Anesthesia and analgesia
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Anesthesia and analgesia · Jan 2004
Randomized Controlled Trial Clinical TrialPreoperative rofecoxib oral suspension as an analgesic adjunct after lower abdominal surgery: the effects on effort-dependent pain and pulmonary function.
Rofecoxib is a selective cyclooxygenase-2 inhibitor that reduces pain and inflammation without inhibiting platelet function. We examined its effects on effort-dependent pain, postoperative morphine requirements, and pulmonary function in 48 patients recovering from open abdominal surgery. Spirometric measurement of forced expiratory volume(1) and vital capacity (FVC) were assessed preoperatively. One hour before the induction of a standardized general anesthetic, patients were given either placebo oral suspension (Group A), or rofecoxib oral suspension (25 mg [Group B] or 50 mg [Group C]) in a double-blinded manner. Postoperative pain control was provided with IV morphine in the postanesthesia care unit and IV-patient-controlled analgesia morphine on the patient care unit. Morphine dose, pain intensity at rest, and pain after respiratory effort (postoperative spirometry) were assessed at 12 and 24 h after study drug administration. The patient-controlled analgesia morphine dose at 24 h was reduced 44% in Group B (30.3 +/- 17.5 mg) and 59% in Group C (22.1 +/- 16.5 mg) versus Group A (53.7 +/- 31.1 mg); P < 0.01 (A versus B). At 12 h, pain scores at rest and after spirometry were lower in Groups B and C than in A (P < 0.05). At 24 h, resting pain scores were lowest in Group C (P < 0.05). Twelve-hour FVC was best preserved in Group C (P < 0.03). There were no inter-group differences in adverse effects or perioperative blood loss. Rofecoxib oral suspension provided a morphine-sparing effect, as well as improvements in pain control and 12-h FVC in patients recovering from open abdominal surgery. ⋯ Rofecoxib belongs to class of analgesics known as cyclooxygenase-2 inhibitors that reduce pain and inflammation with less risk of bleeding than standard nonsteroidal antiinflammatory drugs. We found that patients treated with rofecoxib 25 or 50 mg before open abdominal surgery required less IV morphine during the first day of recovery. Despite reductions in morphine requirements, rofecoxib-treated patients reported lower pain intensity scores at rest and after a vigorous cough. In the 50-mg group, improvements in pain control correlated with greater preservation of baseline cough effectiveness (vital capacity) at 12 h. These findings may offer clinical advantages in patients with preexisting pulmonary disease.
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Anesthesia and analgesia · Jan 2004
Randomized Controlled Trial Clinical TrialSpinal 2-chloroprocaine: the effect of added fentanyl.
Chloroprocaine is being investigated as a possible replacement for spinal lidocaine. Adding fentanyl to lidocaine increases the quality of spinal anesthesia without prolongation of block. We report the characteristics of 2-chloroprocaine (2-CP) spinal anesthesia with or without fentanyl in 8 volunteers receiving 40 mg 2-CP with saline or 20 micro g fentanyl in a double-blinded, randomized, crossover manner. Spinal anesthesia was successful for all subjects with complete block regression, ambulation, and void by 110 min. Itching occurred in all subjects receiving fentanyl, though medication was not required. No subject reported signs of transient neurological symptoms. Peak block with fentanyl averaged T5 (T3-7) and without fentanyl T9 (L1-T4) (P = 0.005). Regression to L1 was 78 +/- 7 min with fentanyl and 53 +/- 19 min without fentanyl (P = 0.02). Tourniquet was tolerated for 51 +/- 8 min with fentanyl and for 34 +/- 14 min without fentanyl (P = 0.02). Complete regression of block occurred at 104 +/- 7 min with fentanyl and by 95 +/- 9 min without fentanyl (P = 0.02). We conclude that 2-CP spinal anesthesia provides rapid onset and adequate potency, giving it a positive profile for ambulatory surgery. The addition of fentanyl lengthens regression to L1 and tourniquet tolerance while minimally lengthening block duration. ⋯ Spinal 2-chloroprocaine (40 mg) provides rapid onset and reliable blockade without signs of transient neurological symptoms, giving it a positive profile for ambulatory surgical settings. The addition of fentanyl appears to lengthen the regression to L1 dermatome and tourniquet time while minimally lengthening duration of block.
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Anesthesia and analgesia · Jan 2004
Randomized Controlled Trial Clinical TrialSpinal 2-chloroprocaine: the effect of added dextrose.
