complications.

CONCLUSIONS

Propofol combined with meperidine and midazolam in endoscopic procedures directed by a trained gastroenterologist is safe. Elderly patients (>75 years old) required significantly less doses of propofol for EGD, colonoscopy, EGD/colonoscopy and EUS.

Comparison of efficacy of meperidine and fentanyl in terms of pain management and quality of life in patients with cervical cancer receiving intracavitary brachytherapy: a double-blind, randomized controlled trial

OBJECTIVE

The aim of this study was to compare the effectiveness of two sedative regimens, a benzodiazepine with either meperidine or fentanyl, in relieving pain in patients with cervical cancer undergoing intracavitary brachytherapy in terms of pain score and quality of life.

METHODS

Forty unselected outpatients undergoing brachytherapy (160 fractions) were enrolled with informed consent and randomized to receive a benzodiazepine with either meperidine or fentanyl. The perceived pain score according to a standard 10-item numeric rating scale was collected every 15 min during the procedure, and the perceived quality of life was determined at the end of each procedure using the EuroQol five-dimension questionnaire. The patients and medical staff members directly involved with the procedure were blinded to the medication used.

RESULTS

The patients' pain levels were mild in both analgesic groups. Meperidine appeared to be slightly more effective than fentanyl, although the differences in the average pain score and quality of life were not statistically significant.

CONCLUSION

Both meperidine and fentanyl in combination with benzodiazepine were effective in relieving pain and discomfort in patients undergoing brachytherapy.

TRIAL REGISTRATION

NCT02684942, ClinicalTrials.gov.

[Comparision for clinical efficiency of continuous adductor canal block and femoral nerve block in total knee arthroplasty]

OBJECTIVE

To compare the pain control efficiency of continuous adductor canal block (ACB) and femoral nerve block (FNB) in total knee arthroplasty.

METHODS

From April to September 2016, patients with severe knee osteoarthritis undergoing primary unilateral total knee arthroplasty (TKA) were prospectively observed, and all the patients were randomized received ultrasound-guided continuous ACB or FNB after surgery. Numeric pain rating scales(NPRS)pain scores in rest and activity 2, 6, 12, 24 and 48 h after surgery were collected, and the preoperative and postoperative quadriceps strength at 24 and 48 h were analyzed. Opioids consumption and anesthesia related adverse effects were also recorded.

RESULTS

In the study, 40 patients were enrolled, with 20 patients in each group, male:female=7:33, the age: (63.8±10.1) years, and the body mass index (BMI): (28.5±3.5) kg/m(2).The general conditions were comparable between the two groups. Though the rest pain 2 h after surgery [ACB=0.0(0,6), FNB=3.0(0,5), P=0.004] and activity pain 12 h post operation [ACB=3.0(3,0), FNB=5.5(0,10), P=0.004] were lower in ACB group compared with FNB group, there was no statistical difference in the other pain checking points between the two groups. The quadriceps strength 24 h and 48 h after surgery were(85.3±27.6) N and (80.0±30.1) N in ACB group, (69.0±29.4) N and (64.4±32.0) N in FNB group, both of them were declined by time. The exact data were higher in ACB group, however, there was no statistical difference between the two group by repeated measurements variance analysis(F=2.703, P=0.108).Four patients in ACB group and five in FNB acquired additional use of dolantin once (100 mg/per time) within 24 h. And among them, three patients acquired once dolantin in ACB, two in FNB, from 24 to 48 h postoperation. There were five patients who suffered nausea postoperation in ACB group, and one who reported xerostomia. Four patients in FNB had nausea with vomiting, and three experienced xerostomia. Deep vein thrombosis appeared in 2 patients in FNB group, but no one in ACB group.

CONCLUSION

Continuous ACB is not superior in pain control after TKA compared with FNB, and the quadriceps strength could be reserved more by this method, which performed early benefits in fast rehabilitation.

Preoperative anxiety may increase postcesarean delivery pain and analgesic consumption

BACKGROUND

The aim of this study was to reveal the relationship between high level of prenatal anxiety and postoperative pain and/or analgesic consumption in women undergoing elective cesarean delivery under spinal anesthesia.

METHODS

Eighty women, aged between 18-45 years with minimum 37 week- gestation and received spinal anesthesia during elective cesarean delivery, were included into this observational cohort study. Prenatal anxiety was measured with state anxiety inventory, trait anxiety inventory and somatosensory amplification scale. Visual Analogue Scale (VAS) was used to quantify postoperative pain. Amount of analgesic consumed was recorded at 6th, 12th and 18th postoperative hours.

RESULTS

State Anxiety Score was above the threshold level (>45) in 18 women (22.5%). No difference was found between women with and without high state anxiety scores except for significantly higher BMI values in high-score group (P=0.07). In multivariate analysis, high BMI at pregnancy (OR: 1.2, 95% CI; 1.0-1.5, P=0.02) and high State Anxiety Score (OR: 1.1, 95% CI; 1.0-1.2, P=0.01) emerged as independent predictors of higher mean pain scores (VAS >4 cm) within 18 hours after cesarean delivery. Also, high State Anxiety Score was found to be independently associated with higher pethidine consumption after cesarean delivery (OR: 1.1, 95% CI; 1.0-1.2, P=0.006).

CONCLUSIONS

State anxiety has a negative effect on postcesarean pain whereas trait anxiety does not seem to produce such effect. The effect seems to be more profound in overweight women. Detection of anxiety level before elective cesarean delivery and therapeutic approach to pregnant women may be useful for postoperative pain control.

Effect of Analgesia Administration Timing on Early Post-operative Period Characteristics: A Randomized, Double-blind, Controlled Study

This study investigated the effect of time of analgesia administration in 64 patients undergoing total abdominal hysterectomy. Patients received standard general anaesthesia and were divided randomly into two equal groups. At the time of fascia closure, patients in the intra-operative (Iop) group received 0.5 mg/kg pethidine intravenously. On arrival in the post-anaesthesia care unit, the same dose of pethidine was given to patients in the post-operative (Pop) group. All patients then used a patient-controlled analgesia pump to administer pethidine analgesia as required. Times to extubation, response to verbal stimulation and orientation, post-operative pain scores and analgesic consumption were recorded. Times to extubation and response to verbal stimulation were significantly longer in the Iop group. Pain scores, analgesic consumption and additional analgesic requirements were significantly higher in the Pop group in the first 2 h post-operatively. In conclusion, intra-operative administration of pethidine provided better pain management than post-operative administration.

Pain Relief for Children after Adenotonsillectomy

Effective pain relief following adenotonsillectomy in children remains a challenge. This study evaluated the effects of intramuscular 0.5 mg/kg ketamine, 1 mg/kg tramadol or 1 mg/kg meperidine on post-operative pain and recovery in 45 children aged 1-7 years undergoing adenotonsillectomy. Anaesthesia was induced with thiopental or sevoflurane (with succinylcholine for intubation) and was maintained with sevoflurane in oxygen and nitrous oxide. Post-operative pain was scored blind using a modified Toddler–Preschooler Post-Operative Pain Scale 30, 60, 120 and 240 min after tracheal extubation. Post-operative agitation scores were also recorded. Mean post-operative pain score was significantly higher in the tramadol-treated group compared with the meperidine-treated group 120 min after extubation. At all other time-points after extubation, mean post-operative pain scores were similar for the three treatment groups. Ketamine was associated with a significantly higher mean agitation score compared with tramadol and meperidine. We conclude that the effects of ketamine, meperidine and tramadol on post-operative pain following adenotonsillectomy in children were similar.

