Comparison of morphine and morphine with ketamine for postoperative analgesia

In addition to the patient's history and a thorough clinical investigation, magnetic resonance imaging (MRI) of the temporomandibular joint (TMJ) has been introduced to complete the findings for the diagnosis of internal derangement of the TMJ. However, 'dynamic information' is desirable to help us to understand the mechanism of internal derangement. This information is given for example by electronic axiography recording systems. The lack of any ability to assess joint function dynamically in MRI is a point of criticism. Using a computer-driven pseudodynamic MRI system (CINE mode) 'dynamic information' should be now available. In this investigation 21 patients with TMJ disorders were examined using both conventional static MRI and CINE mode. For the diagnosis of an anterior displaced disc with or without reduction in 18 cases (86%) it was only necessary to consider two static MRIs: a closed mouth position and a maximal open mouth position. Comparison showed there was no advantage in using CINE mode. Contrast and resolution of the static MRIs were shown to be better and so additional findings such as joint effusion and disc deformation could be diagnosed on static MRIs with greater certainty. Only in three (14%) cases was the dynamic information from CINE mode useful for the diagnosis of the displacement of the disc.     

Midazolam improves postoperative epidural analgesia with continuous infusion of local anaesthetics

BACKGROUND: A number of triple drug regimens using proton pump inhibitors and two antibiotics have been evaluated in the West and reported to achieve Helicobacter pylori eradication rates of over 90%. In developing countries however, these combinations have neither been well evaluated, nor the optimum treatment for H. pylori infection well defined. AIM: To compare the combination of a proton pump inhibitor with a nitroimidazole and another antibiotic in eradicating H. pylori infection and healing duodenal ulcer. METHODS: Sixty consecutive patients with active duodenal ulcer who were positive for H. pylori (by rapid urease test and 14C-urea breath test) were randomized into three treatments groups: (1) LAS (n=21): lansoprazole 30 mg o.m., amoxycillin 500 mg q.d.s. and secnidazole 2 g on alternate days for 2 weeks; (2) LCS (n=18): lansoprazole 30 mg o.m., clarithromycin 500 mg b.d. and secnidazole 2 g on alternate days for 1 week; (3) LPS (n=21): lansoprazole 30 mg o.m., pefloxacin 400 mg o.m. and secnidazole 2 g on alternate days for 2 weeks. Urease and breath tests were performed at 0, 6 and 12 weeks to check for H. pylori eradication. RESULTS: Intention-to-treat eradication rates were as follows: LAS 86%, LCS 83%, LPS 71%; the overall ulcer healing rate was 90% at 6 weeks. CONCLUSIONS: High H. pylori eradication rates were achieved using the amoxycillin- and clarithromycin-based therapies. Fewer side-effects, better compliance and low cost favoured the amoxycillin-based therapy.     

Intraoperative intravenous ketamine in combination with epidural analgesia: postoperative analgesia after renal surgery

We designed this double-blinded, randomized, controlled study to evaluate the effect of small-dose ketamine IV in combination with epidural morphine and bupivacaine on postoperative pain after renal surgery. An epidural catheter was inserted, and the administration of morphine and bupivacaine was started before surgery. Forty patients were assigned to one of two groups (ketamine or control). The ketamine group was administered a ketamine bolus and infusion during surgery. The median visual analog pain scale (VAS) scores at rest were significantly lower in the ketamine group during the first 6 h (P < 0.01). VAS pain scores on coughing were also significantly lower in the ketamine group (P < 0.01). Cumulative postoperative total analgesic consumption was less in the ketamine group on Days 1 and 2 (P < 0.001). The first analgesic demand time was shorter in the control group (9.2 +/- 11.5 min) than in the ketamine group (22.3 +/- 17.1 min) (P < 0.0001). The incidence of nausea and pruritus was more frequent in the control group (P < 0.05). In conclusion, postoperative analgesia was more effective when spinal cord and brain sensitization were blocked by a combination of epidural morphine/bupivacaine and IV ketamine. IMPLICATIONS: Renal nociception conducted multisegmentally by both the spinal nerves (T10 to L1) and the vagus nerve cannot be blocked by epidural analgesia alone. We demonstrated that IV ketamine had an improved analgesic or opioid-sparing effect when it was combined with epidural bupivacaine and morphine after renal surgery.     

