Survey results continue to reveal that postoperative pain is insufficiently managed throughout Europe and the rest of the world. However, the efficient use of existing resources, as well as the introduction of novel technologies, may aid in its improvement. Use of an acute pain service has the potential to improve pain management through specialized patient care and utilization of effective analgesic techniques. Multimodal analgesic techniques, which include adjuvant non-opioids and/or regional analgesic techniques, can provide effective analgesia and reduce the amount of systemic opioids (or obviate the need) for postoperative pain management. Patient-controlled analgesia modalities may also offer improvements to pain management, as in practice they provide pain relief superior to the intermittent administration of bolus doses of opioids. A novel patient-controlled analgesia modality that has been approved by the European Medicines Evaluation Agency (EMEA) for the treatment of acute, moderate-to-severe pain is the needle-free, pre-programmed fentanyl HCl iontophoretic transdermal system. This system was shown in a recent US clinical trial to be comparable in efficacy to a standard regimen of morphine intravenous patient-controlled analgesia. Adverse events associated with the use of the fentanyl iontophoretic transdermal system are generally similar to those experienced by patients using intravenous morphine patient-controlled analgesia. Considerations regarding the selection of patients for treatment with the fentanyl iontophoretic transdermal system are similar to those with other patient-controlled analgesia modalities; sufficient upper limb mobility and alertness are required to operate the system. Utilization of the fentanyl iontophoretic transdermal system, together with the guidance of an effective acute pain service, may lead to improvements in postoperative pain management.

Summary

Background and objective: The use of a pneumatic tourniquet can induce muscular and neurological complications in the operated limb. The genesis of these injuries could involve an ischaemia/reperfusion phenomenon and a compression under the cuff. We evaluated effects of an antioxidant, acetylcysteine and ischaemic preconditioning on the rhabdomyolysis and postoperative pain following a knee ligamentoplasty using a pneumatic tourniquet. Methods: We included 31 patients scheduled for a knee ligamentoplasty randomly assigned in three groups (control, acetylcysteine 1200 mg the day before and 600 mg at the operative day, ischaemic preconditioning). Results: There was a moderate rise in myoglobin and creatinine phosphokinase with no significant difference between the three groups. The muscular functional parameters were similar in all the groups. However, the morphine consumption within the first 48 h was smaller in the treatment groups (0.22 ± 0.31 mg kg−1 and 0.22 ± 0.23 mg kg−1 in the preconditioning and antioxidant groups, respectively) than in the control group (0.47 ± 0.33 mg kg−1, P <0.05). Conclusions: Acetylcysteine and ischaemic preconditioning do not decrease the extent of rhabdomyolysis related to the use of a pneumatic tourniquet and do not improve the postoperative muscle recovery. On the other hand, they allow a significant reduction in the postoperative morphine consumption.

Summary

Background and objectives: This study was designed to quantify the additional postoperative analgesic efficacy of a single dose of ketoprofen in patients undergoing thyroid surgery using two different intraoperative analgesic regimens. Methods: One hundred and twenty patients were randomly assigned to one of four groups: intraoperative fentanyl or remifentanil with or without ketoprofen (n = 30 for each group). Intravenous ketoprofen (1.5 mg kg−1) or saline was administered 45 min before the end of surgery. Pain scores, opioid demand and length of stay in the postanaesthesia care unit were assessed in a blinded manner. Results: Patients receiving intraoperative fentanyl with saline had significantly lower visual analogue scale pain scores in the postanaesthesia care unit compared with those receiving intraoperative remifentanil with saline (55 ± 10 mm vs. 80 ± 18 mm, P < 0.05) and they stayed shorter in the postanaesthesia care unit (86 ± 24 min vs. 126 ± 37 min). In conjunction with intraoperative fentanyl, ketoprofen significantly decreased postoperative pain scores (40 ± 10 mm, P < 0.05 compared with fentanyl alone) and opioid demand (4 of 30 patients vs. 14 of 30 patients compared with fentanyl alone, P < 0.05). Patients receiving intraoperative remifentanil had no additional analgesic benefit with ketoprofen. Conclusion: After thyroid surgery, patients receiving intraoperative fentanyl had lower pain scores and needed less rescue analgesia compared with patients receiving intraoperative remifentanil. The adjunction of ketoprofen further improved analgesia in patients who received intraoperative fentanyl only.

