Anesth Analg 2001 Sep;93(3):803-4
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PMID: 11524365, UI: 21415345
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Anesth Analg 2001 Sep;93(3):761-70
Department of Anaesthesiology and Intensive Care and Unit of Biostatistics and Epidemiology, Orebro Medical Center Hospital, Orebro, Sweden.
The analgesic effects of intraarticular morphine are controversial. To systematically evaluate the effects, we performed a review of the literature and a metaanalysis of the peripheral effects of morphine injected intraarticularly. Research databases were searched to identify articles in which peripheral analgesic effects of morphine were studied in patients undergoing arthroscopic knee procedures under local, regional, or general anesthesia. The review was performed on three issues: does morphine injected intraarticularly produce analgesia, is it a dose-dependent effect, and, if so, is the effect systemic or mediated via peripheral opioid receptors? Visual analog score (VAS) and analgesic consumption were studied during the early phase (0-2 h), intermediate phase (2-6 h), and late phase (6-24 h) postoperatively after injection of morphine intraarticularly. Metaanalysis of these effect variables was performed by the weighted-analysis technique, and the essential homogeneity assumption was tested by the chi(2) test. Forty-five articles could be identified in which the effects of morphine were studied in a prospective, randomized manner, and 32 of these studies included a placebo control. Pooled analyses of data from 19 studies suitable for metaanalysis showed an improvement in analgesia after morphine compared with placebo in the order of 12-17 mm on the VAS during all three phases of treatment. Studies with high quality scores showed somewhat smaller improvements. Total analgesic consumption could not be analyzed statistically, but the number of studies showing decreased analgesic consumption or no differences between groups was identical (six and six). No clear dose-response effect was seen when VAS was used as a measure of pain, but it was seen when area under the curve was used as a measure of pain. A systemic effect of peripherally-injected morphine was not possible to exclude because of the very limited data available. We conclude from this metaanalysis that intraarticularly administered morphine has a definite but mild analgesic effect. It may be dose dependent, and a systemic effect cannot be completely excluded.
PMID: 11524353, UI: 21415333
Anesth Analg 2001 Sep;93(3):721-7
Scirex Corporation, Austin, Texas, USA.
Preoperative administration of analgesics may prevent or reduce hyperalgesia and inhibit inflammation and pain by reducing the synthesis of prostaglandins in response to surgical injury. We evaluated in this placebo-controlled study the analgesic efficacy and safety of single doses of parecoxib sodium (20, 40, and 80 mg IV) when administered before oral surgery. Efficacy assessments were recorded during the 24-h period after completion of surgery. All doses of parecoxib sodium were consistently and significantly superior to placebo as measured by time to rescue medication, proportion of patients requiring rescue medication, patient's global assessment, and pain intensity. There were no significant differences between the Parecoxib Sodium 40- and 80-mg groups, suggesting that the analgesic effect of preoperatively administered parecoxib sodium reaches a plateau at 40 mg in this model. Forty-eight percent of the Parecoxib Sodium 40-mg group required rescue medication in the 24-h study period, compared with 93% of patients in the Placebo group. Overall, there were fewer adverse events in parecoxib sodium-treated patients compared with placebo. These findings suggest that preoperative administration of parecoxib sodium, the injectable prodrug of the cyclooxygenase-2 specific inhibitor valdecoxib, is effective, safe, and well tolerated for treating postoperative pain.
PMID: 11524347, UI: 21415327
Anesth Analg 2001 Sep;93(3):606-12
Department of Anesthesiology, Hopital Ambroise Pare, Boulogne-Billancourt, France.