Pharmacokinetics and efficacy of long-term epidural ropivacaine infusion for postoperative analgesia

The aim of this study was to evaluate the pharmacokinetics and efficacy of the new local anesthetic ropivacaine when used for epidural infusion for up to 72 h after major orthopedic surgery. Immediately after surgery, an epidural infusion of ropivacaine 2 mg/mL was begun at a rate of 6 mL/h in 11 patients. The infusion rate was then adjusted according to patient analgesic needs or side effects. Blood samples were taken during and after the infusion to determine total and unbound ropivacaine and alpha1-acid glycoprotein (AAG) concentrations. Patients were assessed regularly for sensory and motor block and pain using a visual analog scale (VAS) score (0-100 mm). Ten patients received 63-72 h of infusion. Total plasma concentrations of ropivacaine and binding protein (AAG) increased during the infusion such that free concentrations plateaued or began to fall over time. VAS values during mobilization were less than 40 mm in 93% of patients. The majority of patients had no measurable motor block once the surgical block had regressed. When epidural ropivacaine was titrated to achieve a stable sensory block, there was a low incidence of motor block, and free plasma ropivacaine levels were well below the toxic range. Implications: The pharmacokinetics of continuous epidural infusions of ropivacaine are described in patients for up to 72 h postoperatively. Clinical efficacy and side effects are also reported. An understanding of the plasma concentrations obtained and modes of elimination during prolonged epidural infusion is important for safe, routine clinical use in postoperative analgesia.     

Comparison of patient-controlled epidural analgesia with patient-controlled intravenous analgesia using pethidine or fentanyl

OBJECTIVE: To investigate the relationship between physical activity, leisure time activities and dietary habits in adolescents. PATIENTS AND METHODS: We have studied 541 girls and 537 boys from 24 schools. Physical activity, leisure time activities and dietary habits were assessed by 3 different questionnaires, taking into account one week of normal activity and diet. RESULTS: Foods such as milk, fish, meat, egg, fruits, vegetables, pasta and snacks were consumed more frequently in children who spent more time doing sport, but difference were not statistically significant. Boys who spent more time watching T.V. ate greater amounts of almost all foods (p < 0.05). In girls, we have observed the same results, but differences were not statistically significant. CONCLUSIONS: Sports and T.V. watching are both related to a greater amount of food intake From our results we can deduce that in order to prevent obesity, and other cardiovascular risk factors, we must improve food intake related with sedentary habits.     

The epidural use of morphine and alpha 2-agonists for postoperative analgesia

Three protocols of postoperative pain relief after gastric surgery were used in 60 male patients: regular intramuscular morphine, epidural morphine, and epidural morphine with 0.1 mg of clonidine. Pain relief was more effective with the epidural route of administration. Addition of clonidine in a daily dose of 0.1 mg allowed a twofold decrease of epidural morphine dose, involving lesser hyperdynamic postoperative cardiovascular changes and complete elimination of psychotic complications and delirium in alcohol-dependent patients.     

Comparison of morphine with and without fentanyl for epidural analgesia after major abdominal surgery

Expression of fusion proteins between prepro-alpha-factor and somatostatin (SRIF) in yeast, resulted in the correct processing and secretion of the heterologous 14-amino acid SRIF peptide (1). When the chimeric genes were placed under the control of yeast acid phosphatase (PHO5) promoter, significant amount of an unglycosylated form of the fusion precursor molecule accumulated intracellularly, suggesting disruption of an endoplasmic reticulum-mediated function. We report here that the appearance of the precursor is due to an alteration in the three amino terminal residues of the chimera, i.e., Met-Arg-Phe in native prepro-alpha-factor is changed to Met-Phe-Lys in the hybrids. The unglycosylated precursor represents a population of molecules that are disrupted at an early stage of targeting to or translocation across the endoplasmic reticulum membrane. Our data demonstrate that the N-terminus plays an important role in topogenesis. Furthermore, these results show that translocation and glycosylation can be uncoupled from protein synthesis in vivo, and therefore can be posttranslational events in yeast.     