Spinal 2-chloroprocaine is being investigated as an alternative short-acting spinal anesthetic to replace lidocaine for outpatient surgery. Adding dextrose increases the baricity of solutions and alters the characteristics of spinal anesthesia. In this study, we compared 2-chloroprocaine spinal anesthesia performed with or without the addition of dextrose (1.1%). Eight volunteers underwent 2 spinal anesthetics, receiving 40 mg 2-chloroprocaine (2 mL, 2%) with 0.25 mL saline with one and 0.25 mL 10% dextrose with the other in a double-blinded, randomized, balanced crossover manner. Pinprick anesthesia, tolerance to transcutaneous electrical stimulation, and tourniquet, motor strength measurements, and time to ambulation and void were assessed. Postvoid residual bladder volume was measured via ultrasound. Spinal anesthesia was successful in all subjects and regressed within 110 (80-110) min. There was no significant difference in peak height T4 (T7-C6), time to achieve peak block height (14 +/- 6 min), time for 2-segment regression (44 +/- 9 min), regression to L1 (66 +/- 12 min), tolerance of tourniquet (43 +/- 9 min), or return of motor function (81 +/- 14 min). Mean postvoid residual volume was larger with dextrose (74 +/- 67 mL versus 16 +/- 35 mL; P = 0.02). No subject reported signs of transient neurologic symptoms (TNS). In conclusion, spinal 2-chloroprocaine provides adequate potency with reliable regression, seemingly without TNS. Adding dextrose does not significantly alter spinal block characteristics but increases residual bladder dysfunction. Therefore, the addition of glucose to 2-chloroprocaine for spinal anesthesia is not necessary. ⋯ Spinal chloroprocaine provides adequate potency with reliable regression, seemingly without concerns of transient neurologic symptoms, and hence an appealing profile for outpatient surgery. The addition of dextrose does not alter peak block height or tolerance of thigh tourniquet, and increases the degree of residual bladder dysfunction.
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Anesthesia and analgesia · Jan 2004
ReviewAre peripheral opioid antagonists the solution to opioid side effects?
Opioid medication is the mainstay of therapy for severe acute and chronic pain. Unfortunately, the side effects of these medications can affect patient comfort and safety, thus limiting their proven therapeutic potential. Whereas the main analgesic effects of opioids are centrally mediated, many of the common side effects are mediated via peripheral receptors. Novel peripheral opioid antagonists have been recently introduced that can block the peripheral actions of opioids without affecting centrally mediated analgesia. We review the clinical and experimental evidence of their efficacy in ameliorating opioid side effects and consider what further information might be useful in defining their role. ⋯ The major analgesic effects of opioid medication are mediated within the brain and spinal cord. Many of the side effects of opioids are caused by activation of receptors outside these areas. Recently developed peripherally restricted opioid antagonists have the ability to block many opioid side effects without affecting analgesia.
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Anesthesia and analgesia · Jan 2004
Randomized Controlled Trial Clinical TrialThe pharmacokinetics and efficacy of ropivacaine continuous wound instillation after spine fusion surgery.
Because local anesthetic continuous wound instillation has not been evaluated after spine fusion surgery, we designed this study to determine whether this technique could enhance analgesia and improve patient outcome after posterior lumbar arthrodesis. Thirty-eight patients undergoing spine stabilization were randomly divided into two groups. The M group received a postoperative baseline IV infusion of morphine plus ketorolac for 24 h, and the R group received IV saline. In both groups, a multihole 16-gauge catheter was placed subcutaneously; in the R group, the wound was infiltrated with a solution of ropivacaine 0.5% 200 mg/40 mL, and infusion of ropivacaine 0.2% 5 mL/h was maintained for 55 h. In the M group, saline infusion was given at the same rate. Pain scores were taken at rest and on passive mobilization by nurses blinded to patient analgesic treatment. The total plasma ropivacaine concentration was evaluated. Pain scores and rescue medication requirements (diclofenac and tramadol) were significantly less in the R group than in the M group. Postoperative blood loss was less and the length of hospital stay was shorter in the R group. The ropivacaine peak total plasma concentration occurred at 24 h during infusion and was within safe limits; no toxic local anesthetic side effects were observed. These results suggest that wound infiltration and continuous instillation of ropivacaine 0.2% is effective for pain management after spine stabilization surgery. ⋯ Postoperative pain after lumbar arthrodesis is related to soft tissue and muscle dissection and to manipulations and removal at the operation site. By blocking noxious stimuli from the surgical area, infiltration and wound perfusion with ropivacaine were more effective in controlling pain than systemic analgesia.