Ketamine may prevent postoperative hyperalgesia. In patients undergoing arthroscopic meniscectomy using general anesthesia, we tested whether a single intraoperative dose of ketamine enhanced postoperative analgesia and improved functional outcome compared with a typical multimodal analgesic regimen. After the induction of anesthesia, 50 patients were randomly assigned to ketamine (0.15 mg/kg IV just after the induction of anesthesia) or a vehicle placebo. Standardized general anesthesia included propofol, alfentanil, and nitrous oxide. Bupivacaine (0.5%) and morphine (5 mg) were given intraarticularly at the end of surgery. Postoperative analgesia was initially provided with morphine and subsequently with naproxen sodium (550 mg orally twice daily) and Di-Antalvic (400 mg acetaminophen and 30 mg dextropropoxyphene) as needed. Pain scores, analgesic requirements, side effects, and ability to walk were assessed in the ambulatory unit and at home for three postoperative days. Times to awakening and to discharge were similar in the two groups. However, the Ketamine group had significantly less postoperative pain at rest and during mobilization on Days 0, 1, and 2. Furthermore, they consumed significantly fewer Di-Antalvic tablets than the control group (13 [7-17] vs 27 [16-32], median [25%-75% interquartile range]). Patients given ketamine were also able to walk for longer periods of time on the first postoperative day. In conclusion, adding small-dose ketamine to a multimodal analgesic regimen improved postoperative analgesia and functional outcome after outpatient knee arthroscopy.
PMID: 11524327, UI: 21415307
Anesth Analg 2001 Sep;93(3):598-600
Department of Anesthesiology and Surgical Intensive Care 2, Universite Rennes 1, Rennes, France.
IMPLICATIONS: We examined the effects of preoperative epidural morphine associated with general anesthesia on postoperative morphine requirements. Twenty-one children older than 6 yr scheduled for major surgery were randomly assigned to two groups, a control group and an epidural group that received a single epidural morphine injection.
PMID: 11524325, UI: 21415305
BMJ 2001 Sep 22;323(7314):662
Unit of Chronic Disease Epidemiology, Medical School, University of Manchester, Manchester M13 9PT.
[Medline record in process]
Objective: To determine whether there is excess mortality in groups of people who report widespread body pain, and if so to establish the nature and extent of any excess. Design: Prospective follow up study over eight years. Mortality rate ratios were adjusted for age group, sex, and study location. Setting: North west England. Participants: 6569 people who took part in two pain surveys during 1991-2. Main outcome measures: Pain status at baseline and subsequent mortality. Results: 1005 (15%) participants had widespread pain, 3176 (48%) had regional pain, and 2388 (36%) had no pain. During follow up mortality was higher in people with regional pain (mortality rate ratio 1.21, 95% confidence interval 1.01 to 1.44) and widespread pain (1.31, 1.05 to 1.65) than in those who reported no pain. The excess mortality among people with regional and widespread pain was almost entirely related to deaths from cancer (1.55 (1.09 to 2.19) for regional pain and 2.07 (1.37 to 3.13) for widespread pain). The excess cancer mortality remained after exclusion of people in whom cancer had been diagnosed before the original survey and after adjustment for potential confounding factors. There were also more deaths from causes other than disease (for example, accidents, suicide, violence) among people with widespread pain (5.21, 0.94 to 28.78). Conclusion: There is an intriguing association between the report of widespread pain and subsequent death from cancer in the medium and long term. This may have implications for the long term follow up of patients with "unexplained" widespread pain symptoms, such as those with fibromyalgia.
PMID: 11566829, UI: 21450253
BMJ 2001 Aug 25;323(7310):437-40
Archer Street Clinic, Darlington DL3 6LT. sally@wade85.fsnet.co.uk
PMID: 11520846, UI: 21411389
Cephalalgia 2001 Jun;21(5):617-8
PMID: 11472389, UI: 21365373
Clin Orthop 2001 Sep;(390):151-62
Department of Orthopaedic Surgery, University of Innsbruck, Austria.
Lumbar radiographs of 120 adolescent elite skiers were evaluated for radiologic abnormalities by two independent observers. All athletes had no symptoms before the study. Radiographs were taken before enrollment of the students in elite level training. To determine the clinical significance of these abnormalities, all athletes were observed prospectively during the subsequent 2-year period for development of low back pain under high performance training. Anterior end plate lesions, Schmorl's nodes, posterior end plate lesions, spondylolysis, scoliosis, and spina bifida occulta were found. The depth of anterior end plate lesions showed a two-peak distribution, with peaks at 11% and 22% and a valley at 18% vertebral body height. The overall low back pain incidence was 12.5%. Students with severe anterior lesions (greater than 18% vertebral body height, n = 25) had significantly more low back pain (incidence, 32%) than did students without severe anterior lesions (incidence, 7.4%). Accordingly, students with severe anterior lesions had a significantly higher risk of having low back pain develop. Moderate end plate lesions and other abnormalities were not related to an increased incidence of low back pain. Adolescent students of elite sports with severe lumbar anterior end plate lesions have an increased risk of having low back pain develop under high performance training.