A comparison of prophylactic use of meperidine, meperidine plus dexamethasone, and ketamine plus midazolam for preventing of shivering during spinal anesthesia: a randomized, double-blind, placebo-controlled study

STUDY OBJECTIVES

The aim of this study is to compare the efficacy of combination of meperidine and dexamethasone with that of placebo, meperidine alone, and the combination of ketamine and midazolam in preventing shivering during spinal anesthesia.

DESIGN

This is a prospective, placebo-controlled study.

SETTING

The setting is at an operating room of a university-based teaching hospital.

PATIENTS

Two hundred American Society of Anesthesiologists I and II patients undergoing orthopedic and urologic surgery under spinal anesthesia were included.

INTERVENTIONS

Subarachnoid anesthesia was performed by using 15mg of 0.5% hyperbaric bupivacaine. Patients were randomly allocated to receive saline (placebo, group C), meperidine 0.4mg/kg (group Me), ketamine 0.25mg/kg plus midazolam 37.5μg/kg (group KMi), and meperidine 0.2mg/kg plus dexamethasone 0.1mg/kg (group MeD). All drugs were given as an intravenous bolus immediately after intrathecal injection.

MEASUREMENTS

During surgery and stay in the recovery room, shivering score, blood pressure, and some other adverse effects were recorded at 5-minute intervals. Axillary and tympanic temperatures were recorded at 15-minute intervals during the perioperative period.

MAIN RESULTS

The incidence of shivering after 30minutes of spinal anesthesia in groups C, Me, KMi, and MeD was 64%, 20%, 20%, and 4%, respectively, which was significantly higher in group C compared with other groups (P<.0001). Regarding adverse effects, there was no significant difference between groups (P≥.2). Axillary temperature significantly increased in the 15th-120th-minute interval in groups Me, KMi, and MeD (P<.0001) and in group MeD was higher than that in other groups. Core temperature decreased in the 15th-120th-minute interval in group MeD, lower than that in other groups (P<.0001).

CONCLUSIONS

Prophylactic use of meperidine 0.2mg/kg plus dexamethasone 0.1mg/kg was more effective than meperidine 0.4mg/kg as a sole agent or the combination of ketamine 0.25mg/kg and midazolam 37.5μg/kg in preventing shivering resulting from spinal anesthesia.

Safety and Efficacy of Dexmedetomidine in Treating Post Spinal Anesthesia Shivering: A Randomized Clinically Controlled Dose-Finding Trial

BACKGROUND

The optimum dose of dexmedetomidine for shivering control with the least hemodynamic derangements is still under research.

OBJECTIVE

To compare the efficacy, hemodynamic and side effects of dexmedetomidine in 3 different doses with those of meperidine for the treatment of shivering in patients undergoing spinal anesthesia for minor elective lower abdominal surgery.

STUDY DESIGN

Prospective double-blind randomized clinically controlled study.

SETTING

University hospital.

METHODS

One hundred twenty patients who developed shivering under spinal anesthesia.On shivering, patients were randomly allocated to receive an intravenous 2 mL bolus dose of meperidine 0.4 mg/kg (meperidine group, n = 30), dexmedetomidine 0.5 µg/kg (DEX I group, n = 30), 0.3 µg/kg (DEX II group, n = 30), or 0.2µg/kg (DEX III group, n = 30). Control of shivering, time taken for cessation of shivering, response rate, recurrence, hemodynamic changes, sedation score, tympanic temperature, and side effects were noted and compared between groups.

RESULTS

The groups were comparable regarding demographic profile, tympanic temperature decline, and shivering onset time (P > 0.05). Lower shivering cessation time (P < 0.001) and higher response rate (P < 0.01) were observed in DEX I and II groups compared with DEX III and meperidine groups, with a nonsignificant difference between DEX I and II groups. Recurrence of shivering activity was higher in DEX III group (36.7%, P < 0.01) compared with DEX I (10%), DEX II (6.7%) and meperidine (16.7%) groups. Lower heart rates, systolic and diastolic blood pressure mean values were recorded in DEX I group (P < 0.05). Nine patients (30%) in DEX I group were in levels 3 - 5 of sedation (P < 0.02) compared with 5 (16.66%), 2 (6.66%), and 4 (13.3) patients in DEX II, DEX III, and meperidine groups, respectively.

LIMITATIONS

This study is limited by its small sample size.

CONCLUSIONS

Among the 3 doses investigated, dexmedetomidine 0.3µg/kg effectively treated shivering associated with spinal anesthesia with modest hemodynamic and sedation effects.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02382432.

KEY WORDS

Dexmedetomidine, hypothermia, shivering, spinal anesthesia.

[Calcinosis cutis treatment with extracorporeal shockwave therapy]

Calcinosis cutis is a rare disease entity characterized by deposits of calcium in the skin and subcutaneous tissue causing hard-to-heal ulcers. This is a case report on a patient with femoral ulcers in connection with densely mineralized skin caused by ketobemidon injections. Next to surgical excision of calcified tissue the patient received extracorporeal shockwave therapy (ESWT). On the basis of excellent healing, partial skin transplant was feasible. We advocate for randomized trials on ESWT as an adjunctive therapy for complex non-healing wounds.

Oral Sedation Postdischarge Adverse Events in Pediatric Dental Patients

The study investigated patient discharge parameters and postdischarge adverse events after discharge among children who received oral conscious sedation for dental treatment. This prospective study involved 51 patients needing dental treatment under oral conscious sedation. Each patient received one of various regimens involving combinations of a narcotic (ie, morphine or meperidine), a sedative-hypnotic (ie, chloral hydrate), a benzodiazepine (ie, midazolam or diazepam), and/or an antihistamine (ie, hydroxyzine HCl). Nitrous oxide and local anesthesia were used in conjunction with all regimens. After written informed consent was obtained, each guardian was contacted by phone with specific questions in regard to adverse events following the dental appointment. Out of 51 sedation visits, 46 were utilized for analysis including 23 boys and 23 girls ranging from 2 years 2 months to 10 years old (mean 5.8 years). 60.1% of patients slept in the car on the way home, while 21.4% of that group was difficult to awaken upon reaching home. At home, 76.1% of patients slept; furthermore, 85.7% of patients who napped following the dental visit slept longer than usual. After the appointment, 19.6% exhibited nausea, 10.1% vomited, and 7.0% experienced a fever. A return to normal behavior was reported as follows: 17.4% in <2 hours, 39.1% in 2-6 hours, 28.3% in 6-10 hours, and 15.2% in >10 hours. Postdischarge excessive somnolence, nausea, and emesis were frequent complications. The time to normality ranged until the following morning demonstrating the importance of careful postdischarge adult supervision.

The safety and acceptability of intravenous fentanyl versus intramuscular pethidine for pain relief during labour

OBJECTIVES

This trial aimed to ascertain the relative efficacy, adverse effects, and acceptability of fentanyl versus pethidine for pain relief during labour.