Comparison of propacetamol and morphine in postoperative analgesia]

To compare the analgesic efficacy and tolerance of propacetamol and morphine, 80 patients in good clinical condition were included in a prospective, parallel, randomized double blind trial after elective surgery expected to elicit light to moderate postoperative pain. At the end of general anesthesia, 40 patients received 30 mg/kg propacetamol and 40 0.2 mg/kg morphine, as a 15-min intravenous infusion. The groups were similar for age, weight and duration of anesthesia. Supplemental analgesia had to be given in 7 cases from the propacetamol group vs. 2 cases from the morphine group. The postoperative pain, evaluated 7 times during 4 h from the end of infusion with a visual analog scale, revealed a modest advantage for morphine at 0.5 and 4 h (p = 0.05). The respiratory rate was slightly lower after morphine (p = 0.02). No significant differences were observed in blood oxygen saturation, blood pressure, heart rate, body temperature and vigilance evaluated by the trailmaking test. Nausea was present in 4 cases under propacetamol and 3 under morphine, and pruritus in 2 and 7 cases, respectively. In conclusion, propacetamol may represent an alternative to morphine for pain prevention after mildly to moderately painful surgery in situations where the use of opioids is unsuitable.     

Comparison of 0.25% ropivacaine and bupivacaine for epidural analgesia for labor and vaginal delivery

STUDY OBJECTIVE: Part 1: To measure ropivacaine levels in the mother and infant at delivery after continuous lumbar epidural infusion. Part 2: To compare epidural ropivacaine to epidural bupivacaine for labor analgesia in regard to effectiveness, motor blockade, and maternal and neonatal effects. DESIGN: Part 1: Open-labelled, non-blind study. Part 2: Randomized, double-blind study. SETTING: Labor and delivery units of two academic hospitals. PATIENTS: Part 1: 20 ASA physical status I and II parturients in active labor. Part 2: 81 ASA physical status I and II parturients in active labor. INTERVENTIONS: For Part 1, 8 to 12 ml of 0.25% ropivacaine was administered through a lumbar epidural catheter to achieve a T10 dermatomal sensory level. An infusion of 0.25% ropivacaine, 8 to 10 ml/hr, maintained this sensory level. Maternal and umbilical cord blood samples obtained at delivery were analyzed for ropivacaine concentration. For Part 2, anesthetic management was similar to that previously described except patients were randomized to receive either 0.25% ropivacaine or 0.25% bupivacaine. Onset, regression, maximal spread of sensory block, and onset and degree of motor blockade were measured. Contraction pain as assessed using a visual analog scale (VAS), maternal blood pressure, and heart rate were determined every 5 minutes until a stable VAS-contraction score was achieved, and every 30 minutes thereafter. Neonatal assessment included Apgar scores and neurologic and adaptive capacity scores (NACS) at 15 minutes, 2 hours, and 24 hours. MEASUREMENTS AND MAIN RESULTS: For Part 1, the total and free maternal arterial concentrations of ropivacaine at delivery were 0.64 +/- 0.14 microgram/ml and 0.10 +/- .02 microgram/ml, respectively; the umbilical venous total and free concentrations were 0.19 +/- 0.03 microgram/ml and 0.12 +/- 0.07 microgram/ml, respectively (n = 12). The umbilical arterial and venous concentrations did not differ for both the free and total concentrations. For Part 2, there was no difference between ropivacaine and bupivacaine in the variables measured. Umbilical cord gases and Apgar scores were not different between the two groups; NACS were higher at 15 minutes and 2 hours in the ropivacaine group (p < 0.05) than the bupivacaine group. CONCLUSION: Both ropivacaine and bupivacaine produced excellent analgesia for labor with no major adverse effect on the mother or neonate.     

Intrathecal and epidural analgesia

Centroneuraxis analgesia has a place in the management of critically ill patients. With the safety of the intrathecally placed microcatheter now in question, epidural blockade is more suitable in the intensive care unit setting. The different mechanisms of action and the resultant synergy of local anesthetic agents and opioids, as well as their different side effects, are outlined. The contraindications to neuraxial blockade are discussed, and the role of epidural analgesia in the management of flail chest syndrome is addressed in detail.     

