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Am J Emerg Med 2003 Jan;21(1):39-42
Department of Emergency Medicine, University of Florida Health Science Center, Jacksonville, FL 32610, USA.
The purpose of the present study was to compare the use of lorazepam plus nitroglycerine (NTG) versus NTG alone in the reduction of cocaine induced chest pain in the emergency department. The secondary objective of the study was to help determine the safety of lorazepam in the treatment of cocaine- associated chest pain. The study was a prospective, randomized, single-blinded, controlled trial conducted at an university-affiliated urban emergency department (ED). All patients who presented with cocaine-associated chest pain were enrolled. Exclusion criteria included age greater than 45 years, documented coronary artery disease, chest pain of more than 72 hours duration, or pretreatment with nitroglycerin. Patients were given either sublingual nitroglycerine (SL NTG) (Group 1) or SL NTG plus 1 mg of lorazepam intravenously (Group 2) every 5 minutes for a total of 2 doses. Chest pain was recorded on an ordinal scale of 0 to 10 at baseline, and then at 5 minutes after each dose. Adverse reactions to medication were also recorded. Twenty-seven patients met the inclusion criteria and were enrolled in the study. The average age of these subjects was 34.1 years, and 67% were men. The NTG-only group consisted of 15 patients and the NTG-plus-lorazepam group consisted of 12 patients. Baseline mean chest-pain scores were 6.87 in Group 1 and 6.54 in Group 2, with no differences between groups. Five minutes after initial treatment, mean scores for the two groups were 5.2 and 3.9, respectively, with a difference in means of 1.24 (95% confidence interval [CI] -0.8-3.8). Five minutes after the second treatment, the mean scores were 4.6 and 1.5, respectively, with a difference in means of 3.1 (95% CI 1.2-5). Kruskal-Wallis testing showed a significant difference in pain relief between the two study groups (P =.003), with greater pain relief noted at 5 and 10 minutes in the NTG-plus-lorazepam group (P =.02 and P =.005, respectively). All patients in the study were admitted to the hospital, but no patient in either group had an acute myocardial infarction or cardiac complications in the ED. No adverse side effects were noted for either group. The early use of lorazepam with NTG was more efficacious than NTG alone, and appears to be safe in relieving cocaine-associated chest pain. Copyright 2003, Elsevier Science (USA). All rights reserved.)
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PMID: 12563578, UI: 22449929
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Am J Emerg Med 2003 Jan;21(1):35-8
Department of Anesthesia and Intensive Care Medicine, Helsinki University Hospital, Helsinki, Finland.
The risk of respiratory depression can prevent the proper use of opioids in trauma patients and lead to use of supplemental oxygen. However, high FiO(2) might contribute to atelectasis formation and consequently to relative hypoxia. Supplemental oxygen also can cause a risk of fire. In a randomized, controlled study we evaluated the need and effects of supplemental oxygen in 13 patients with extremity trauma who were treated pain-free with an intravenous opioid, oxycodone (dose range 6.75-13.6 mg). After opioid injection, 7 patients received 40% supplemental oxygen and 6 were breathing room air. Pulse oxygen saturation (SpO(2)), arterial blood gases, and hemodynamic parameters were monitored for 30 minutes. Atelectasis formation was evaluated with a computed tomography scan. No hypoxia, hypoventilation, or significant atelectasis formation was detected in any of the patients. Accordingly, routinely given supplemental oxygen was not considered necessary in these patients because no complications were seen. Copyright 2003, Elsevier Science (USA). All rights reserved.)
PMID: 12563577, UI: 22449928
Anesth Analg 2003 Mar;96(3):789-95
Post-Anesthesia Care Unit, Tel Aviv Sourasky Medical Center, and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
[Medline record in process]
It is a common clinical observation that postoperative pain may be resistant to morphine. The analgesic potentials of ketamine have also been well documented. In this study, we evaluated the effects of postoperative coadministration of small doses of ketamine and morphine on pain intensity, SpO(2), and subjectively rated variables in surgical patients who underwent standardized general anesthesia and complained of pain (>/=6 of 10 on a visual analog scale [VAS]) despite >0.1 mg/kg of IV morphine administration within 30 min. Patients randomly received up to three boluses of 30 micro g/kg of morphine plus saline (MS; n = 114) or 15 micro g/kg of morphine plus 250 micro g/kg of ketamine (MK; n = 131) within 10 min in a double-blinded manner. The MS group's pain VAS scores were 5.5 +/- 1.18 and 3.8 +/- 0.9 after 10 and 120 min, respectively, after 2.52 +/- 0.56 injections, versus the MK group's VAS scores of 2.94 +/- 1.28 and 1.47 +/- 0.65, respectively (P < 0.001), after 1.35 +/- 0.56 injections (P < 0.001). The 10-min level of wakefulness (1-10 VAS) in the MS group was significantly (P < 0.001) less (6.1 +/- 1.5) than the MK group's (8.37 +/- 1.19). SpO(2) decreased by 0.26% in the MS group but increased by 1.71% in the MK patients at the 10-min time point (P < 0.001). Thirty MS versus nine MK patients (P < 0.001) experienced nausea/vomiting; nine MK patients sustained a 2-min light-headed sensation, and one patient had a weird dream after the second drug injection. IMPLICATIONS: A small-dose ketamine and morphine regimen interrupted severe postoperative pain that was not relieved previously by morphine. Ketamine reduced morphine consumption and provided rapid and sustained improvement in morphine analgesia and in subjective feelings of well-being, without unacceptable side effects.
