Evaluation of the effectiveness of NSAIDs in the prevention of postoperative pain. Comparison between pre- and postoperative administration of sodium naproxen in orthopedic surgery

The aim of the study was to assess the efficacy of the preoperative sodium Naproxen administration to reduce analgesic requirements in the postoperative period. 75 patients (ASA I-II), 50 male and 25 female, aged between 25 and 70 years and weighed between 50 and 90 kg, undergoing lumbar laminectomy were subjected to the same anesthetic technique. Patients were allocated randomly to one of three groups. Group I received intravenous sodium naproxen (550 mg) immediately after induction of anesthesia. Group II received intravenous sodium Naproxen (550 mg) at the end of surgery. Group III received intravenous normal saline immediately after induction of anesthesia. Postoperative every patient was given by request intramuscular Buprenorphine (0.3 mg) for pain relief (at 6 h intervals). Buprenorphine requirements in the group I were significantly lower than in either of the other groups (p < 0.01 and p < 0.0001 respectively), while significant differences were not observed between group II and III. Moreover the 54% of patients in the group I did not require analgesic drugs in the postoperative period in opposition to the 20% of pts. in the group II and the 12% of pts. in the group III (p < 0.05 and p < 0.01 respectively). We conclude that NSAIDs when given before tissue damage may prevent nociceptor sensitisation and probably reduce hyperexcitability of the spinal cord. Preoperative administration of NSAIDs provides better protection against peripheral nerve sensitisation than postoperative administration.     

A double-blind, randomized study of naproxen sodium, ibuprofen, and placebo in postoperative dental pain

In a double-blind, parallel, placebo-controlled study, 203 patients with post-operative dental pain following the extraction of one or two bony impacted third molars were randomized to receive a single dose of naproxen sodium 220 mg, ibuprofen 200 mg or placebo. Pain intensity and pain relief were assessed at intervals for 12 hours postdose. Both active drugs demonstrated superior analgesic efficacy over placebo. Naproxen sodium and ibuprofen were comparable both in onset of analgesic action and in pain relief. From 1 to 12 hours postdose, naproxen sodium showed a trend for superior analgesic efficacy compared with ibuprofen; this trend reached statistical significance at the 12-hour time point. Both drugs were well-tolerated and effective analgesics for postoperative dental pain.     

The relationship between the content of aggressive and protective components in gastric juice and endoscopic findings after naproxen sodium and acetaminophen administration

Transforming growth factor-alpha (TGF-alpha) is a growth-regulatory peptide found in a wide range of embryonic and adult tissues. TGF-alpha is produced by keratinocytes and has been reported to be overexpressed in several epidermal diseases, including middle ear cholesteatoma. This report describes ear pathology in the waved-1 mutant mouse, which is severely deficient in TGF-alpha. Morphologic changes of the external and middle ear were studied histologically in waved-1 mutants 2 weeks to 6.5 months of age. Abnormalities found in the mutants included epidermal hyperplasia of the external ear canal (EAC) and tympanic membrane (TM) and enlargement of specialized sebaceous glands adjacent to the cartilaginous EAC. Sebum and desquamated keratin progressively accumulated within the EAC, displacing the TM into the middle ear. These changes appear similar to those occurring in Mongolian gerbils, which are known to develop cholesteatoma. The alterations found in waved-1 mutants are discussed in relation to the possible involvement of TGF-alpha in cholesteatoma pathogenesis.     

Intraoperative and postoperative autologous transfusion in orthopedic surgery

Information was collected retrospectively on three comparable groups, 25 patients in each, who had been operated on for thoracic scoliosis. Group 1 received homologous transfusions only. Group 2 and group 3 were transfused postoperatively with drained whole blood (Solcotrans orthopaedics). Group 3 received in addition peroperatively washed packed red blood cells (Haemolite 2 Cell Saver) recirculated. The need for homologous transfusions was reduced from 119 units to 23 patients in group 1, to 36 units to 14 patients in group 2 and 34 units to 13 patients in group 3. Three of the first 15 patients in group 2 experienced chills and fever reactions in connection with the autologous transfusion. No reactions were seen after infusion when we scrapped the last 50 to 100 ml of drained blood.     