Informed consent for epidural analgesia in labor

Characteristics and reproducibility of bulbocavernosus reflex (BCR) and pudendal somatosensory evoked potentials (PSEP) elicited by mechanical stimulation in children were tested. Twenty-five male children aged 5-14 years without uroneurological complaints were enrolled in the study. In addition to electrical stimulation, a specially constructed electromechanical hammer triggered by an oscilloscope was used for mechanical stimulation of distal penis. All responses were detected by surface electrodes. The latencies and amplitudes of averaged as well as latencies of single BCR on single and double electrical stimuli were determined. Mechanical stimulation was described as much less unpleasant than electrical stimulation. Both mechanical/electrical stimulation elicited consistent and reproducible responses in high percentages of children (BCR: average, 80%/71%, single, 94%/100%; PSEP: 96%/96%, respectively). BCR latencies were significantly longer and PSEP amplitudes were significantly higher on mechanical stimulation. The compliance with mechanical was much better than with the electrical stimulation and the former can be recommended for clinical use. The effective mechanical stimulus delivered by a particular mechanical stimulator has a characteristic 'delay' (as to the actual point of triggering the oscilloscope ray) which influences the latency reading of responses; appropriate control data are therefore necessary.     

Long-term epidural analgesia for pregnancy-induced intercostal neuralgia

Intercostal neuralgia is one of many possible neurological disorders associated with pregnancy. A woman presented in the 34th week of her 4th pregnancy with progressing right-sided pain and hypoesthesia in the ribs, right upper quadrant of the abdomen, and mid-thoracic area of her back. With a clinical diagnosis of pregnancy-related intercostal neuralgia, we inserted an epidural catheter at T8 for ambulatory pain management. A continuous infusion of bupivacaine was titrated by concentration and rate until adequate analgesia was obtained. The final effective dose consisted of 0.125% bupivacaine at 6 ml/h with a patient-controlled bolus dose of 2 ml every 30 min as needed (4-6 boluses per 24-h period). This allowed the patient to continue to work full-time and perform daily activities with minimal discomfort. The epidural infusion was continued until the patient went into spontaneous labor 28 days after the initial clinical visit. A full-term infant was delivered without incident. No major complications occurred such as local anesthetic toxicity, hypotension, motor weakness, or infection. Minor complications included disconnection of the catheter cap and accidental dislodgment, which required placement of a second epidural catheter. For this patient, an appropriately placed chronic epidural catheter and a titrated continuous infusion of bupivacaine provided adequate and safe analgesia for pregnancy-associated intercostal neuralgia.     

Control of postoperative pain with intrapleural analgesia

INTRODUCTION: Personal experience in the treatment of postoperative pain using intrapleural analgesia applied on 50 patients chosen at random in a group of 90 after thoracotomy is reported. METHODS: At the end of operation a peridural catheter for continuative infusion was applied in the paravertebral socket by direct transfixion of chest wall. A local anaesthetic has been given (75 mg of bupivacaine 0.50%) through the catheter at 8 hours interval for three times at the most. The degree of analgesia has been valued immediately before and after medicine administration and during the 8 hours interval by recording the cardiocirculatory and haemogasanalytical parameters. The measurement of pain intensity has been achieved by visual analogous just an hour after operation and subsequently every 4 hours during the first post operative day and every 8 hours during the following days. RESULTS: Most of the examined patients (90%), reported a remarkable attenuation of pain, valued by achromatic grey test after 4 hours since the first giving. The catheter has always been removed during the 8th postoperative day and it did not cause intrapleural complications. The method used warrants a good level of analgesia, improving the respiratory per-formance and giving a rapid mobilization, essential items in the reduction of immediate post operative complications. CONCLUSIONS: The results confirm the validity of this treatment in the pain control of thoracothomized patients with a positive answer in 45 out of 50 examined patients without remarkable complications.     