Summary

Background and objective: Adenosine, by intravenous and intrathecal routes, is known to alleviate various types of pain. However, the role of intrathecal adenosine in providing postoperative analgesia has not been confirmed. The aim of the present study was to evaluate the efficacy of intrathecal adenosine for postoperative pain relief, and to determine its role for pre-emptive analgesia. Methods: Ninety ASA I and II females, undergoing elective abdominal hysterectomy, were randomly divided into three groups of 30 patients each. Patients in the ‘early adenosine’ group received intrathecal adenosine 1000 μg, 30 min before induction of anaesthesia. Patients in the ‘late adenosine’ group received the same dose before reversal of neuromuscular blockade. Control patients did not receive any test drug. A balanced general anaesthesia technique was used in all patients. Pain intensity scores using a visual analogue scale, sedation scores, time to first rescue analgesic and total morphine requirement were recorded. Results: There was no significant difference in pain intensity scores, sedation scores, total morphine requirements and time to first rescue analgesic among the three groups. Conclusion: Intrathecal adenosine 1000 μg is not effective as an analgesic for postoperative pain relief, and there is no pre-emptive effect.

Summary

Background: In this double-blind randomized study, the analgesic effects of morphine alone and with methylprednisolone were examined in 72 patients undergoing arthroscopic knee surgery. Methods: At the end of arthroscopy, patients were allocated randomly to one of four groups to receive intra-articular administrations of saline, morphine 1 mg, morphine 5 mg or morphine 1 mg with methylprednisolone 40 mg. Preoperative and postoperative pain levels at rest and during movement (active flexion of the knee) were measured by a visual analogue scale (VAS). Postoperative analgesic requirements to alleviate pain were evaluated. Results: Pain scores were significantly lower for the patients who received 5 mg morphine and 1 mg morphine with 40 mg methylprednisolone than for those who received saline or 1 mg morphine. This was accompanied by a decrease in the postoperative consumption of analgesics and prolongation of the duration of pain relief. Conclusions: This study confirms that the analgesic effect of morphine given intra-articularly is dose dependent and that combination of methylprednisolone with morphine has an additive effect on analgesia.

Summary

Background and objectives: To compare the analgesic effects of intrathecal fentanyl and low-dose intravenous ketamine as adjuvants to intrathecal bupivacaine for Caesarean section. Methods: Ninety elective Caesarean section patients were randomized into three groups. Spinal anaesthesia was performed with 15 mg hyperbaric bupivacaine in all groups. Ketamine (0.15 mg kg−1) or an equal volume of normal saline was given intravenously immediately after initiating spinal anaesthesia in the ketamine and control group, respectively. In the fentanyl group, 10 μg fentanyl was added to the intrathecal bupivacaine. Arterial pressures, heart rate values, adverse effects, the time of first request for postoperative analgesia, visual analogue pain scores, total analgesic consumptions at 24 and 48 h were recorded in all patients. Results: The time to first request for analgesia was significantly longer in the ketamine (197 min) and fentanyl (165 min) groups compared to the control group (144 min). Postoperative pain scores were significantly lower in the ketamine group than in both other groups. Although the analgesic requirements during first 24 h were significantly lower in the ketamine group, there was no significant difference between the groups during the following 24 h. Conclusion: Intravenous low-dose ketamine combined with intrathecal bupivacaine for Caesarean section provides longer postoperative analgesia and lower postoperative analgesic consumption than bupivacaine alone suggesting a pre-emptive effect.

Summary

Background and objective: The use of remifentanil requires other analgesics for postoperative pain relief compared to fentanyl in patients undergoing craniotomy. This could possibly reduce the postoperative advantages of this short-acting opioid.

Methods: We compared remifentanil and fentanyl-based anaesthesia in a randomized observer and patient blinded trial on patients, undergoing an elective craniotomy. Twenty patients received anaesthesia using remifentanil with a small dose of piritramide (0.1 mg kg−1) after closure of the dura mater. Twenty patients underwent a fentanyl-based protocol. In both groups, anaesthesia was induced with thiopental and rocuronium, and maintained with 0.6–1 minimum alveolar concentration (MAC) isoflurane in a nitrous oxide/oxygen mixture 2 : 1 and rocuronium. Patients received 1 g of paracetamol rectally postoperatively. A visual analogue scale (VAS) for pain, the Glasgow Coma Score, a modified Aldrete Score, arterial carbon dioxide tension (PaCO2) and piritramide consumption were evaluated every half an hour postoperatively.