Assessment of postoperative pain after laryngeal surgery for cancer

OBJECTIVES: To assess the intensity of postoperative pain after laryngeal surgery for cancer and the efficacy of analgesic injections at fixed hours. DESIGN: A prospective clinical study performed during the 3 days following laryngeal cancer surgery. SETTING: A university medical center. PATIENTS: Fifteen men (age range, 38-74 years) having just undergone a partial or total laryngectomy for epidermoid carcinoma. INTERVENTIONS: The analgesic treatment consisted of intravenous administrations at fixed hours (propacetamol or nalbuphine hydrochloride), with the possibility of rescue doses on demand. Pain and anxiety were assessed by means of visual analog scales (graduated from 0-10) every 3 hours on postoperative day 1, then every 6 hours on postoperative days 2 and 3. Objective criteria, ie, heart and respiratory rates and mean blood pressure, were measured with the same schedule. MAIN OUTCOME MEASURES: Postoperative pain and anxiety intensities and their variations were analyzed. Correlations between postoperative pain and other criteria were researched. RESULTS: Postoperative pain had a high initial level (maximum median, 7), then decreased and reached a score of 3 at the 30th hour. Unpredictable individual peaks of pain were reported. Anxiety was never high (maximum median, 4). No individual correlation was found between pain and objective parameters. CONCLUSIONS: After laryngeal surgery for cancer, pain can reach high levels, particularly in the first hours following recovery. Analgesic administrations at fixed hours are not effective enough. Postoperative analgesic treatment should aim to prevent the high initial pain and be individually adapted.     

The comparative efficacy of aceclofenac and ibuprofen in postoperative pain after third molar surgery

BACKGROUND AND OBJECTIVES: Congenital lens subluxation may be a difficult therapeutic problem. Surgical treatment options include iris manipulation or lens decision, aspiration, intracapsular or extracapsular extraction, and lensectomy through the pars plana. It is not established which kind of aphakic correction is the most appropriate in these cases. PATIENTS AND METHODS: A father and his two sons with Marfan's syndrome were operatively treated for lens dislocation in both eyes. Pars plana vitrectomy was done in all eyes. Dislocated lenses were removed by lensectomy in three eyes and with an intracapsular method in three eyes. The outside-in scleral fixation technique was used for primary posterior chamber intraocular lens (PC IOL) implantation in all cases. RESULTS: All eyes achieved good visual acuity (20/20-20/25). Time of observation ranged between 8 and 20 months. There were no intraoperative or post-operative complications. CONCLUSION: Pars plana vitrectomy and primary scleral-fixated IOL implantation is a safe procedure and gives good visual rehabilitation in adult patients with Marfan's syndrome.     

The peripheral effect of fentanyl on postoperative pain

The clinical value of the analgesic effect of opioids administered peripherally (except for intraarticular administration) has not been clearly demonstrated. The aim of this study was to test the hypothesis that fentanyl, added to a local anesthetic for wound infiltration, can enhance postoperative analgesia via a peripheral mechanism. Patients with inguinal herniorrhaphy performed under spinal anesthesia were randomly assigned to one of two groups (n = 10 each). At the end of surgery, the wound was infiltrated with 10 mL of lidocaine 0.5% and fentanyl 0.001% (10 microg) in one group; in the other group, the wound was infiltrated with 10 mL of lidocaine 0.5% alone (and fentanyl 10 microg IM contralaterally). The following variables were determined in a double-blind manner: the duration of anesthesia (response to a von Frey filament), the duration of analgesia (time to mild postoperative pain), postoperative meperidine consumption, intensity visual analog scale of spontaneous and movement-associated pain 24 h after surgery, and wound pain threshold 24 h after surgery (pressure algometry). The addition of fentanyl for wound infiltration enhanced the duration of anesthesia (130+/-37 vs 197+/-27 min; P < 0.001) and decreased the intensity of spontaneous (50+/-17 vs 19+/-18 mm; P < 0.002) and movement-associated (56+/-15 vs 26+/-21 mm; P < 0.002) pain 24 h postoperatively. Differences between groups for other variables were not statistically significant. Fentanyl added to a local anesthetic for wound infiltration after spinal anesthesia can enhance postoperative analgesia by a peripheral mechanism. IMPLICATIONS: Fentanyl can enhance analgesia by a peripheral mechanism. Added to a local anesthetic for wound infiltration, it may be of benefit for the relief of postoperative pain.     