MATERIALS AND METHODS

Parturients (n=80) in the active phase who requested analgesia were randomly assigned to receive either intravenous fentanyl (n=40) or intramuscular pethidine (n=40). Pain scores hourly, maternal and fetal adverse effects, neonatal outcome, and maternal acceptability were assessed.

RESULTS

Pain scores decreased in both groups, the decrease varying from mild to moderate, average pain scores remaining above 3.5 in both groups. Pain scores returned towards baseline over time; three hours after the initiation of treatment in the fentanyl group. Pethidine was associated with more maternal nausea and vomiting (p < 0.05) while fentanyl was associated with more neonates with low Apgar scores at one minute and more need for neonatal resuscitation and naloxone administration when compared to pethidine (p < 0.05). Both drugs were acceptable for pain relief during labour.

CONCLUSION

Fentanyl is comparable to pethidine for pain relief during labour regarding efficacy and acceptability, but with more neonates with low Apgar scores at one minute and higher need for neonatal resuscitation and naloxone administration. Further larger trials are needed to confirm its safety.

Comparison of the postoperative analgesic effects of naproxen sodium and naproxen sodium-codeine phosphate for arthroscopic meniscus surgery

BACKGROUND AND OBJECTIVES

Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used to control arthroscopic pain. Addition of oral effective opioid "codeine" to NSAIDs may be more effective and decrease parenteral opioid consumption in the postoperative period. The aim of this study was to compare the efficacy and side effects of naproxen sodium and a new preparation naproxen sodium-codeine phosphate when administered preemptively for arthroscopic meniscectomy.

METHODS

Sixty-one patients were randomized into two groups to receive either oral naproxen sodium (Group N) or naproxen sodium-codeine phosphate (Group NC) before surgery. The surgery was carried out under general anesthesia. Intravenous meperidine was initiated by patient-controlled analgesia (PCA) for all patients. The primary outcome measure was pain score at the first postoperative hour assessed by the Visual Analogue Scale (VAS). Sedation assessed by Ramsey Sedation Scale, first demand time of PCA, postoperative meperidine consumption, side effects and hemodynamic data were also recorded.

RESULTS

The groups were demographically comparable. Median VAS scores both at rest and on movement were significantly lower in Group NC compared with Group N, except 18(th) hour on movement (p<0.05). The median time to the first demand of PCA was shorter in Group N compared with Group NC (p<0.001). Meperidine consumption was higher in Group N compared with Group NC (p<0.001). There was no difference between groups with respect to side effects (p>0.05).

CONCLUSIONS

The combination of naproxen sodium-codeine phosphate provided more effective analgesia than naproxen sodium and did not increase side effects.

Postdischarge events occurring after pediatric sedation for dentistry

PURPOSE

To investigate postdischarge events occurring in children during the 24 hours following sedation for dentistry.

METHODS

A convenience sample of 50 children undergoing sedation with combinations of midazolam, hydroxyzine, and meperidine were included. Parents received a standardized timesheet to record child's behavior, alertness, activity level, motor imbalance, emesis, and soft tissue trauma every two hours from discharge until bedtime. A questionnaire asked about transportation, supervision, and return to normal activity. Families were telephoned after 24 hours to collect the information.

RESULTS

Sixty-six percent of children slept in the car; of these, 30 percent were supervised by only the driver, and 12 percent were difficult to awaken. Agitation was observed in 22 percent, restlessness in 10 percent, withdrawn behavior in 16 percent, and soft tissue trauma in 18 percent. Motor imbalance was significantly associated with midazolam (P=.002), as was restlessness (P=.004). Eighty-two percent slept between discharge and bedtime, with 16 percent sleeping for greater than four hours. Return to normal activity was greater than four hours in 36 percent, and was inversely correlated with age (P=.02).

CONCLUSIONS

Postdischarge sleepiness, drug-specific motor imbalance, sleep during transit, and recovery times greater than four hours were common and warrant vigilant adult supervision.

Chronopharmacodynamics and chronopharmacokinetics of pethidine in mice

BACKGROUND

Many studies have demonstrated that the pharmacokinetics and pharmacodynamics of analgesic drugs vary according to the circadian time of drug administration. This study aims at determining whether the analgesic effect and pharmacokinetics of pethidine in male BALB/c mice are influenced by administration time.

METHODS

A hot-plate test was used to evaluate the analgesic effect after pethidine (20 mg/kg) or saline injection at different dosing times. Mouse blood samples were collected at different intervals after dosing at 9:00 am and 9:00 pm, and were determined via liquid chromatography-tandem mass spectrometry (LC-MS/MS).

RESULTS

A significant 24-h rhythm was observed in the latency to thermal response at 30 min after dosing, with the peak during the dark phase and the nadir during the light phase. Tolerance to analgesic effect was produced after chronic pethidine injection at 9:00 am or 9:00 pm, and the recovery from tolerance was faster during the dark phase. The peak concentration (Cmax) and area under the concentration-time curve (AUC) of pethidine and its metabolite norpethidine were significantly higher during the dark phase than during the light phase, but the total serum clearance (CL/F) exhibited the opposite trend. The rhythm of drug plasma concentration was positively correlated with the analgesic effect.

CONCLUSION

These results suggest that the pharmacodynamics and pharmacokinetics of pethidine in mice vary significantly according to the dosing time, which implies that the time of administration should be considered in the rational clinical use of pethidine to maximise analgesia and minimise the adverse effects.

A comparison of sedation-related events for two multiagent oral sedation regimens in pediatric dental patients

PURPOSE

This study compared the incidence of adverse sedation-related events occurring with two different multiagent oral sedation regimens in pediatric dental patients.

METHODS

Forty healthy patients (three to six years old), received either a sedation regimen of chloral hydrate, meperidine, and hydroxyzine with nitrous oxide (CH/M/H/N2O; N=19) or a regimen of midazolam, meperidine, and hydroxyzine with nitrous oxide (MZ/M/H/N2O; N=21). The two treating dentists answered a questionnaire regarding the perioperative period. Parents received two phone interviews at eight and 24 hours after sedation. Statistical analysis included chi-square, Pearson correlation coefficient, and t-test (P<.05).

RESULTS

Children sedated with MZ/M/H/N2O showed a significant increase in hyperactivity during dental treatment, slurring/difficulty speaking, and difficulty walking postoperatively within eight hours after discharge. Children sedated with CH/M/H/N2O showed a significant increase in frequency of sleeping, talking less than normal after arriving home, and an increased need for postoperative pain medication.

CONCLUSIONS

Different oral sedation regimens produce different adverse sedation-related events. The provider of pediatric oral sedation should select a sedative regimen with an adverse sedation-related profile that he/she believes is optimal for the patient being treated. Parents should be counseled as to possible postsedation effects anticipated based on the sedative regimen administered.

The safety of propofol infusion compared to midazolam and meperidine intravenous bolus for patients undergoing double balloon enteroscopy

OBJECTIVE

The double balloon enteroscopy (DBE) procedure is long and requires moderate sedation. We aim to determine whether the administration of propofol infusion is safe by comparing it to intravenous midazolam/meperidine in patients undergoing DBE.