Results: No significant differences were found for pain, Aldrete or Glasgow Coma scores or for PaCO2 between the groups when controlled for age, although the pain and Glasgow Coma Scores were consistently higher and PaCO2 lower in the remifentanil group. Furthermore, 13 out of 20 patients in the remifentanil group requested extra piritramide as opposed to 7 out of 20 in the fentanyl group (P = 0.11).

Conclusions: Despite the intraoperative use of piritramide in the remifentanil group, patients experienced more pain postoperatively. A significant influence of age on pain intensity was found. The use of remifentanil with a small dose of piritramide of 0.1 mg kg−1 has no evident advantage over the use of fentanyl considering the postoperative conditions after craniotomy.

Summary

Background and objective: This randomized, double-blinded clinical study was designed to compare the efficacy and safety of remifentanil and morphine administered using intravenous (i.v.) patient-controlled analgesia (PCA) for postoperative analgesia after major abdominal surgery during the first 24 postoperative hours.

Methods: Sixty-nine patients were randomly allocated into two groups, each receiving remifentanil or morphine. The first group received i.v. remifentanil PCA with a loading dose of 45 μg, a maintenance dose of 1 μg min−1, a bolus dose of 15 μg and a lockout interval of 10 min during the first 24 postoperative hours. The second group received i.v. morphine PCA with a loading dose of 5 mg, a maintenance dose of 0.3 mg h−1, a bolus dose of 1 mg and a lockout interval of 15 min. Age, weight, sex, history of general anaesthesia, duration of surgery and time spent in the post-anaesthesia care unit were recorded. Preoperative pulse rate, systolic and diastolic blood pressures (BP), respiration rate and arterial blood gases were collected. Pulmonary function was tested before induction of anaesthesia, as well as at 4 and 26 h after operation. Pulse rate, systolic and diastolic BP, respiration rate, arterial blood gases, sedation and visual analogue scores, and presence of side-effects in the recovery room and on the ward for 24 h were recorded at 0, 1, 2, 4, 6, 12, 18 and 24 h after operation. Total drug use, number of boluses delivered, number of boluses demanded and delivery/demand ratio were collected.

Results: Sixty patients were evaluated. The groups did not differ in age, weight, sex, history of general anaesthesia, duration of surgery or time spent in the recovery unit. There were also no clinically relevant differences between the groups with regard to haemodynamic and respiratory parameters as well as sedation and visual analogue scores (P > 0.05). More bolus doses were demanded and delivered and the delivery/demand ratio was significantly higher in the remifentanil group (P < 0.05). There was no finding suggesting acute opioid tolerance during remifentanil or morphine PCA.

Conclusion: The i.v. remifentanil PCA with the chosen dosage regimen after abdominal surgery produces postoperative analgesia and has cardiovascular side-effects similar to those achieved with i.v. morphine. Special attention must be given to respiratory depression during establishment of PCA with remifentanil.

Summary

Background and objective: The combination of non-opioid analgesic drugs, though widely used, has been rarely evaluated. The aim of this study was to compare the efficacy of propacetamol and the non-steroidal analgesic drug ketoprofen, alone or in combination, on pain relief after thyroid surgery performed using remifentanil.

Methods: Ninety-seven patients were randomly allocated to one of the three groups: propacetamol 2 g (32), ketoprofen 100 mg (33) and propacetamol 2 g + ketoprofen 100 mg (32). Each regimen was administered intravenously (i.v.) 30 min before the end of surgery and then every 6 h. If pain was not relieved, patients received an i.v. bolus of tramadol 100 mg. Tramadol consumption and pain intensity using a visual analogue scale was recorded at 1, 2, 8 and 14 h after the end of surgery.