Failure of pain relief after surgery. Attitudes of ward staff and patients to postoperative analgesia

Three surveys of postoperative patients and surgical ward staff were conducted in an 840-bed university hospital to ascertain the severity of pain after surgery and the reasons why patients in pain do not receive more of the analgesia prescribed for them. In the first survey, 206 inpatients were questioned within 24 h following operation, and 25.2% of patients experienced moderate pain whilst 9.2% experienced severe pain but received only 36% of their prescribed analgesics. In the second survey, 176 staff reported that the commonest reasons why patients in pain did not receive analgesics were that they did not request analgesia, were too sleepy or refused the dose. In the final survey, of 200 inpatients questioned, 88% had experienced pain since operation, 97% had been offered analgesics, 14% refused a dose. Twenty-nine percent were moderately or very concerned about injections. The beliefs of both ward staff and patients could have contributed to this failure of pain relief.     

The effect of occlusal reduction on pain after endodontic instrumentation

Since 1987, about 60 cases of porphyria cutanea tarda (PCT) associated with human immunodeficiency virus (HIV) have been reported. The respective roles of HIV and toxic hepatic factor in PCT remain unclear. We report 10 new cases and analyse the following toxic hepatic factors: hepatitis C and B, alcoholism, drugs. The route of HIV transmission to these 10 men were: IV drugs abuse (3), homo/bisexuality (4), heterosexuality (1), and unknown (2). When PCT was diagnosed, their average age was 38 years (29-54) and the HIV-infection had been established for 4.8 years (0.33-9). Seven men had HIV-related symptoms and a CD4+ lymphocyte count below 200/mm3. Cutaneous signs and urinary porphyrin count were characteristic. Alcohol abuse was present in 8/10 patients. AST, ALT and/or gamma GT were high in 9/10 patients; 5/10 patients had HCV antibodies (4 were HCV-PCR positive). HBs antigenemia was negative among the 5/8 patients with HBV antibodies; 10/10 patients took prescribed hepatotoxic drugs. Our series confirms the presence of toxic hepatic factors in PCT of HIV-positive patients. Hepatitis C, alcoholism and hepatotoxic drug consumption seem to be triggers for the appearance of PCT in HIV-positive patients.     

The impact of postoperative pain on the development of postoperative delirium

We performed a prospective observational study to examine the role of postoperative pain and its treatment on the development of postoperative delirium. Pain was measured in direct patient interviews using a visual analog scale (VAS) and was assessed for pain at rest, pain with movement, and maximal pain over the previous 24 h. Postoperative delirium was diagnosed during these interviews by using the confusion assessment method (CAM) and/or by using data from the medical record and the hospital's nursing intensity index. The method of postoperative analgesia, type of opioid, and cumulative opioid dose were also recorded. After controlling for known preoperative risk factors for delirium (age, alcohol abuse, cognitive function, physical function, serum chemistries, and type of surgery), higher pain scores at rest was associated with an increased risk of delirium over the first 3 postoperative days (adjusted risk ratio 1.20, P = 0.04). Pain with movement and maximal pain were not associated with delirium. Method of postoperative analgesia, type of opioid, and cumulative opioid dose were not associated with an increased risk of delirium. We conclude that more effective control of postoperative pain reduces the incidence of postoperative delirium. Implications: We performed daily interviews in a large population of patients undergoing noncardiac surgery to measure their level of pain and development of delirium. We found an association between higher pain levels at rest and the development of delirium. Our results suggest that better control of postoperative pain may reduce this serious complication.     

Effects of stress inoculation training on athletes' postsurgical pain and rehabilitation after orthopedic injury.