PMID: 12598264, UI: 22486029
Anesth Analg 2003 Mar;96(3):694-5
Department of Pediatric Anesthesiology, Children's Memorial Hospital, Northwestern University's Feinberg School of Medicine, Chicago, Illinois.
IMPLICATIONS: We report our experience with ketorolac/lidocaine IV regional anesthesia (Bier block) (IVRA) in two adolescents with complex regional pain syndrome 1. IVRA resulted in complete resolution of symptoms.
PMID: 12598246, UI: 22486011
Anesthesiology 2003 Mar;98(3):781-3
*Staff Anesthesiologist, dagger Professor and Chairman, Department of Anesthesiology and Intensive Care, Hamamatsu University School of Medicine. double dagger Director of Anesthesiology, Shizuoka General Hospital.
PMID: 12606926, UI: 22494332
Anesthesiology 2003 Feb;98(2):571-3
Klinik fur Anasthesiologie und Intensivmedizin, Universitatsklinikum Essen, Germany. christa.breitfeld@uni-essen.de
PMID: 12552218, UI: 22437801
Anesthesiology 2003 Feb;98(2):495-8
Hospital das Clinicas, Department of Biomechanics, Medicine and Rehabilitation, Faculty of Medicine of Ribeirao Preto, University of Sao Paulo, Brazil.
BACKGROUND: The purpose of this study was to determine whether combination of 1-5 microg intrathecal neostigmine would enhance analgesia from a fixed intrathecal dose of morphine. METHODS: A total of 60 patients undergoing gynecologic surgery were randomized to one of five groups. Patients received 15 mg bupivacaine plus 2 ml of the test drug intrathecally (saline, 100 microg morphine, or 1-5 microg neostigmine). The control group received spinal saline as the test drug. The morphine group received spinal morphine as test drug. The morphine + 1 microg neostigmine group received spinal morphine and 1 microg neostigmine. The morphine + 2.5 microg neostigmine group received spinal morphine and 2.5 microg neostigmine. Finally, the morphine + 5 microg neostigmine group received spinal morphine and 5 microg neostigmine. RESULTS: The groups were demographically similar. The time to first rescue analgesic (minutes) was longer for all patients who received intrathecal morphine combined with 1-5 microg neostigmine (median, 6 h) compared with the control group (median, 3 h) (P < 0.02). The morphine group (P < 0.05) and the groups that received the combination of 100 microg intrathecal morphine combined with neostigmine (P < 0.005) required less rescue analgesics in 24 h compared with the control group. The incidence of perioperative adverse effects was similar among groups (P > 0.05). CONCLUSIONS: The addition of 1-5 microg spinal neostigmine to 100 microg morphine doubled the duration to first rescue analgesic in the population studied and decreased the analgesic consumption in 24 h, without increasing the incidence of adverse effects. The data suggest that low-dose spinal neostigmine may improve morphine analgesia.
PMID: 12552210, UI: 22437793
Anesthesiology 2003 Feb;98(2):485-94
Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada.
BACKGROUND: The objectives of this study were to compare the incidence, onset, duration and pain scores of transient neurologic symptoms (TNS) with 1% versus 5% hyperbaric lidocaine in spinal anesthesia for short urological procedures in a large prospective study. This study would also evaluate patient satisfaction, and impact of TNS on functional recovery to assess the clinical significance of TNS. METHODS: This was a multicenter, double-blind, randomized controlled trial. Four hundred fifty-three patients undergoing short transurethral procedures were randomized to receive 1% or 5% hyperbaric lidocaine. Eighty milligrams of 1% or 5% hyperbaric lidocaine was administered. During the first 3 days after surgery, the presence of TNS, its intensity and duration, and patient functional level were recorded. An intention-to-treat analysis was used. RESULTS: There was no difference in the incidence of TNS (21% vs. 18%) between 1% versus 5% lidocaine. Patients with TNS had significantly higher pain scores (5.3 +/- 3 vs. 2.3 +/- 3) than patients without TNS during the first 24 h. This difference in pain scores persisted until 72 h postoperatively. There was a significant difference in the daily activities functional scores (2.2 +/- 1 vs. 1.4 +/- 0.8) of TNS non-TNS patients during the first 24 h postoperatively. CONCLUSIONS: There was no difference in the incidence of TNS between the 1% versus 5% spinal lidocaine groups. Pain scores were higher in patients with TNS than those who did not have TNS. During the first 48 h postop, a small proportion of patients who had TNS experienced functional impairment of walking, sitting, and sleeping.