MATERIAL AND METHOD

A prospective study with 48 patients was conducted at King Chulalongkorn Hospital randomizing (block of four) patients into two groups. In group 1, 28 patients were enrolled for intravenous midazolam/meperidine, and one patient was dropped out before underwent DBE due to hemodynamic instability. Therefore, 27 (n = 27) participants were included in Group 1. In group 2, 28 patients were enrolled for propofol infusion, and seven patients were dropped out before underwent DBE, five due to hemodynamic instability (n = 5), and two refused treatment (n = 2). Therefore, 1 (n = 21) participants were included in Group 2. Vital signs and oxygen saturation were regularly monitored.

RESULTS

Mean +/- SD age of patients was 56.8 +/- 9.2 years, and 41.7% of patients were male. There was no difference in demographic data between the groups. For the safety profile, 25.9% of the midazolam/meperidine group and 33.3% of the propofol group developed hypotension and/or desaturation (p = 0.45). The patients' satisfaction of group 1 and group 2 were 86.7 +/- 6.5% and 86.3 +/- 8.1%, respectively, and presented no significant difference (p = 0.89).

CONCLUSION

Propofol infusion is safe and shows no difference in outcome from the midazolam and meperidine sedation for the DBE procedure.

Opioids for acute pancreatitis pain

BACKGROUND

Acute pancreatitis is an acute inflammatory process of the pancreas that may also involve adjacent tissues and/or remote organ systems. Abdominal pain is the main symptom and is usually accompanied by nausea, vomiting and fever. Opoids are commonly used to manage pain in acute pancreatitis but there are still some uncertainties about their clinical effectiveness and safety.

OBJECTIVES

To assess the effectiveness and safety of opioids for treating acute pancreatitis pain.

SEARCH METHODS

The search strategy included the Cochrane Upper Gastrointestinal and Pancreatic Diseases Review Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2013, Issue 6), MEDLINE (from 1950 to June 2013) and EMBASE (from 1980 to June 2013). There were no restrictions by language or publication status.

SELECTION CRITERIA

We considered randomised clinical trials (RCTs) assessing the effectiveness of any opioid drug used for treating acute pancreatitis pain.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed risks of bias and extracted data. We estimated risk ratios (RRs) for dichotomous data and calculated a 95% confidence interval (CI) for each RR. We performed an intention-to-treat (ITT) analysis. We undertook meta-analysis for some outcomes.

MAIN RESULTS

We included five RCTs with a total of 227 participants (age range 23 to 76 years; 65% men) with acute pancreatitis pain. The opioids assessed were intravenous and intramuscular buprenorphine, intramuscular pethidine, intravenous pentazocine, transdermal fentanyl and subcutaneous morphine.One RCT, comparing subcutaneous morphine with intravenous metamizole reported non-significant reduction in the number of participants with improvements in pain intensity (primary outcome) (RR 0.50, 95% CI 0.19 to 1.33). Three studies compared analgesia using opioids with non-opioid treatments. After excluding one study that used opioids through continuous intravenous infusion, there was a decrease in the number of patients requiring supplementary analgesia (RR 0.53, 95% CI 0.30 to 0.93). In a single study, there were no differences in the number of patients requiring supplementary analgesia between buprenorphine and pethidine (RR 0.82, 95% CI 0.61 to 1.10).Pancreatitis complications were not associated with a significant difference between the drugs tested. No clinically serious or life-threatening adverse events occurred related to treatment. No differences for this outcome were found between opioid and non-opioid treatments, or for type of adverse event (nausea-vomiting and somnolence-sedation). One death in the procaine group was reported across all the trials.One RCT comparing pethidine with intramuscular buprenorphine reported non-significant differences of supplementary analgesic, adverse events or deaths. One RCT comparing fentanyl with placebo found no difference in adverse events.The findings of this review are limited by the lack of information to allow full appraisal of the risk of bias, the measurement of relevant outcomes and the small numbers of participants and events covered by the trials.

AUTHORS' CONCLUSIONS

Opioids may be an appropriate choice in the treatment of acute pancreatitis pain. Compared with other analgesic options, opioids may decrease the need for supplementary analgesia. There is currently no difference in the risk of pancreatitis complications or clinically serious adverse events between opioids and other analgesia options.Future research should focus on the design of trials with larger samples and the measurement of relevant outcomes for decision-making, such as the number of participants showing reductions in pain intensity. The reporting of these RCTs should also be improved to allow users of the medical literature to appraise their results accurately. Large longitudinal studies are also needed to establish the risk of pancreatitis complications and adverse events related to drugs.

Post-sedation events in children sedated for dental care

Moderate oral sedation is used in pediatric dentistry for safe delivery of dental care to children. However, there is a paucity of data on the effects of pediatric dental sedations after discharge of children from the dental office. The purpose of this study was to evaluate and compare the incidence of adverse events occurring with meperidine and hydroxyzine versus midazolam alone 8 and 24 hours after sedation in pediatric dental patients. In this prospective study, a convenience sample of 46 healthy children presenting to a private pediatric dental practice for dental treatment needs was selected. A telephone survey of the parents of children sedated with either meperidine and hydroxyzine or midazolam alone was conducted 8 and 24 hours after the administration of sedation medications. Data analysis included descriptive statistics, frequency and proportion analysis, and Fisher exact test. Forty children were sedated with meperidine and hydroxyzine, and 6 who were sedated with midazolam. In both groups, 50% of the children slept in the car on the way home. Three children in the meperidine and hydroxyzine group vomited in the car. A significantly larger proportion of children in the meperidine and hydroxyzine group experienced prolonged sleep at home (P = .015). More children in the midazolam group exhibited irritability in the first 8 hours (P = .07). There were no statistical differences between the 2 groups with respect to incidence of pain, fever, vomiting, sleeping in the car, snoring, and difficulty in waking up. The lingering effects of orally administered sedation medications can lead to prolonged sleep, irritability, and vomiting in children after they have been discharged from the dental clinic. Most of these events occurred within the first 8 hours, but in some children the effects were seen up to 24 hours later.

From multi-incision to single-incision laparoscopic cholecystectomy step-by-step: one surgeon's self-taught experience and retrospective analysis

BACKGROUND/OBJECTIVE

Single-incision laparoscopic cholecystectomy (SILC) is emerging as an alternative to standard four-incision laparoscopic cholecystectomy (4ILC). This study presents one surgeon's experience of SILC and a retrospective analysis of the data.

METHODS

Sixty-seven consecutive patients treated by a single surgeon and undergoing laparoscopic cholecystectomy (LC) for benign gallbladder diseases were enrolled. LCs were attempted with conventional instruments as follows: 24 three-incision laparoscopic cholecystectomies (3ILC); 10 two-incision laparoscopic cholecystectomies (2ILC); and 33 SILC.

RESULTS

The procedure conversion rate into the SILC, 2ILC, and 3ILC groups was 9.1%, 0%, and 8.3% respectively. Operative time was significantly longer with SILC (111.1±30.34 minutes) compared to 2ILC (79.1±15.74 minutes) and 3ILC (80.2±29.41 minutes) (p<0.01). Post-operative pethidine dosage was significantly lower in the 2ILC group (0.29±0.358 mg/kg) compared to the 3ILC group (1.02±0.802 mg/kg) (p<0.05). Length of hospital stay (LOS) was significantly shorter in the SILC group (2.52±0.566 days) compared to the 3ILC group (3.1±1.02 days) (p<0.05). There were no complications.