PMID: 11550861, UI: 21434719
Eur J Anaesthesiol 2001 Jul;18(7):450-7
Department of Anaesthesiology, University Hospital Carl-Gustav-Carus, Dresden, Germany.
BACKGROUND AND OBJECTIVE: The aim of the present study was to compare and assess the quality of analgesia, the safety and the side-effects after the use of a continuous, thoracic epidural infusion of sufentanil (5 microg h(-1)), 0.25% bupivacaine (10 mL h(-1)), 0.2% ropivacaine (10 mL h(-1)) alone or in combination in patients who had undergone major urological surgery. This prospective, randomized, double-blinded study investigated the efficacy of thoracic epidural infusions after major urological surgery. METHODS: Patients received a 72-h continuous infusion (10 mL h(-1)) of 0.25% bupivacaine (B), 0.2% ropivacaine (R), 0.25% bupivacaine with 0.5 microg mL(-1) sufentanil (BS), 0.2% ropivacaine with 0.5 microg mL(-1) sufentanil (RS) or 0.5 microg mL(-1) sufentanil only (S). The analysis included 109 patients. RESULTS: The mean visual analogue scale (VAS) scores for pain were highest in the groups R and S (P < 0.001). The PaCO2 values were significantly higher in the groups RS and S (P = 0.003). Motor block occurred more frequently in the groups B and BS than in the other groups (P < 0.001). Sedation, nausea and pruritus were more common in the groups that received sufentanil. CONCLUSIONS: A continuous, epidural infusion with these drugs was safe and effective in our patients. The combination of 0.2% ropivacaine plus sufentanil appeared preferable because of the low incidence of motor block.
PMID: 11437873, UI: 21331520
J Pain Symptom Manage 2001 Aug;22(2):672-87
Division of Palliative Medicine, University of Calgary, Calgary, Alberta, T2N 2T9 Canada.
Clinicians involved in the opioid pharmacotherapy of cancer-related pain should be acquainted with a variety of opioids and be skilled in the selection of doses when the type of opioid or route of administration needs changing. The optimal dose should avoid under-dosing or overdosing, both associated with negative outcomes for the patient. Although equianalgesic dose tables are generally used to determine the new doses in these circumstances, the evidence to support the ratios indicated in these tables largely refers to the context of single dose administration. The applicability of these ratios to the setting of chronic opioid administration has been questioned. A systematic search of published literature from 1966 to September 1999 was conducted to critically appraise the emerging evidence on equianalgesic dose ratios derived from studies of chronic opioid administration. There were six major findings: 1) there exists a general paucity of data related to long-term dosing and studies are heterogeneous in nature; 2) the ratios exhibit extremely wide ranges; 3) methadone is more potent than previously appreciated; 4) the ratios related to methadone are highly correlated with the dose of the previous opioid; 5) the ratio may change according to the direction the opioid switch; and 6) discrepancies exist with respect to both oxycodone and fentanyl. Overall, these findings have important clinical implications for clinicians and warrant consideration in the potential revision of current tables. The complexity of the clinical context in which many switches occur must be recognized and also appreciated in the design of future studies.
