Incisional morphine has no analgesic effect on postoperative pain following inguinal herniotomy.
Rosenstock C. Rasmussen H. Andersen G. Lund C.
Department of Anesthesia, Herlev University Hospital, University of Copenhagen, Denmark.
BACKGROUND AND OBJECTIVES: Opioids induce antinociceptive effects after peripheral administration in experimental and clinical studies. The results of the clinical studies are conflicting. The objective of this study was to examine a possible analgesic effect of incisionally administered morphine on postoperative pain in patients undergoing inguinal herniotomy during general anesthesia. METHODS: Forty-six consecutive outpatients were included in a double-blind, randomized, placebo-controlled study. At conclusion of herniotomy 5 mg morphine was injected incisionally in 11 patients, intravenously in 10, and subcutaneously in 13. The placebo group of 12 had saline injected in the incision. Postoperative pain at rest and during mobilization was assessed with a visual analog scale. Assessments were made immediately before and after herniotomy, at 2, 4, and 6 hours after surgery, and on the second and seventh postoperative day. Postoperative morphine and acetaminophen consumptions were recorded within the same period. RESULTS: There were no significant differences in visual analog scores between the groups at any time during the study. Overall differences in postoperative acetaminophen and morphine consumptions were insignificant. CONCLUSIONS: The analgesic effect of a single 5 mg dose of morphine injected in a herniotomy wound is not superior to saline or to morphine given subcutaneously or intravenously.
Intrathecal addition of morphine to bupivacaine is not the cause of postoperative nausea and vomiting.
Weber EW. Slappendel R. Gielen MJ. Dirksen R.
Department of Anesthesiology, Nijmegen, The Netherlands.
BACKGROUND AND OBJECTIVES: Postoperative nausea and vomiting after anesthesia is an distressing side effect. This study was undertaken to determine to what extent spinal opioids contribute to postoperative nausea and vomiting (PONV) and secondly to how effectively metoclopramide can reduce the incidence of PONV after intrathecal administration of morphine. METHODS: Patients were allocated to three groups all undergoing major joint surgery of the lower limb. In group 1 (n = 200), intrathecal anesthesia was assessed by administration of 20 mg bupivacaine and 0.2 mg morphine. In Group 2 (n = 100) intrathecal anesthesia was assessed in the same way and in addition, 20 mg metoclopramide intramuscular during maintenance of anesthesia and a second dose of 20 mg metoclopramide was administered intramuscular after arrival at the recovery room. Finally, in group 3 (n = 100), intrathecal anesthesia was assessed after administration of 20 mg bupivacaine. RESULTS: The maximum PONV percentages were 41.1%, 32.7%, and 37% in groups 1, 2, and 3, respectively. The consumption of antiemetics was similar in all groups. The number of patients who needed one or more additional antiemetics during the first 24 hours after surgery was 112 (56.6%), 57 (58%), and 60 (60%) in groups 1, 2, and 3, respectively. CONCLUSIONS: Administration of metoclopramide did not reduce the overall incidence of PONV. Our study shows no relationship between the use of intrathecal morphine and the incidence of PONV during the first 24 hours postoperative.
Pain evaluation in the intensive care unit: observer-reported faces scale compared with self-reported visual analog scale.
Terai T. Yukioka H. Asada A.
Department of Anesthesiology and Intensive Care Medicine, Osaka City University Medical School, Osaka, Japan.