CONCLUSIONS

SILC is a safe and feasible procedure that is comparable to multi-incision laparoscopic cholecystectomy (MILC). We have introduced a recommended step-by-step training program. SILC needed longer operative time than MILC but has potential benefits in terms of LOS and post-operative pain.

The analgesic requirement after thyroid surgery under general anaesthesia with bilateral superficial cervical plexus block

In this study we evaluated the analgesic efficacy of bilateral superficial cervical plexus block after thyroid surgery. Sixty patients were assigned to two groups. General anesthesia was induced with 2mg/kg propofol, 0.1mg/kg vecuronium and 1.5μg fentanyl IV for both group. After endotracheal intubation, bilateral superficial cervical plexus block with 0.25% bupivacaine 15ml in each side was performed in Group I. In Group II (control) no regional block was administered. Intravenous on demand analgesic was used to evaluate postoperative analgesic requirement. Neither visual analog scale scores nor intravenous analgesics doses were different between the groups. The first analgesic requirement time in Group I was significantly longer than for the control group. The incidence of nausea and vomiting was significantly lower in Group I than Group II. We concluded that bilateral superficial cervical plexus block with 0.25% bupivacaine did not decrease analgesic requirement after thyroid surgery.

Sedative techniques for endoscopic retrograde cholangiopancreatography

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is an uncomfortable therapeutic procedure that cannot be performed without adequate sedation or general anaesthesia. A considerable number of ERCPs are performed annually in the UK (at least 48,000) and many more worldwide.

OBJECTIVES

The primary objective of our review was to evaluate and compare the efficacy and safety of sedative or anaesthetic techniques used to facilitate the procedure of ERCP in adult (age > 18 years) patients.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 8); MEDLINE (1950 to September 2011); EMBASE (1950 to September 2011); CINAHL, Web of Science and LILACS (all to September 2011). We searched for additional studies drawn from reference lists of retrieved trial materials and review articles and conference proceedings.

SELECTION CRITERIA

We considered all randomized or quasi-randomized controlled studies where the main procedures performed were ERCPs. The three interventions we searched for were (1) conscious sedation (using midazolam plus opioid) versus deep sedation (using propofol); (2) conscious sedation versus general anaesthesia; and (3) deep sedation versus general anaesthesia. We considered all studies regardless of which healthcare professional administered the sedation.

DATA COLLECTION AND ANALYSIS

We reviewed 124 papers and identified four randomized trials (with a total of 510 participants) that compared the use of conscious sedation using midazolam and meperidine with deep sedation using propofol in patients undergoing ERCP procedures. All sedation was administered by non-anaesthetic personnel. Due to the clinical heterogeneity of the studies we decided to review the papers from a narrative perspective as opposed to a full meta-analysis. Our primary outcome measures included mortality, major complications and inability to complete the procedure due to sedation-related problems. Secondary outcomes encompassed sedation efficacy and recovery.

MAIN RESULTS

No immediate mortality was reported. There was no significant difference in serious cardio-respiratory complications suffered by patients in either sedation group. Failure to complete the procedure due to sedation-related problems was reported in one study. Three studies found faster and better recovery in patients receiving propofol for their ERCP procedures. Study protocols regarding use of supplemental oxygen, intravenous fluid administration and capnography monitoring varied considerably. The studies showed either moderate or high risk of bias.

AUTHORS' CONCLUSIONS

Results from individual studies suggested that patients have a better recovery profile after propofol sedation for ERCP procedures than after midazolam and meperidine sedation. As there was no difference between the two sedation techniques as regards safety, propofol sedation is probably preferred for patients undergoing ERCP procedures. However, in all of the studies that were identified only non-anaesthesia personnel were involved in administering the sedation. It would be helpful if further research was conducted where anaesthesia personnel were involved in the administration of sedation for ERCP procedures. This would clarify the extent to which anaesthesia personnel should be involved in the administration of propofol sedation.

[Pethidine for labor analgesia; monitoring of newborn heart rate, blood pressure and oxygen saturation during the first 24 hours after the delivery]

BACKGROUND

There is no information about an effect of pethidine labor analgesia on newborn vital signs in the first hours after the delivery.

OBJECTIVES

The aim of the study was to assess changes in heart rate, blood pressure and oxygen saturation during the first 24 hours of life in neonates born after using pethidine for labor analgesia.

METHODS

55 full-term neonates, 34 from intramuscular pethidine labor anesthesia in doses 50-100 mg and 21 born to mothers without any pharmacological form of anesthesia, were studied. Heart rate, oxygen saturation and blood pressure (SBP and DPB) were monitored using a Nellcor Oxi Max monitor N5500 (Tyco Healthcare), and recorded at 1, 6, 12 and 24 hours.

RESULTS

No significant differences in the heart rate (144; 139; 141; 142,5 versus 142; 140,5; 138; 141 beats/minute), oxygen saturation (97%; 98%; 98%; 98,5%; versus 98%, 98%, 98%, 98%), SBP (66,5; 67; 66; 66,5 versus 68,5; 65; 64; 64,5 mmHg) and DBP (33,5; 35; 37; 40 versus 34; 32; 32; 38 mmHg) at 1, 6, 12 and 24 hours between pethidine and controls groups were found.

CONCLUSIONS

Intramuscular pethidine analgesia during the first stage of labor in doses 50-100 mg does not significantly modify the oxygen saturation, heart rate and blood pressure in infants during the first 24 hours of their life.

Sedation of children undergoing dental treatment

BACKGROUND

Children's fear about dental treatment may lead to behaviour management problems for the dentist, which can be a barrier to the successful dental treatment of children. Sedation can be used to relieve anxiety and manage behaviour in children undergoing dental treatment. There is a need to determine from published research which agents, dosages and regimens are effective.

OBJECTIVES

To evaluate the efficacy and relative efficacy of conscious sedation agents and dosages for behaviour management in paediatric dentistry.

SEARCH METHODS

Electronic searches of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Dissertation Abstracts, SIGLE, the World Wide Web (Google) and the Community of Science Database were conducted for relevant trials and references up to 4th August 2011. Reference lists from relevant articles were scanned and the authors contacted to identify trials and obtain additional information. There were no language restrictions. Trials pre-1966 were not searched.

SELECTION CRITERIA

Studies were selected if they met the following criteria: randomised controlled trials of conscious sedation comparing two or more drugs/techniques/placebo undertaken by the dentist or one of the dental team in children up to 16 years of age. Crossover trials were excluded.

DATA COLLECTION AND ANALYSIS

Information regarding methods, participants, interventions, outcome measures and results were independently extracted, in duplicate, by two review authors. Where information in trial reports was unclear or incomplete authors of trials were contacted. Trials were assessed for risk of bias. The Cochrane Collaboration statistical guidelines were followed.

MAIN RESULTS

Thirty-six studies were included with a total of 2810 participants. Thirty trials (83%) were at high risk of bias and six (17%) were at unclear risk of bias. There were 28 different sedatives used with or without inhalational nitrous oxide. Dosages, mode of administration and time of administration varied widely. Trials were grouped into placebo-controlled, dosage and head-to-head comparisons. Meta-analysis of the available data was possible for studies investigating oral midazolam vs placebo only. There is weak evidence from five small clinically heterogeneous trials at high risk of bias, that the use of oral midazolam in doses between 0.25 mg/kg to 0.75 mg/kg is associated with more co-operative behaviour compared to placebo; standardised mean difference (SMD) favoured midazolam (SMD 2.98, 95% confidence interval (CI) 1.58 to 4.37, P < 0.001, I² = 91%), which translates to an increase of approximately 1.8 points on the six-point Houpt behaviour scale. There is very weak evidence from two trials which could not be pooled that inhalational nitrous oxide is more effective than placebo.