The efficacy of a cognitive-behavioral intervention ( stress inoculation training; SIT ) for postsurgical anxiety, pain, and physical rehabilitation in injured athletes was tested. Sixty male athletes who underwent arthroscopic surgery for miniscus injury in 1 knee were randomly assigned to either treatment (SIT and physical therapy) or control (physical therapy only) conditions. Results showed that participants in the treatment group demonstrated significantly less postsurgical pain and anxiety during the rehabilitation process, compared with controls. Additionally, treated participants required fewer days to return to criterion physical functioning, compared with nontreated participants. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The influence of retinol, tocopherol and cimetidine on the ulcerogenic effect of Orthofen, indomethacin and naproxen

The influence of retinol, alpha-tocopherol, and cimetidine on ulceration induced by ortophen, indomethacin, naproxen was studied on rats. It was shown that alfa-tocopherol, retinol, and cimetidine reduce the damaging effect of these drugs on the gastroduodenal mucosa of rats thus normalizing the phospholipid content. The influence of alpha-tocopherol and retinol on the side-effects of ortophen was studied in children with rheumatoid arthritis. Ortophen was found to cause gastroduodenal side-effects in more than 30% of patients and decrease the levels of vitamin A and E in children. The use of retinol and alpha-tocopherol in cotherapy decreases the frequency and severity of side-effects and reduces the vitamin deficiency.     

The influence of biliary infection on the postoperative course after biliary tract surgery

A prospective clinicobacteriological study was undertaken in 167 patients undergoing biliary surgery so as to assess the possible influence of the endogenous preoperative biliary infection on postoperative morbidity. Bile cultures were positive in 33% (55 patients); in those undergoing cholecystectomy alone this finding was present in 23% while in those in whom a choledochotomy was also performed cultures were positive in 65%. The incidence of wound infection was found to be twice as high in those undergoin choledochotomy as in those undergoing cholecystectomy alone--37.8% vs. 18.5%. There was no appreciable difference in the rate of wound infection when a routine appendectomy was performed during biliary tract surgery. Among the 38 patients with wound infection, bile cultures were positive in 16. In 13 cases the offending organism in the wound was identical with that recovered from the bile coulture. This finding suggests an endogenous source for the wound infection. This study further indicated that wound infection is most likely to be encountered in patients with pathogenic organisms in the bile, in the aged and in those whose resistance to infection has been lowered by concomitant disease.     

Bioavailability, food effect and tolerability of S-naproxen betainate sodium salt monohydrate in steady state

S-Naproxen betainate sodium salt monohydrate (naproxen-beta Na, CAS 104124-26-7, Aprenin) in 550 mg capsules (corresponding to 327 mg of naproxen) was administered to 24 healthy volunteers (12 males and 12 females) b.i.d. to steady state in order to check its bioavailability, food interaction and tolerability. Plasma concentrations of naproxen were measured by a well validated HPLC method with fluorimetric detection as a morning pre-dose on days 1 to 6 and in timed samples in three different situations, as follows: a) after the morning dose on day 7 in a fasting status, b) after the evening dose and dinner on day 7 and c) after the morning dose of day 8, taken after a high-fat content breakfast. Pharmacokinetic parameters were evaluated from plasma concentrations by non-compartmental analysis to describe the above three situations. The steady state was reached early, namely by the second day of treatment. The extent of absorption did not differ in the three situations tested, whereas the rate of absorption was fastest in fasting conditions, lowest with the evening dose and intermediate after the high-fat content breakfast. The slow absorption rate of the evening dose was attributed to a circadian rhythm and should allow therapeutically active levels early in the morning, when arthritis pain is particularly tedious. In the three situations explored Cmax, Cmin and AUC were associated with CV % values ranging from 11.7 to 17.2%, which are very low and rare in pharmacokinetic trials. This low variability should allow an accurate estimate of the therapeutic effect expected. Tolerability was checked by objective and subjective symptoms, including vital signs, blood/urine biochemical parameters and occult blood in stools, and proved to be very good. From the comparison of these data with those previously published by other authors who have administered 500 mg of naproxen b.i.d., pre-dose concentrations in a steady state proved to be similar, despite the different doses administered, whereas Cmax and AUC obtained in this study were marginally lower. The kind of food interaction was the same as previously described in literature with naproxen.     