Results: Pain scores were significantly higher with propacetamol compared with ketoprofen 2 h after surgery (35 ± 3.7, 21 ± 2.6, respectively; P < 0.01). The number of patients receiving tramadol was higher with propacetamol alone compared with the two other groups, 1 h (14/32, 4/33, 2/32, respectively; P > 0.01) and 2 h (24/32, 6/33, 8/32, respectively; P < 0.01) after surgery. There was no difference between ketoprofen alone and ketoprofen plus propacetamol, and there was no difference between the three groups from the 8th hour onward.

Conclusions: In the immediate postoperative period after thyroid surgery performed using remifentanil, the concomitant use of propacetamol and ketoprofen does not improve analgesia compared with ketoprofen alone.

Summary

Background and objective: Continuous spinal anaesthesia and continuous epidural anaesthesia are both able to provide adequate postoperative pain relief. Combining local anaesthetics and opioids results in synergistic effects. The purpose of this randomized, prospective study was to compare quality of analgesia, side-effects and patient's satisfaction between spinal bupivacaine alone and epidural bupivacaine with sufentanil postoperatively.

Methods: Fifty-nine patients scheduled for hip arthroplasty were randomly assigned either to Group 1 receiving continuous spinal anaesthesia or Group 2 receiving continuous epidural anaesthesia. Postoperatively, those in Group 1 received a 1 mL bolus followed by a continuous infusion of 10 mL/24 h of bupivacaine 0.25%. Those in Group 2 received a 5 mL bolus of lidocaine 2%, followed by a continuous infusion of bupivacaine 0.25% with sufentanil 0.001 mg mL−1 at 4 mL h−1. Pain was measured using a verbal rating score and a visual analogue scale.

Results: Group 1 and Group 2 of 43.3% and 37.9% reported complete analgesia on the verbal rating score. No statistically significant difference was found in the visual analogue scale. Nausea and vomiting occurred significantly more often in Group 2. The patient satisfaction rates did not differ significantly.

Conclusions: Continuous spinal analgesia with bupivacaine alone and continuous epidural analgesia with bupivacaine/sufentanil are both effective for postoperative pain relief after hip replacement. Those patients in the epidural group reported better analgesia but had a higher rate of postoperative nausea and vomiting. Efficacy of pain therapy did not correlate with patient satisfaction.

Summary

Background and objective: The aim of this study was to investigate the quality of intra- and postoperative analgesia obtained by alfentanil compared to that produced by peripheral blockade in children.

Methods: During sevoflurane-nitrous oxide atracurium anaesthesia for minor abdominal or genito-urinary surgery, three groups of children aged 0–8 yr received 25 μg kg−1 alfentanil intravenously (n = 28), or peripheral nerve blockade using 1 mL−1 ropivacaine 0.475% (n = 24), or 12.5 μg kg−1 alfentanil intravenously with peripheral nerve blockade using 1 mL kg−1 ropivacaine 0.475% (n = 30). Changes in blood pressure and heart rate were measured during the procedures. Postoperative pain was assessed using the face, legs, activity, cry, consolability (FLACC) observational tool for quantifying pain behaviour and a numerical scale scored by nurses, doctors, parents and children.

Results: There was no significant difference in intra- or postoperative analgesic efficacy among the three groups. Patients who received alfentanil had significantly lower heart rates than those who received nerve blockade only (96.0 ± 15.6 vs. 115.9 ± 23.2 beats min−1, P < 0.001). FLACC and numerical scale scores did not differ among the groups. There were no significant differences in incidence of vomiting or use of pain medications.

Conclusions: It was concluded that a low-dose, intravenous bolus of alfentanil may be an efficient alternative to peripheral nerve blockade in controlling pain during and after minor abdominal and genito-urinary surgery.

Summary

Background and objective: A randomized controlled trial of patients undergoing laparoscopic cholecystectomy. To evaluate whether the instillation of levobupivacaine, with epinephrine, intraperitoneally, reduces morphine consumption; further, to consider the degree of abdominal and shoulder pain in the presence of local anaesthetic at the site of surgical incision.

Methods: Patients received a standardized procedure and were allocated randomly to receive either (a) 2.5 mg mL−1 levobupivacaine 30 mL, with epinephrine 5 μg mL−1, or (b) normal saline 30 mL, with epinephrine 5 μg mL−1, to the bed of the gall bladder and above the liver, immediately before wound closure.