AUTHORS' CONCLUSIONS

There is some weak evidence that oral midazolam is an effective sedative agent for children undergoing dental treatment. There is very weak evidence that nitrous oxide inhalation may also be effective. There is a need for further well designed and well reported clinical trials to evaluate other potential sedation agents. Further recommendations for future research are described and it is suggested that future trials evaluate experimental regimens in comparison with oral midazolam or inhaled nitrous oxide.

Regional versus IV analgesics in labor

AIM

The aim of this study was to compare combined spinal epidural (CSE), epidural (E) and IV pethidine analgesia and their effects on the mother, fetus, newborn and the labor course.

METHODS

This is a prospective parallel single blind study, where 60 women in active labor were recruited and were allocated to five subgroups to receive analgesia by different routes. The mother and the fetus were assessed. The results were recorded and compared using Visual Analogue Scale (VAS) and modified Bromage scale for motor block, in addition to other clinical findings.

RESULT

The duration of first stage of labor was significantly longer in the E group, compared with the CSE and IV pethidine groups. When the pain control achieved by CSE bupivacaine and lidocaine was compared with the corresponding epidural, it was found that the first technique achieved better pain control. Women who received pethidine had higher incidence of nausea and vomiting compared to those received CSE or E analgesia. There was no significant difference between the five groups with respect to other side effects.

CONCLUSION

Regional analgesia especially CSE using bupivacaine or lidocaine is a safe effective method for analgesia in labor with relative better efficacy of bupivacaine.

Prevention of shivering during therapeutic temperature modulation: the Columbia anti-shivering protocol

BACKGROUND

As the practice of aggressive temperature control has become more commonplace, new clinical problems are arising, of which shivering is the most common. Treatment for shivering while avoiding the negative consequences of many anti-shivering therapies is often difficult. We have developed a stepwise protocol that emphasizes use of the least sedating regimen to achieve adequate shiver control.

METHODS

All patients treated with temperature modulating devices in the neurological intensive care unit were prospectively entered into a database. Baseline demographic information, daily temperature goals, best daily GCS, and type and cumulative dose of anti-shivering agents were recorded.

RESULTS

We collected 213 patients who underwent 1388 patient days of temperature modulation. Eighty-nine patients underwent hypothermia and 124 patients underwent induced normothermia. In 18% of patients and 33% of the total patient days only none-sedating baseline interventions were needed. The first agent used was most commonly dexmeditomidine at 50% of the time, followed by an opiate and increased doses of propofol. Younger patients, men, and decreased BSA were factors associated with increased number of anti-shivering interventions.

CONCLUSIONS

A significant proportion of patients undergoing temperature modulation can be effectively treated for shivering without over-sedation and paralysis. Patients at higher risk for needing more interventions are younger men with decreased BSA.

Subarachnoid bupivacaine and pethidine for caesarean section: assessment of quality of perioperative analgesia and side effects

AIMS AND OBJECTIVES

This study determined the quality of perioperative analgesia and side effect profile of spinal bupivacaine plus pethidine for caesarean section.

PATIENTS AND METHODS

Patients were randomised to receive 2.0mL of bupivacaine + pethidine 7.5mg or 2.0mL bupivacaine + saline of equal volume. Spinal anaesthesia was instituted at L2/3, L3/4 or L4/5 using a 25G pencil point spinal needle. Heart rate, blood pressure and oxygen saturation were monitored. Timelines such as time of injection of study medication, skin incision, delivery time, termination of surgery and time to first request for analgesia as well as complications were noted. Demographic characteristics were also recorded.

RESULTS

50 patients were studied in 2 groups and the demographic characteristics were similar. Addition of pethidine resulted in block height greater than T6 and longer duration of analgesia (256.9 ± 112.2 min.) compared with the saline group (160.5 ± 65.0 min; p = 0.0005). Maternal hypotension occurred more in the pethidine group (10/25 vs 2/25; p = 0.01). Peritoneal irritation and inadequate anaesthesia were more frequent in the saline group. Nausea and vomiting and drowsiness were mild and occurred only in the pethidine group. In the Post Anaesthetic Care Unit (PACU), more patients reported pain in the saline group (p = 0.002).

CONCLUSION

Bupivacaine with pethidine 7.5mg resulted in better quality of anaesthesia, longer postoperative analgesia with acceptable side effect profile. This will be of value in the management of post-caesarean section pain particularly in the resource poor setting.

Determining the effect of intraperitoneal pethidine on postoperative pain

The main problem in the postoperative period is pain relief. Adequate postoperative analgesia not only leads to patient's comfort but also decreases morbidity, nursing care and time of hospitalization. Determination of the effect of intraperitoneal pethidine on postoperative pain in women scheduled for elective tubal ligation was undertaken. In a double blind clinical trial study of 60 women, ASA I, 25-45 years old, were enrolled for elective tubal ligation in Kosar hospital in Qazvin, IRAN. Patients were randomly divided in two equal groups (30 each).One group received pethidine intraperitoneally and the other group received equal amount of placebo in the same region. The intensity of postoperative pain was evaluated by visual analogue scale (VAS) for about 8 hours. Incidence of nausea was also evaluated. Data was transformed to SPSS software. Then data analysis was performed by U-test. There was no significant statistical difference with regard to age, weight, and time of operation between the two groups. The mean score of pain was significantly lower in intraperitoneal pethidine group than placebo group but the incidence of nausea in the intraperitoneal pethidine group was more than in placebo group (P < 0.05). Thus, intraperitoneal pethidine decreases postoperative pain but increases postoperative nausea.

Preemptive peritonsillar ketamine infiltration: postoperative analgesic efficacy versus meperidine

OBJECTIVES

The current study was planned to assess post-tonsillectomy analgesic efficacy of pre-emptive peritonsillar ketamine infiltration with or without bupivacaine in comparison to meperidine alone or in combination with bupivacaine.

PATIENTS & METHODS

The study included 100 patients with mean age of 10.5 +/- 2.3 years assigned for adenotonsillectomy. Patients were randomly allocated into 4 groups (n = 25): Group K1: received peritonsillar infiltration of ketamine (0.5 mg/kg), Group M1: received peritonsillar infiltration ofmeperidine (1 mg/kg), and groups K2 and M2 received either ketamine (0.5 mg/kg) or meperidine (1 mg/kg) in combination with bupivacaine (5 mg/ml). All medications were prepared as 2 ml in volume and were applied as 1 ml per tonsil 3 min prior to tonsillectomy. On admission to the post-anesthesia care unit (PACU) pain was assessed using the objective pain scale (OPS) score which evaluates 5 parameters each was scored from 0 to 2 for a collective score ranged from 0 = best to 10 = worst. OPS score was assessed at time of admission to PACU and every 15 min for one hour and every 30 minutes till patients were ready for discharge from PACU at an Aldrete score of 9. Rescue analgesia with morphine 0.05 mg/kg i.v. was administered, after operation; for OPS score > or = 5 and time elapsed till first request of rescue analgesia was determined. Upon patient discharge, parents were asked to rate their satisfaction with patient analgesia on 7-point scale; 1 = extremely dissatisfied and 7 = extremely satisfied.