PMID: 11495714, UI: 21387424
Reg Anesth Pain Med 2001 Sep-Oct;26(5):468-72
Department of Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
Background and Objectives: Many women who choose natural childbirth for labor ultimately request epidural analgesia to control labor pain. Unfortunately, parturients and family members may often be unprepared for epidural anesthesia, which can contribute to disappointment and dissatisfaction with their labor and delivery. This study examines how epidural analgesia for labor influences maternal satisfaction in women who initially choose natural childbirth. METHODS: This study compared pain and maternal satisfaction in women who elected natural childbirth and successfully followed through (n = 23), with those who elected natural childbirth, but requested epidural analgesia during their labor (n = 24). Subjects rated their pain throughout labor and completed pre- and postlabor questionnaires. RESULTS: Women who requested epidural analgesia for pain during labor reported significantly lower pain scores than those women who had natural childbirth (P <.001). However, 88% of women who requested an epidural for pain reported being less satisfied with their childbirth experience than those who did not, despite lower pain intensity. Antenatal survey results suggest that concerns about epidurals and their effect on the baby, greater than anticipated labor pain, perceived failure of requesting an epidural, and longer duration of labor may have accounted for these findings. CONCLUSIONS: This study examined the influence of epidural analgesia in parturients electing natural childbirth. Pain relief alone was not found to improve maternal satisfaction. This study highlights the importance of experience and prelabor expectations on maternal satisfaction with childbirth. Reg Anesth Pain Med 2001;26:468-472.
PMID: 11561269, UI: 21445367
Reg Anesth Pain Med 2001 Sep-Oct;26(5):414-9
Laboratory of Pain Physiology, Department of Anaesthesiology, Herlev Hospital, Denmark.
Background and Objectives: Adenosine is an endogenous compound that may have analgesic effects. Results from clinical trials are not consistent, however, and there is a need for large-scale, randomized, placebo-controlled studies to clarify the role of adenosine in the treatment of pain states, including acute nociceptive pain and pain involving central sensitization. METHODS: The analgesic and antihyperalgesic effect of systemic adenosine on the heat/capsaicin sensitization model of experimental pain was investigated in 25 healthy human volunteers. Sensitization was produced by heating the skin to 45 degrees C for 5 minutes, followed by a 30-minute application of 0.075% capsaicin cream, and maintained by periodically reheating the sensitized skin to 40 degrees C for 5 minutes at 40-minute intervals. Subjects received intravenous adenosine 60 &mgr;g/kg/min or saline for 85 minutes. Areas of secondary hyperalgesia to von Frey hair and brush stimulation, heat-pain detection thresholds (HPDTs) in normal and sensitized skin, and painfulness of stimulation with 45 degrees C for 1 minute (LTS) in normal skin were quantified before, during, and after study drug infusion. RESULTS: Systemic adenosine had no effect on the area of secondary hyperalgesia to von Frey hair or brush stimulation, HPDT in normal or sensitized skin, or painfulness of LTS in normal skin. CONCLUSION: We conclude that adenosine has no effect on acute nociceptive pain induced by heat stimulation or on secondary hyperalgesia induced by heat/capsaicin sensitization in healthy volunteers. Reg Anesth Pain Med 2001;26:414-419.
PMID: 11561260, UI: 21445358
Reg Anesth Pain Med 2001 Sep-Oct;26(5):389-93
Department of Anesthesia, New England Medical Center, Boston, Massachusetts.
PMID: 11561256, UI: 21445354
Reg Anesth Pain Med 2001 Jul-Aug;26(4):363-7
Department of Anesthesiology, Northwestern University Medical School, Chicago, Illinois 60611, USA.
BACKGROUND AND OBJECTIVES: Cerebrospinal fluid (CSF) leakage secondary to surgery of the spine is usually treated by drainage of CSF through a subarachnoid catheter or surgical repair of the dural tear. We present 2 cases in which the pseudomeningocele was treated by aspiration of the leaked CSF and blood patch under computed tomography (CT) guidance. CASE REPORT: Two patients had headache after spine surgery. Physical examination showed a bulging accumulation of fluid at the laminectomy site. Aspiration of the fluid followed by injection of the patients' blood was performed aseptically under CT guidance. The patients had resolution of their headache, and follow-up showed no recurrence of the CSF leak. CONCLUSIONS: CSF leak secondary to a surgical tear of the dura can be successfully treated by aspiration of the fluid followed by injection of the patient's blood. CT guidance is recommended to assess the extent of the CSF leakage, determine the degree of evacuation of the leaked CSF, and to confirm the injection of the blood into the epidural space and the space created by the pseudomeningocele.