Results: Median (interquartile range) total abdominal pain during inspiration in the levobupivacaine group was significantly (P = 0.041) lower (71 (21–129) mm) than that in the placebo group (123 (71–179) mm). However, there was no significant difference between the two groups with respect to total abdominal pain at rest, right shoulder pain or the consumption of rescue morphine and rescue dihydrocodeine. There were no differences between the two groups with respect to the administration of cyclizine, total nausea and total sedation scores. In addition, the number of episodes of vomiting was not significantly different.

Conclusions: Intraperitoneal administration of levobupivacaine with epinephrine is associated with modest analgesia following laparoscopic cholecystectomy.

Summary

Background and objective: Our purpose was to evaluate the analgesic and sedative effects of intrathecal midazolam when added to spinal bupivacaine in patients undergoing perianal surgery under spinal anaesthesia.

Methods: Forty-four patients were randomly allocated into two equal groups: Group I (B) received hyperbaric bupivacaine 0.5% 2 mL + saline 0.9% 1 mL in a total volume of 3 mL intrathecally; Group II (BM) received hyperbaric bupivacaine 0.5% 2 mL + 1 mL of 2 mg preservative-free midazolam in a total volume of 3 mL intrathecally. In both groups, the onset and recovery times of sensory block, the degree and recovery times of motor block as well as the sedation and visual analogue pain scores were recorded, and statistically compared.

Results: In Group BM, the postoperative visual analogue pain scores were significantly lower at the first 4 h (P < 0.05), the average time until the first dose of additional analgesic requirement was significantly longer (P < 0.05), and sedation scales were significantly higher (P < 0.05), compared to Group B. There were no statistically significant differences in the onset and the full recovery times of sensory and motor blocks in the two groups.

Conclusion: The use of intrathecal midazolam combined with intrathecal bupivacaine produces a more effective and longer analgesia with a mild sedative effect in perianal surgery.

Summary

Background and objective: Levobupivacaine is the most recently introduced local anaesthetic into clinical practice. In a randomized double-blinded study, the onset, intraoperative tolerance, postoperative analgesic effect, motor blockade and any adverse reactions produced by levobupivacaine were compared with ropivacaine.

Methods: Sixty children, ASA I–II, 2–6 yr old, undergoing elective minor surgery, received a single caudal injection of 1 mL kg−1 of either levobupivacaine 0.25% or ropivacaine 0.25%. Caudal blocks were performed after induction of inhalation general anaesthesia using sevoflurane; anaesthesia was maintained via a laryngeal mask airway using a mixture of sevoflurane, oxygen and air.

Results: Onset time, intraoperative tolerance, postoperative analgesic effect and motor blockade were comparable between the two groups. The mean onset of the block was 8.2 ± 2.2 min for levobupivacaine and 8.5 ± 3.0 min for ropivacaine (P = 0.66). Additional analgesics during operation were not required in any of the children. No significant difference was found for mean time to requirement of additional analgesia with rectal acetaminophen (paracetamol) (302 ± 29 min for the levobupivacaine group and 230 ± 38 min for the ropivacaine group (P = 0.32)). During the first 4 h after placement of caudal block, the pain assessment score (according to the Children Hospital Eastern Ontario Pain Scale) was comparable for the two groups. No motor block was observed in any group on awakening, nor during the observation period.

Conclusions: We conclude that levobupivacaine 0.25% 1 mL kg−1 provides caudal block of comparable onset and duration, as produced by the same volume and concentration of ropivacaine.

Summary

Background and objective: Adequate relief of pain after tonsillectomy is a common problem. We compared meperidine and tramadol when given at induction of anaesthesia with respect to their effects on postoperative pain relief and emergence characteristics after adenotonsillectomy in children.

Methods: Fifty children aged 4–7 yr undergoing tonsillectomy were randomly assigned to receive either tramadol 1 mg kg−1 (n = 25) or meperidine 1 mg kg−1 (n = 25) before commencement of the surgical procedure. Anaesthesia was induced with propofol (with cis-atracurium for muscle relaxation) and maintained with sevoflurane in oxygen and nitrous oxide. Postoperative pain was scored by a blinded observer using a facial pain scale in the recovery room at 0 (at arrival of the patient in the postoperative care unit) and at 10, 20 and 45 min thereafter. Agitation scores were also assessed by the same observer at 0 min. Heart rate and mean arterial pressure were recorded at regular intervals. The time to recovery to spontaneous respiration and the incidence of postoperative nausea and vomiting were noted.