RESULTS

All enrolled patients passed smooth intraoperative course without complication. Mean duration ofPACU stay was significantly shorter in group K2 compared to the other 3 groups and in group K1 compared to groups M1 and M2. Moreover, total hospital stay was significantly shorter in group K2 compared to groups M1 and M2 but was non-significantly shorter compared to group K1. Both duration of PACU and hospital stay showed a non-significant difference between groups M1 and M2. In group K1 number of patients who had short hospital stay was significantly higher compared to groups M1 and M2. Number of patients in group K2 and had short hospital stay was significantly higher compared to groups M1 and M2. Mean recorded OPS scores showed progressive increase in all patients reaching a peak at 90-min after PACU admission in groups K1, M1 and M2 and at 120-min in K2 group. At 60- and 90-minutes after admission to PACU patients enrolled in group K2 had a significantly lower OPS scores compared to groups K1 and M1 but non-significantly lower scores compared to group M2. Mean parents' satisfaction scores reported in group K2 were significantly higher compared to groups K1 and M1 and were non-significantly higher compared to group M2 with non-significant difference among the other three groups despite being in favor of group M2.

CONCLUSION

Peritonsillar injection of a combination of bupivacaine and ketamine provided efficient postoperative analgesia after adenotonsillectomy and achieved higher parents' satisfaction for the outcome of surgery. The used drugs' combination and volume could be recommended as a routine preemptive analgesic policy for children assigned for adenotonsillectomy.

[Nalbuphine at maternal analgesia]

OBJECTIVE

Comparison between particular methods of obstetrics analgesia, their analgetic efects and influence on progress of delivery and postpartum adaptation of fetus.

DESIGN OF THE STUDY

Prospective study.

SETTING

The Department of Gynecology and Obstetrics of the Teaching Hospital and the 2nd Medical Faculty of the Charles University in Prague.

METHODS

A prospective study of 644 patients who received intravenous increments of nalbuphine (196 women) or epidural analgesia (217 women) or pethidin (231 women). Assessment of maternal analgesia, satisfaction was carried out. Apgar scores and resuscitative measures required for the neonate were noted at delivery.

RESULTS

The best analgetic effect was in the group with using peridural analgesia, where max. score was 3. The highest value was in the group of women who received pethidin. The most decrease of score after aplication of analgesia was in group with epidural analgesia, the least decrease of score was in group with pethidin. The Apgar score at 1. minute was the lowest in the group with epidural analgesia, the highest score was in the group with nalbuphine.

CONCLUSION

The mixed agonist/antagonist narcotic analgesic like nalbuphine have the place in clinical practice. The obstetric analgesia is very common in obstetrics practice. The epidural analgesia is very popular but not everytimes accessible. Nalbuphine is the option who is analgetic effective and have minimal side-effect.

Magnesium sulphate versus lytic cocktail for eclampsia

BACKGROUND

Eclampsia, the occurrence of a seizure in association with pre-eclampsia, is a rare but serious complication of pregnancy. A number of different anticonvulsants have been used to control eclamptic fits and to prevent further seizures.

OBJECTIVES

The objective of this review was to assess the effects of magnesium sulphate compared with lytic cocktail (usually chlorpromazine, promethazine and pethidine) when used for the care of women with eclampsia. Magnesium sulphate is compared with diazepam and with phenytoin in other Cochrane reviews.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (July 2010) and the Cochrane Central Register of Trials (The Cochrane Library 2010, Issue 2).

SELECTION CRITERIA

Randomised trials comparing magnesium sulphate (intravenous or intramuscular administration) with lytic cocktail for women with a clinical diagnosis of eclampsia.

DATA COLLECTION AND ANALYSIS

Two review authors (L Duley and D Chou) assessed trial quality and extracted data.

MAIN RESULTS

We included three small trials (total 397 women) of average quality in the review. Magnesium sulphate was associated with fewer maternal deaths (risk ratio (RR) 0.14, 95% confidence interval (CI) 0.03 to 0.59; 3 trials, 397 women) and was better at preventing further seizures (RR 0.06, 95% CI 0.03 to 0.12; 3 trials, 397 women) than lytic cocktail. Magnesium sulphate was also associated with less respiratory depression (RR 0.12, 95% CI 0.02 to 0.91; 2 trials, 198 women), less coma (RR 0.04, 95% CI 0.00 to 0.74; 1 trial, 108 women), and less pneumonia (RR 0.20, 95% CI 0.06 to 0.67; 2 trials, 307 women). There was no clear difference in the RR for any death of the baby (RR 0.35, 95% CI 0.05 to 2.38, random effects; 2 trials, 177 babies).

AUTHORS' CONCLUSIONS

Magnesium sulphate, rather than lytic cocktail, for women with eclampsia reduces the RR of maternal death, of further seizures and of serious maternal morbidity (respiratory depression, coma, pneumonia). Magnesium sulphate is the anticonvulsant of choice for women with eclampsia; the use of lytic cocktail should be abandoned.

[A combination of dexmedetomidine with ketamine and opioids results in significant inhibition of hemodynamic changes associated with laparoscopic cholecystectomy and in prolongation of postoperative analgesia]

THE AIM OF THE STUDY

Recently, alpha2 sympathoadrenergic drugs are used in premedication to improve the perioperative course. The aim of our study was to compare a premedication with a new alpha2 sympathoadrenergic drug and standard premedication.

METHODS

After ethic committee approval and written patient consent, in a randomised, double-blinded study, combination of dexmedetomidine 1.0 microg x kg(-1) + ketamine 0.5 mg x kg(-1) + fentanyl 1.0 microg x kg(-1) + atropine 0.5 mg (group FNT), dexmedetomidine 1.0 microg x kg(-1) + ketamine 0.5 mg x kg(-1) + alfentanil 5.0 microg x kg(-1) + atropine 0.5 mg (group ALFNT), or pethidine 1.0 mg x kg(-1) + atropine 0.5 mg (group Dolsin) was administered to a deltoid muscle 15 min. before anaesthesia (GA) in patients elicited for laparoscopic cholecystectomy (LCHE). GA was performed in a standard way, ECG, NIBP, respiration rate, SpO2, onset of effect, Observers Assessment of Alertness Sedation Score (OAASS) before GA, circulatory reaction to intubation and capnoperitoneum, fentanyl consumption during GA, time to the first request for post-operative analgesia and postoperative nausea and vomiting were measured. The data were processed by Kruskal-Wallis and Fisher tests. P-value < 0.05 was considered significant.

RESULTS

There were 16 patients in FNT and Dolsin and 15 patients in ALFNT with no differences in demography except for younger age in ALFNT. The main differences were in hypertension during capnoperitoneum: 0/16 FNT and 1/15 ALFNT vs. 11/16 Dolsin, both p < 0.001, per-operative fentanyl consumption: FNT 31.5 microg vs. Dolsin 165.0 microg, p < 0.001 and ALFNT 50.0 microg, p < 0.05 (ALFNT vs. Dolsin, p < 0.01) and request to the first analgesic post surgery: FNT 1.3 h. vs. Dolsin 0.45 h., p < 0.05 vs. ALFNT 0.8 h., p < 0.01. There were no differences in side effects except for bradycardia in ALFNT (p < 0.05).