PMID: 11464358, UI: 21357127
Reg Anesth Pain Med 2001 Jul-Aug;26(4):352-6
Department of Anesthesiology and Pain Management, Cook County Hospital, Chicago, IL, USA.
BACKGROUND AND OBJECTIVES: Over the past 10 years, several studies have suggested that the addition of certain opiates to the local anesthetic used for brachial block may provide effective, long-lasting postoperative analgesia. One of these studies indicated that the agonist-antagonist, buprenorphine, added to bupivacaine provided a longer period of postoperative analgesia than the traditional opiates, but in this study, it is impossible to determine the relative contributions of the local anesthetic and the opiate to the postoperative analgesia because of the extremely long duration of the anesthesia provided by the local anesthetic, bupivacaine. By repeating the study using a local anesthetic of a shorter duration, the present study delineates more clearly the contribution of the buprenorphine to postoperative analgesia when added to a shorter-acting local anesthetic. METHODS: Forty, healthy, consenting adult patients scheduled for upper extremity surgery were enrolled in the study. Premedication was provided by intravenous midazolam 2 mg/70 kg and anesthesia by a subclavian perivascular brachial plexus block. The patients were assigned randomly to 1 of 2 equal groups based on the agents used for the blocks. The patients in group I received 40 mL of a local anesthetic alone, while those in group II received the same local anesthetic plus buprenorphine 0.3 mg. The study was kept double-blind by having 1 anesthesiologist prepare the solutions, a second anesthesiologist perform the blocks, and a third anesthesiologist monitor the anesthesia and analgesia thereafter, up to and including the time of the first request for an analgesic medication. The data were reported as means (+/- SEM), and differences between groups were determined using repeated measures of analysis of variance (ANOVA) and chi(2), followed by the Fisher exact test for post hoc comparison. A P value of less than.05 was considered to be statistically significant. RESULTS: The mean duration of postoperative pain relief following the injection of the local anesthetic alone was 5.3 (+/- 0.15) hours as compared with 17.4 (+/- 1.26) hours when buprenorphine was added, a difference that was statistically (and clinically) significant (P <.0001). CONCLUSIONS: The addition of buprenorphine to the local anesthetic used for brachial plexus block in the present study provided a 3-fold increase in the duration of postoperative analgesia, with complete analgesia persisting 30 hours beyond the duration provided by the local anesthetic alone in 75% of the patients. This practice can be of particular benefit to patients undergoing ambulatory upper extremity surgery by providing prolonged analgesia after discharge from the hospital.
PMID: 11464356, UI: 21357125
Reg Anesth Pain Med 2001 Jul-Aug;26(4):348-51
Department of Anesthesiology and Critical Care Medicine, Hospital of the Philipps-University, Marburg, Germany. wulf@mailer.uni-marburg.de
BACKGROUND AND OBJECTIVE: The aim of this study was to evaluate the pharmacokinetics, feasibility, and clinical effects of ropivacaine in regional anesthesia (ilioinguinal-iliohypogastric blocks [IIB], genitofemoral block plus local infiltration) for inguinal hernia repair. METHODS: Following ethics committee approval and informed consent, 21 male adults received 60 mL ropivacaine 0.5% (without vasoconstrictor). In 11 patients, further injections of 5 to 10 mL were given while preparing the hernial sack. Plasma concentration of ropivacaine was determined in venous blood after 10, 20, 30, 45, 60, 90, 120, and 300 minutes using reversed-phase high pressure liquid chromatography (HPLC). RESULTS: Peak plasma concentrations of ropivacaine were 1.5 +/- 0.6 (0.7 to 2.6) microg/mL (mean +/- SD [range]). These maximum concentrations occurred after 45 (30 to 60) minutes (median [range]). No signs of central nervous or cardiovascular toxicity were observed. Twelve of 21 patients did not need any additional analgesics within 24 hours postoperatively. One patient had a femoral motor block lasting 6 hours, 5 patients reported sensory femoral block lasting 5 to 12 hours. Patients, as well as the surgeon, were very satisfied with the procedure, and all patients stated that they would like to have it performed again that way in case of an inguinal hernia on the opposite side. CONCLUSION: A ropivacaine dose of 60 to 70 mL of 0.5% appears adequate for regional anesthesia for inguinal hernia repair regarding conditions for surgery, safety, ambulation, and postoperative pain relief.