Thrombosis in trauma and orthopedic surgery. Prevention, diagnosis, therapy

The connection between drugs and violence has been well documented. Understanding the intricacies of this connection is essential to finding effective interventions. Much has been written about the psychosocial causes of these problems, but there have been few studies exploring the biophysiological interface between drug effects, violent behavior and brain metabolism. Over the past eight years, The Amen Clinic has been extensively involved in the clinical use of brain SPECT imaging to evaluate complicated neuropsychiatric problems, especially related to the issues of both violence and substance abuse. From this work several clinical patterns, as well as brain SPECT imaging patterns, have been recognized that may help further our understanding of these problems. In this article, following a brief review of the literature on drugs, violence and the brain, five clinical examples are explored; the authors show how these support the clinical utility of incorporating SPECT imaging into psychiatric assessment of drug abuse and violence. Finally, a model is proposed to help explain the complex interaction between the brain, violence and drug abuse.     

Frequency, intensity, development and repercussions of postoperative pain as a function of the type of surgery

Type of surgery is the most important factor conditioning intensity and duration of postoperative pain. Thoracic and spinal surgery are the most painful procedures. Abdominal, urologic and orthopedic surgery lead to severe postoperative pain. Duration of severe pain rarely exceeds 72 hours. Mobilization increases pain intensity after abdominal, thoracic and orthopaedic surgery. Pain could occur after daycase minor surgical procedures and is often underestimated. Postoperative complications related to pain are difficult to disclose because of the interposition of the direct effects of analgesic treatments. Respiratory and cardiovascular postoperative complications are unrelated to postoperative pain in healthy subjects. This could be different in high risk patients. The surgical procedure is the major determinant of metabolic and psychologic postoperative deterioration. Adequate pain relief allows postoperative rehabilitation and physiotherapy programmes after abdominal and orthopaedic surgery. This could be expected to reduce hospital stay and improve convalescence.     

Immune responsiveness in orthopedic surgery patients after transfusion of autologous or allogeneic blood

BACKGROUND: The proposed immunosuppressive effect of blood transfusion is not yet understood, and the clinical relevance is a controversial topic of discussion. STUDY DESIGN AND METHODS: The effect of blood transfusions on the capacity of the host's immunocompetent cells to react to mitogenic stimulation was evaluated. Patients undergoing hip replacement surgery received either allogeneic (n = 13) or autologous (n = 14) buffy coat-depleted red cells or plasma. Patients' blood samples taken before and on Days 1 and 5 after surgery were stimulated in a whole-blood assay. The release of interleukin 2, soluble interleukin 2 receptor, interleukin 6, tumor necrosis factor alpha, interferon alpha 2, and interferon gamma was assessed by enzyme-linked immunosorbent assay. In addition, the white cell counts and frequencies of the lymphocyte subsets CD4+, CD8+, and natural killer cells were analyzed. RESULTS: For both groups, decreased levels of interleukin 2 and interferon-gamma were detected postoperatively, whereas the values for soluble interleukin 2 receptor and tumor necrosis factor alpha showed no significant change. Interferon alpha 2 was decreased on Day 1, but returned to normal by Day 5. Interleukin 6 increased during the time of observation. There were no significant differences between the two groups in cytokine production and lymphocyte-subset analysis that could be attributed to the transfusion of allogeneic blood. CONCLUSION: The transfusion of buffy coat-depleted red cells showed no immediate suppressive effect on the immune function of the host's peripheral blood cells.     

Intravenous regional analgesia using morphine. The effect on postoperative pain following total knee arthroplasty

BACKGROUND: We hypothesised that any peripheral action of morphine may contribute to improved postoperative analgesia. The aim of this study was to evaluate the analgesic efficacy of morphine administered preoperatively into an exsanguinated limb prior to total knee arthroplasty. METHODS: A randomised, double-blind, controlled study was performed in 50 patients having total knee arthroplasty surgery. Patients were divided into two groups. In the study group, 0.125 mg/kg morphine in 60 ml of saline was administered intravenously (iv) into the exsanguinated operative limb via a cannula in the foot. A saline intramuscular (im) injection was administered into the opposite leg. The control group received 60 ml saline iv into the operative leg and 0.125 mg/kg morphine im into the opposite leg. Pain was assessed postoperatively using a 10-point visual analogue scale and by comparing morphine requirements and demand:delivery ratios from a patient-controlled analgesic pump. RESULTS: We found no statistically significant difference between the groups in relation to any of the analgesic measures employed. CONCLUSIONS: Intravenous regional analgesia using morphine provides no analgesic advantage over the intramuscular route from 6-24 h postoperatively.