BACKGROUND AND OBJECTIVES: The visual analog scale (VAS) is a simple and sensitive mean of pain assessment. The faces scale is also a simple, self-reporting method for children. Facial signs of pain have not been used to assess pain in postoperative adult patients in the intensive care unit (ICU). METHODS: Fifty patients undergoing esophageal cancer surgery by a thoracoabdominal procedure were studied. Epidural opioids, such as morphine or buprenorphine, combined with bupivacaine were administered during and after surgery. Pain measurement was performed by a physician in the ICU using the self-reported VAS 0.5, 1, 2, 4, and 6 hours after tracheal extubation and thereafter every 4 hours during the stay in the ICU. A nurse who was unaware of the patients' VAS scores assessed facial expression as a measure of pain intensity using a five-grade faces scale immediately before pain evaluation by VAS. The VAS was rescaled into five discrete units that would match the five faces scale scores. Weighted kappa statistics were used to establish a relative level of agreement between the five-grade VAS and faces scale. RESULTS: Good agreement was found between the five-grade VAS and the faces scale 30 minutes and 1 hour after tracheal extubation (weighted kappa values .67 and .62, respectively). The VAS and faces scales were measured 7-13 times per patient during the stay in the ICU, and 518 observations were collected. Although moderate agreement was found between the five-graded VAS and faces scale for all pairs of observation (weighted kappa values .54), less agreement was found between them in patients with moderate pain. In addition, the calculated mean differences between the five-graded VAS and faces scale differed significantly between patients. CONCLUSION: The faces scale may be useful for pain evaluation in the ICU.
Addition of bupivacaine to sufentanil in patient-controlled epidural analgesia after lower limb surgery in young adults: effect on analgesia and micturition.
Vercauteren MP. Van Den Bergh L. Kartawiadi SL. Van Boxem K. Hoffmann VL.
University Hospital Antwerp, Edegem, Belgium.
BACKGROUND AND OBJECTIVES: The usefulness of adding bupivacaine to an opioid administered by the epidural route is controversial. This study examines both the quality of pain relief and side effects, in particular urinary retention, during patient-controlled epidural analgesia (PCEA) with sufentanil alone or in combination with two different concentrations of bupivacaine. METHODS: In a double-blind randomized study, 60 healthy young adults undergoing open knee or ankle surgery with combined spinal-epidural anesthesia received postoperative analgesia via PCEA with sufentanil alone or with 0.06% or 0.12% bupivacaine. In addition to pain scores at rest and during mobilization, bladder function was evaluated. Strict criteria were respected in scoring the occurrence of problems suggestive of urinary retention. The 24-hour analgesic consumption and the incidence of other side effects were also recorded. RESULTS: Patients receiving bupivacaine had better pain relief than those receiving only the opioid, but this difference was more pronounced when measuring dynamic pain scores. The consumption of sufentanil was significantly higher in the group receiving the opioid alone than in the group receiving 0.06% bupivacaine. The bupivacaine dose requirements were twice as high with the 0.12% concentration. Bladder problems occurred significantly more frequently in patients treated with the highest bupivacaine concentration. Motor impairment was not a major problem. CONCLUSIONS: A 0.06% bupivacaine-sufentanil combination offered the best results in terms of analgesic quality and lower side effects, mainly micturition problems, which may be explained by the higher consumption of local anesthetic at the higher bupivacaine concentration. Analgesic quality could not be improved by increasing the bupivacaine concentration.
High-dose ropivacaine wound infiltration for pain relief after inguinal hernia repair: a clinical and pharmacokinetic evaluation.
Pettersson N. Emanuelsson BM. Reventlid H. Hahn RG.
Department of Surgery, Huddinge University Hospital, Sweden.
BACKGROUND AND OBJECTIVES: Early data on ropivacaine, a recently introduced local anesthetic, indicate a longer duration of skin analgesia than with bupivacaine, along with lower toxicity. The objective of this study was to evaluate ropivacaine 7.5 mg/mL for wound infiltration pain relief after hernia surgery, in higher doses than used before, in an open, nonrandomized design. METHODS: Twenty otherwise healthy men underwent elective unilateral open hernia repair by the same surgeon. General anesthesia was used during surgery, and infiltration of the operating field with 300 mg (n = 10) or 375 mg (n = 10) ropivacaine, 7.5 mg/mL, was employed for postoperative pain relief. Any sign of an adverse event was recorded. Plasma concentrations of ropivacaine were monitored. Pain at rest and on mobilization was regularly assessed over 24 hours by a visual analog scale. Patients' ability to walk and void and the need for supplementary analgesics were recorded. RESULTS: No serious adverse effects occurred. Plasma concentrations showed large variations but no toxic levels. No significant differences between the two groups were detected in pain scores which were low in both groups, at rest or on mobilization, or in the consumption of supplementary analgesics. At 4 hours, 19 patients were able to walk. Within 8 hours of surgery, all patients had passed urine without any problem. Wound healing was normal. CONCLUSIONS: Infiltration of ropivacaine 7.5 mg/mL during hernia surgery can be employed safely in doses of 300 mg and 375 mg to control pain after hernia surgery. The lower dose is recommended, since the higher one did not give any clinically relevant advantages.