PMID: 12552209, UI: 22437792
Br J Anaesth 2003 Feb;90(2):166-72
Pharmacia, 5200 Old Orchard Road, Skokie, IL 60077, USA. richard.c.hubbard@pharmacia.com
BACKGROUND: This multicentre, double-blind, placebo-controlled study compared the opioid-sparing effectiveness and clinical safety of parecoxib sodium over 48 h, in 195 postoperative patients after routine total knee replacement surgery. METHODS: Elective total primary knee arthroplasty was performed under spinal anaesthesia, with a single dose of spinal bupivacaine 10-20 mg, and intraoperative sedation with midazolam 0.5-1.0 mg i.v., or propofol <6 mg kg(-1)h(-1). Patients were randomized to receive either parecoxib sodium 20 mg twice daily (bd) i.v. (n=65), parecoxib sodium 40 mg bd i.v. (n=67), or placebo (n=63) at the completion of surgery, and after 12, 24, and 36 h. Morphine (1-2 mg) was taken by patient-controlled analgesia or by bolus doses after 30 min. RESULTS: Patients receiving parecoxib sodium 20 mg bd and 40 mg bd consumed 15.6% and 27.8% less morphine at 24 h than patients taking placebo (both P<0.05). Both doses of parecoxib sodium administered with morphine provided significantly greater pain relief than morphine alone from 6 h (P<0.05). A global evaluation of study medication demonstrated a greater level of satisfaction among patients taking parecoxib sodium than those taking placebo. Parecoxib sodium administered in combination with morphine was well tolerated. However, a reduction in opioid-type side-effects was not demonstrated in the parecoxib sodium groups. CONCLUSION: Parecoxib sodium provides opioid-sparing analgesic effects in postoperative patients.
PMID: 12538372, UI: 22425671
Eur J Anaesthesiol 2002 Aug;19(8):616-7
PMID: 12200956, UI: 22189795
Eur J Anaesthesiol 2002 Aug;19(8):589-93
Hospital Universitari de Girona Dr. Josep Trueta, Department of Anesthesia, Av. de Franca s/n., E-17007 Girona, Catalonia, Spain. anestesia@htrueta.scs.es
BACKGROUND AND OBJECTIVE: The alpha 2-adrenoceptor agonist clonidine has potent central antinociceptive properties. The study was designed to investigate the effects of the combined subarachnoid administration of clonidine and prilocaine on spinal block and postoperative analgesia for the transurethral resection of tumours in the urinary bladder. METHODS: The controlled, prospective, double-blind study enrolled 40 patients scheduled for elective transurethral resection of bladder tumours under spinal anaesthesia with prilocaine. Patients were randomly assigned to receive an intrathecal injection of prilocaine 75 mg alone (control group) or in combination with clonidine 75 micrograms. We assessed haemodynamic changes (non-invasive arterial pressure, heart rate), pulse oximetry, the upper level of block, the onset and duration of sensory and motor block, postoperative analgesia and any adverse effects. RESULTS: There were no statistically significant differences in demographic data, heart rate, onset time or the levels of sensory or motor block. Analgesia lasted significantly longer in the clonidine group (498.4 +/- 226.9 versus 187.2 +/- 103.1 min; P < 0.05). The duration of motor block was longer in the clonidine group (165.5 +/- 30.6 min) than in the control group (139.7 +/- 40.4 min; P < 0.05) and the duration of sensory block was also longer in the clonidine group (157.3 +/- 24.5 min) than in the control group (137.2 +/- 31.2 min; P < 0.05). Fewer patients in the recovery room needed metamizol (dipyrone) in the clonidine group (5%) than in the control group (50%). Arterial pressure decreased significantly in the clonidine group 75-135 min after the block. CONCLUSIONS: The addition of clonidine 75 micrograms to prilocaine 75 mg for subarachnoid anaesthesia increased the duration of sensory and motor block and reduced the need for additional postoperative analgesics by providing excellent analgesia for about 8 h during recovery from transurethral resection of bladder tumours.