PMID: 11464355, UI: 21357124
Reg Anesth Pain Med 2001 Jul-Aug;26(4):342-7
Centre Medico-Chirurgical Saint-Vincent, Rennes, France.
BACKGROUND AND OBJECTIVE: Clonidine and neostigmine have a central mechanism of analgesic action and are synergistic when given intrathecally. Both drugs also have a peripheral analgesic effect. The purpose of this study was to compare the analgesic effect of intraarticular clonidine and neostigmine, used separately and in combination, in patients undergoing knee arthroscopy. METHODS: Eighty-four American Society of Anesthesiologists (ASA) I and II patients scheduled for meniscus repair under arthroscopy were allocated randomly in 6 groups to receive in a double-blind manner at the end of surgery 150 microg of intraarticular clonidine with subcutaneous saline, 500 microg of intraarticular neostigmine with subcutaneous saline, an intraarticular combination of 150 microg of clonidine and 500 microg of neostigmine with subcutaneous saline, 150 microg of intraarticular clonidine with 500 microg of subcutaneous neostigmine, 500 microg of intraarticular neostigmine with 150 microg of subcutaneous clonidine, or intraarticular and subcutaneous isotonic saline. Postoperative pain scores were measured on a visual analog scale (VAS) at rest and on mobilization. Paracetamol (1 g) was given as a rescue medication when pain score was greater than 40. RESULTS: VAS scores at rest and on mobilization were lower in the first 5 groups compared with the intraarticular saline group (P <.05), but no significant difference was documented between the treated groups. The time to the first paracetamol administration was shorter in the saline group compared with the other groups, and the paracetamol demand was also higher in this group. Forty-five percent of the patients who had received clonidine had at least 1 episode of hypotension versus 4% of those who did not (P <.01). The incidence of bradycardia was 20% and 0%, respectively (P =.01). The incidence of nausea was not statistically different in patients who did and did not receive neostigmine (43% v. 36%, respectively). CONCLUSION: Intraarticular administration of 150 microg of clonidine, 500 microg of neostigmine, or both produce postoperative analgesia, and the combination is not more effective.
PMID: 11464354, UI: 21357123
Reg Anesth Pain Med 2001 Jul-Aug;26(4):301-5
Albuquerque Veterans Administration Hospital, Albuquerque, New Mexico, USA.
BACKGROUND AND OBJECTIVES: We investigated whether the injection of 10 mL of normal saline into the subarachnoid space following accidental dural puncture reduced the incidence of postdural puncture headache (PDPH) and the need for epidural blood patch (EBP). METHODS: Twenty-eight patients who experienced accidental dural puncture with an epidural needle had 10 mL of normal saline injected into the subarachnoid space. In 22 patients, the injection was performed immediately through the epidural needle. In 6 patients who had intrathecal catheters placed through the epidural needle, the saline was injected through the catheter before removal. All other patients who experienced wet taps during the same period that the study was in progress but did not receive the saline injection served as a control group, 26 in number. Patients with severe or persistent PDPHs were treated with EBP. RESULTS: Of those patients who received intrathecal normal saline immediately through the epidural needle, 32% developed a headache compared with 62% of controls. Of these, 1 patient who received saline required EBP compared with nine in the control group (P =.004). Of those patients who had intrathecal catheters placed, there were no headaches in the saline group of 6 compared with 3 in the control group of 5, 1 of whom was treated with EBP (P >.05). CONCLUSIONS: The immediate injection of 10 mL intrathecal normal saline after a wet tap significantly reduced the incidence of PDPH and the need for EBP. When an intrathecal catheter had been placed following a wet tap, injection of 10 mL of normal saline before its removal effectively prevented PDPH.
PMID: 11464346, UI: 21357115
Reg Anesth Pain Med 2001 Jul-Aug;26(4):293-5
PMID: 11464343, UI: 21357112
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