Cholestasis as a side effect of bupivacaine?
Wulf H. Leger R. Raetzell M. Olmer A. Scheiderer U.
Department of Anesthesiology and Intensive Care Medicine, Hospital of the Christian-Albrechts-University of Kiel, Germany.
BACKGROUND AND OBJECTIVES: Cholestasis has been proposed as a side effect of interpleural bupivacaine. Therefore, the effects of various application techniques on liver enzymes were studied following ethics committee approval and informed patient consent. METHODS: Patients following scheduled thoracotomy and laparoscopic cholecystectomy were prospectively studied and randomized to the following application techniques of bupivacaine: Thoracic surgery. T0: Control (systemic analgesia only: patient-controlled analgesia with opioids; n = 26); T1: Repetitive intercostal blocks (10-20 mL 0.5% bupivacaine, 2-4 times per day for 3-6 days; n = 17); T2: Interpleural injections via a catheter placed intraoperatively (20 mL 0.25%, 4-6 times per day for 3-6 days, right: n = 25 or left: n = 12). Laparoscopic cholecystectomy. Intraperitoneal application (single injection). L0: 50 mL saline (Control) (n = 21). L1: 50 mL 0.125% bupivacaine (n = 18); L2: 50 mL 0.25% (n = 20). The serum concentrations of bilirubin, gamma-GT, alkaline phosphatase, leucine amino peptidase, glutamate oxalacetate transaminase, and glutamate pyruvate transaminase were measured preoperatively and on day 1, 3, and 7 postoperatively. RESULTS: Neither application of plain bupivacaine was associated with significant changes in the postoperative concentration of hepatic enzymes. In particular, there was no difference between left- and right-sided interpleural application. Although increases in hepatic enzyme concentrations were observed in some patients postoperatively, this was similar in the bupivacaine and control groups. CONCLUSION: Perioperative interpleural, intercostal, and intraperitoneal administration of bupivacaine was not associated with findings indicative of cholestasis in the early postoperative course.
Paravertebral somatic nerve block for outpatient inguinal herniorrhaphy: an expanded case report of 22 patients.
Klein SM. Greengrass RA. Weltz C. Warner DS.
Department of Anesthesiology and Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA.
BACKGROUND AND OBJECTIVES: Inguinal herniorrhaphy is a common outpatient surgical procedure. However, anesthetic techniques for inguinal herniorrhaphy are still associated with numerous side effects. Paravertebral somatic nerve block (PSNB) has the potential advantage to offer unilateral abdominal wall anesthesia and long-lasting pain relief with minimal side effects. We report our initial trial of PSNB for outpatient inguinal herniorrhaphy. METHODS: Twenty-two patients received a PSNB at T10 to L2 using 5 mL of 0.5% bupivacaine with epinephrine 1:400,000 at each of the five levels. The onset of surgical anesthesia, duration of analgesia, side effects, and patient satisfaction with the technique were documented. RESULTS: Surgical anesthesia occurred 15-30 minutes after injection. Two patients had a failed block. The mean +/- SD time to onset of discomfort was 14 +/- 11 hours. Time until first narcotic requirement was 22 +/- 18 hours. Thirteen patients (n = 20) had no incisional discomfort 10 hours or longer after their blocks. Three patients had epidural spread. Most patients were very satisfied with their anesthetic technique. CONCLUSIONS: The results of our initial experience suggest that PSNB is a potentially safe and effective technique. In general, the block provided long-lasting pain relief in most patients with few side effects. A randomized study comparing paravertebral blocks with conventional anesthesia choices is suggested given the findings in this initial series of patients.