PMID: 12200949, UI: 22189788
J Pain Symptom Manage 2003 Feb;25(2 Suppl):21-31
Department of Family Practice, Michigan State University College of Medicine, East Lansing, MI, USA
The role of the coxibs in the management of osteoarthritis and rheumatoid arthritis has been widely discussed, but there are other potential applications for the coxibs that have received less attention. Here we consider the use of the coxibs in acute pain syndromes such as primary dysmenorrhea and the pain associated with dental extraction, as well as considering their application in chronic low back pain and cancer pain. Another area where the coxibs may prove particularly beneficial is in the management of post-surgical pain. Traditional post-surgical analgesia has involved the use of non-selective NSAIDs and opioids, but these agents can be associated with side effects such as post-operative bleeding, gastrointestinal problems, nausea, and constipation. Because the coxibs do not inhibit COX-1 dependent platelet aggregation like traditional NSAIDs, the risk of post-surgical bleeding is reduced. The careful application of coxibs as part of a multi-modal approach to pain management in the perioperative period can reduce the requirement for opioid medications and thus reduce the risk of post-operative complications such as ileus. In the future, coxibs are likely to play an important role in multi-modal perioperative analgesic regimens with the aim of reducing post-operative periods of convalescence.
PMID: 12604154, UI: 22492880
J Pain Symptom Manage 2002 Nov;24(5):455
PMID: 12547043, UI: 22435958
Neurology 2003 Feb 11;60(3):520
Department of Neurosurgery, Walton Centre for Neurology and Neurosurgery, Liverpool, England.
PMID: 12578946, UI: 22467169
Spine 2002 Dec 15;27(24):E518-25; discussion E526-7
International Spinal Development & Research Foundation, Las Vegas, NV 89106, USA. spine@spine-research.org
STUDY DESIGN: A retrospective review of 20 patients undergoing circumferential lumbar fusion with coralline hydroxyapatite blocks anteriorly and autograft with transpedicular or translaminar facet screw fixation posteriorly. OBJECTIVES: To examine the efficacy of coralline hydroxyapatite as a bone graft substitute for anterior lumbar interbody fusion. SUMMARY OF BACKGROUND DATA: Autograft is the gold standard for bone grafting in the anterior lumbar spine. Harvesting bone from the iliac crest leads to significant postoperative pain and morbidity. Femoral ring allograft is a widely used alternative to autograft but has some inherent problems. Coralline hydroxyapatite was shown to be 100% successful for anterior cervical fusion when combined with rigid plating. METHODS: A retrospective review of 20 patients with low back pain and indicated for surgical intervention. A circumferential instrumented fusion was performed with coralline hydroxyapatite blocks anteriorly and transpedicular or translaminar facet fixation and autograft posteriorly. All patients reached a minimum 3-year clinical and radiologic follow-up. RESULTS: Radiographic follow-up yielded a solid arthrodesis rate of 93.8% by level (30 of 32 disc spaces) and 90% by patient (18 of 20). Clinical follow-up generated a mean pain reduction of 61.8% with clinical success demonstrated in 80% (16 of 20) of all patients who reported good or excellent pain relief. Eight of 12 (66.7%) patients employed before surgery returned to work in some capacity. CONCLUSIONS: Coralline hydroxyapatite is a practicable anterior lumbar interbody fusion alternative to autograft and allograft as part of a circumferential fusion with rigid posterior fixation. It is not recommended for stand-alone anterior lumbar interbody fusion without further study.
PMID: 12486360, UI: 22374685
Spine 2002 Dec 15;27(24):2747-52
Medical Research Unit in Ringkjobing County, Denmark. fekl@ringamt.dk
SUMMARY OF BACKGROUND DATA: Back schools may be effective in treating back problems, but there is conflicting evidence of the effect on prevention. OBJECTIVES: To investigate if passive prone extensions of the back can prevent back problems. STUDY DESIGN: Prospective, randomized controlled intervention trial. METHODS: In total, 314 male conscripts were randomized into two groups. After randomization, 65 conscripts dropped out for administrative reasons, leaving 249 conscripts to participate fully in the study. Data were collected through questionnaires at the start of military duty and after 10 months. All conscripts in the intervention group had one 40-minute theoretical lesson on back problems and ergonomics and had to perform passive prone extensions of the back daily during the rest of their military duty. The control group had no intervention. Outcome variables were as follows: 1) number of persons with self-reported back problems during the last 3 weeks; 2) number of persons with self-reported back problems during the last year; and 3) number of persons who reported having consulted the regiment medical physician with back problems during their military service. RESULTS: In an intention-to-treat analysis, significantly fewer persons in the intervention group versus those in the control group reported back problems during the last year (33% versus 51%), and the number needed to prevent was 6. Significantly fewer persons in the intervention group versus those in the control group consulted the regiment infirmary (9% versus 25%), and the number needed to prevent was 6. CONCLUSION: It may be possible to reduce the prevalence rate of back problems and the use of health care services during military service, at a low cost, using passive prone extensions of the back motivated by a back school approach, including the theory of the disc as a pain generator and ergonomic instructions.
PMID: 12486341, UI: 22374666