Results: Facial pain scale scores were increased in the tramadol group at 0, 10 and 20 min (P < 0.05). No difference was observed in scores at the 45th min postoperation. Agitation scores were higher in the tramadol group than in the meperidine group. No statistical difference was found between the two groups. Heart rates and mean arterial pressures were similar in both groups. The time to recovery to spontaneous respiration was delayed with meperidine compared with tramadol (P < 0.05). The incidence of nausea and vomiting was not statistically different between groups.

Conclusions: Meperidine was more effective for pain relief and provides better emergence characteristics than tramadol after tonsillectomy in children.

Summary

Background and objective: The study compared the analgesic efficacy and safety of two preoperatively administered cyclo-oxygenase-2 inhibitors, celecoxib and rofecoxib.

Methods: Ninety adult patients undergoing thyroid surgery were divided into three groups (each n = 30). They were given a single oral dose of placebo, celecoxib 200 mg or rofecoxib 50 mg 1 h before induction of anaesthesia. All patients received a standard anaesthetic. Intraoperative blood loss was measured. Pain scores, sedation scores, heart rate, mean arterial pressure and respiratory rate were noted at 0, 1, 2, 4, 6, 12 and 24 h postoperatively. Analgesic (meperidine) requirements and adverse effects were recorded during the first postoperative 24 h.

Results: Compared with placebo, pain scores were significantly lower with rofecoxib at all time points (P < 0.05) and were significantly lower with celecoxib (P < 0.05) during the first 4 h. Pain scores were significantly lower with rofecoxib compared with celecoxib at 6, 12 and 24 h (P < 0.05). The average cumulative 24 h meperidine dose was significantly lower with both celecoxib (54.9 ± 34.4 mg) and rofecoxib (42.8 ± 40.9 mg) compared with placebo (76.8 ± 6.2 mg) (P < 0.01 and P < 0.001, respectively). There were no differences in the intraoperative blood loss, heart rate, mean arterial pressure, respiratory rate, sedation scores and incidence of adverse effects among groups.

Conclusions: The preoperative administration of rofecoxib 50 mg and less so of celecoxib 200 mg provide a significant analgesic benefit with regard to postoperative pain relief and decrease in additional opioid requirements after thyroid surgery.

Summary

Background and objective: This double-blind randomized study tested whether the addition of magnesium or ketamine to morphine for intravenous patient-controlled analgesia resulted in improved analgesic efficacy and lower pain scores compared with morphine patient-controlled analgesia alone after major abdominal surgery.

Methods: Ninety patients (3 × 30) were randomly allocated to receive either morphine 0.4 mg mL−1 (Group M) by patient-controlled analgesia, morphine 0.4 mg mL−1 + MgSO4 30 mg mL−1 (Group MM) or morphine 0.4 mg mL−1 + ketamine 1 mg mL−1 (Group MK). Postoperative analgesia was started when the verbal rating scale was ≥2. Patients were first given a standardized loading dose (0.05 mg kg−1) of the study solution. They were then allowed to use bolus doses of this solution (0.0125 mg kg−1 every 20 min without time limit). Discomfort, sedation, pain scores, cumulative morphine consumption and adverse effects were recorded up to 24 h after the start of the patient-controlled analgesia.

Results: The level of discomfort, level of sedation and verbal rating scores decreased significantly with time in all groups (P < 0.05). Both verbal rating and discomfort scores were significantly lower in Groups MM and MK at 15, 30 and 60 min compared with Group M (P < 0.001). Cumulative morphine consumption after 12 and 24 h was significantly higher in Group M alone (median 26 and 49 mg, respectively) compared with Group MM (24.2 and 45.7 mg) and Group MK (24.4 and 46.5 mg).

Conclusions: In the immediate postoperative period, the addition of magnesium or ketamine to morphine for intravenous patient-controlled analgesia led to a significantly lower consumption of morphine. However, these differences are unlikely to be of any clinical relevance.