CONCLUSIONS

Dexmedetomidine-ketamine-fentanyl-atropine combination is superior to pethidine-atropine combination in suppressing of adverse hemodynamic effects of capnoperitoneum, decreased need for analgesia during GA and prolonged postoperative analgesia.

[A survey of anaesthesia for caesarean section in Poland]

BACKGROUND

Obstetric anaesthesia and analgesia have come to be regarded as a subspecialty.Various countries and societies have published evidence-based guidelines. In this paper are presented the results of a survey of anaesthesia for Caesarean section (CS), conducted in Poland in 2009.

METHODS

432 questionnaires were sent. The questions asked related to: characteristics of the hospital, premedication, preoperative laboratory screening, methods of anaesthesia, local analgesic agents (LA), postoperative enteral feeding, positioning, and analgesia.

RESULT

The questionnaire return rate was 24%. Only 10 hospitals (out of 98) employed anaesthesiologists exclusively for obstetric anaesthesia and analgesia. Alkalinisation of gastric contents, gastric emptying drugs and H blockers were used in 38% of hospitals in elective CS, and in 32% of hospitals in emergency CS. Preoperative laboratory screening was conducted in 93% of hospitals before elective CS, and 77% before emergency CS (usually haematocrit, haemoglobin concentration, red blood count and platelets). In 50% of hospitals, the lowest acceptable concentration of platelets before central blocks was 100,000; while in 30% of hospitals, a level of 50,000 was considered acceptable. Spinal anaesthesia was used in more than 90% of elective CS cases in 75% of hospitals, in emergency CS--in 50% of patients only and in the presence of a foetal stress in 65% of hospitals general anaesthesia was preferred. Bupivacaine remains the most commonly used LA (97%). Lidocaine is still used in 3% of hospitals, and adjuvants are used in 42% of hospitals. The flat supine position was recommended in 75% of hospitals; and 13% of parturients were requested to stay in this position for 24 hours. In 74% of hospitals, enteral feeding was delayed, and in 27% was delayed for 24 hours after CS (27%). Postoperative analgesia was based on parenteral analgesics (usually paracetamol and ketoprofen). Pethidine was used in 35% of hospitals.

CONCLUSION

There is an urgent need for national guidelines on obstetric anaesthesia and analgesia in Poland.

Pharmacokinetics after an intravenous single dose of the opioid ketobemidone in children

BACKGROUND

Ketobemidone is often used as an alternative to morphine in children in the Scandinavian countries. The aim of this clinical trial was to explore the pharmacokinetics of ketobemidone in children because these properties have not been reported previously.

METHODS

Thirty children, newborn to 10 years, scheduled for elective surgery were included in the trial. Ketobemidone hydrochloride was administered as a single intravenous bolus dose and ketobemidone and norketobemidone concentrations were measured by LC-MS over 8 h. Pharmacokinetic parameters were determined using compartmental methods.

RESULTS

Six children were excluded from pharmacokinetic analysis because of incomplete blood sampling. The values of ketobemidone clearance (l/h/kg) given as median (range) were 0.84 (0.29-3.0) in Group A (0-90 days), 0.89 (0.55-1.35) in Group B (1-2.5 years) and 0.74 (0.50-0.99) in Group C (7-10 years). The corresponding values for apparent volume of distribution (l/kg) were 4.4 (3.7-6.9) (Group A), 2.6 (2.0-5.6) (Group B) and 3.9 (2.7-5.0 (Group C), and for elimination half-life (h) 3.0 (1.4-8.9) (Group A), 2.0 (1.2-4.7) (Group B) and 3.7 (2.4-6.9) (Group C), respectively. In the two neonates the elimination half-life was almost 9 h. The metabolite norketobemidone did not reach levels above the limit of quantification (0.07 ng/ml) in any of the patients.

CONCLUSION

The pharmacokinetic parameters of ketobemidone in children older than 1 month appear to be similar to those in adults. Because of the large interindividual variability of the pharmacokinetics in neonates, further studies especially in this age group are warranted.

[Excessive shivering after remifentanil infusion in a muscular karate player for tracheal resection and construction surgery]

A 22-year-old muscular karate player was diagnosed to have a tracheal tumor with a diameter of 2.8 cm that existed 2 cm under the glottis and occupied 60% of his trachea. He was scheduled for trachea resection and construction surgery. After awake-fiber intubation, anesthesia was maintained by continuous infusion of propofol and remifentanil, together with thoracic epidural anesthesia (T4-5). After 431 minutes of surgery, 50 mm of trachea was rejected. To prevent him from extending his neck, the surgeon placed stay-sutures between the patient's chin and chest wall. Twenty minutes after the termination of propofol and remifentanil infusion, the patient became awake and was extubated. Subsequently, although the body temperature was 37.6 degrees C, excessive shivering occurred and his neck was nearly extended. We immediately injected 0.8 mEq of magnesium sulfate and 70 mg of pethidine. It took almost 10 minutes to stop shivering completely, and the patient became too sedated and required noninvasive positive pressure ventilation overnight. We speculate that intraoperative remifentanil infusion induced severe shivering in this case. Shivering after remifentanil infusion can be a fatal complication in tracheal resection and construction surgery, especially in muscular patients.

Intravenous paracetamol reduced the use of opioids, extubation time, and opioid-related adverse effects after major surgery in intensive care unit

BACKGROUND

This study assessed the analgesic efficacy, side effects, and time to extubation of intravenous paracetamol when administered as an adjuvant to intravenous meperidine after major surgery in intensive care unit (ICU).

MATERIAL

Patients were randomized postoperatively into 2 groups in ICU. Patients received either 100 mL of serum saline intravenous (IV) every 6 hours and IV meperidine (n = 20 group M) or IV paracetamol 1 g every 6 hours and IV meperidine (n = 20, group MP) into a peripheral vein for 24 hours. Behavioral Pain Scale (BPS) is used until extubation, and visual analog score (VAS) is used after extubation. When BPS and VAS values were more than 4, meperidine, 1 mg/kg IV, was administered and noted in 2 groups. Pain scores, total meperidine consumption, time to extubation, sedation scores, and side effects are 24-hour postoperatively noted.

RESULTS

Behavioral Pain Scale and VAS scores are significantly lower in group paracetamol-meperidine at 24 hours (P < .05). In group MP, postoperative meperidine consumption (76.75 ± 18.2 mg vs. 198 ± 66.4 mg) and extubation time (64.3 ± 40.6 min vs. 204.5 ± 112.7 min) were lower than in group M (P < .01). In addition to, postoperative nausea-vomiting and sedation scores were significantly lower in group MP when compared with group M (P < .05).

CONCLUSION

We have demonstrated important clinical benefits by the addition of 4 g/d of paracetamol to meperidine after major surgery. This benefit has been shown in a range of patients under routine clinical conditions and therefore has important practical consequences in ICU. These data suggest that intravenous paracetamol is a useful component of the multimodal analgesia model, especially after major surgery.