Epidural abscess following continuous epidural analgesia in two traumatized patients

We present a mutational analysis of the iduronate-2-sulfatase (IDS) gene of 36 Russian patients with Hunter syndrome. Among 29 mutant alleles, there were 19 missense mutations, 1 nonsense mutation, 6 mutations affecting splice sites, and 3 major structural alterations resulting in deletions. Of the 25 different mutations, 15 are novel and unique. Most of the missense mutations result in intermediate or severe phenotypes.     

Postoperative patient-controlled epidural analgesia with opioid bupivacaine mixtures

PURPOSE: To determine the efficacy and safety of patient-controlled epidural analgesia of morphine or fentanyl in combination with bupivacaine for postoperative pain relief. METHODS: Forty ASA I-II patients scheduled for major abdominal surgery were studied. After insertion of a lumbar epidural catheter, patients were given a non-opioid general anaesthetic. After surgery patients complaining of pain, received a loading dose of 2 mg morphine (Group I) or 50 micrograms fentanyl (Group II). For continuing pain, 1 mg morphine in 4 ml bupivacaine 0.125% (0.25 mg.ml-1 morphine and 1 mg.ml-1 bupivacaine, Group I) or 20 micrograms fentanyl in 4 ml bupivacaine 0.125% (5 micrograms.ml-1 fentanyl and 1 mg.ml-1 bupivacaine Group II) were administered. Blood pressure, heart rate, respiratory rate and SpO2 were monitored. Assessments of pain (VAS), nausea-vomiting, motor block, pruritus and sedation were recorded for 24 hr. RESULTS: No difference in pain or sedation was observed between groups. The 24 hr postoperative opioid consumption was 15.50 +/- 7.53 mg morphine and 555.10 +/- 183.85 micrograms fentanyl. Total bupivacaine 0.125% consumption was 58.00 +/- 30.14 ml in Group I and 101.05 +/- 36.77 ml in Group II. One patient in Group II complained of motor weakness in one leg. The incidence of nausea (Group I 45%, Group II 10% P < 0.05) and pruritus (Group I 30%, Group II 5% P < 0.05) was less in patients receiving fentanyl. CONCLUSION: Both methods were effective in the prevention of pain but, because of fewer side effects, fentanyl may be preferable to morphine.     

Perinatal mortality after epidural analgesia

A retrospective survey has been carried out of 6442 births during 1973-1974 in Cardiff. Lumbar epidural block had been administered to the mothers of 13-7% (885) of the births, the principle indication being relief of pain. In the management of the mother special emphasis was laid upon avoiding aorto-caval compression. The perinatal mortality associated with epidural block (14-8 per 1000) was not significantly different from that after other forms of analgesia (19-2 per 1000). There were less first week deaths in babies weighing less than 2-5 kg after epidural block (0 of 45) than in those who had other methods of pain relief (41 of 414) (P = 0-023). The choice of maternal medication did not influence the perinatal mortality rate of the immature baby, but there is a positive but non-significant, trend in favour of epidural block in the premature baby. This improvement in mortality could simply be related to the increased use of forceps delivery associated with epidural block. A controlled trial of epidural block is therefore indicated in the management of the premature fetus. In babies over 2-5 kg, or, those who were immature, epidural block was not associated with a reduction or increase in perinatal mortality.     

Comparison of pethidine, buprenorphine and ketoprofen for postoperative analgesia after ovariohysterectomy in the cat

Sixty cats which underwent an ovariohysterectomy were randomly allocated into four treatment groups. One group (controls) received no analgesics postoperatively, and the others received either a single dose of buprenorphine (0.006 mg/kg) intramuscularly, or pethidine (5 mg/kg) intramuscularly, or ketoprofen (2 mg/kg) subcutaneously. The analgesia obtained after each treatment was assessed by three measures. There were significant differences between the groups both for the requirement for intervention analgesia (P = 0.0008) and for the overall clinical assessment (P = 0.0003) with ketoprofen requiring least intervention analgesia and having the best overall clinical assessment, followed by buprenorphine then pethidine. The control group required the most intervention analgesia and had the worst overall clinical assessment. Visual analogue scale scoring for pain produced significant differences between the groups from one hour after the operation, with the cats which were given ketoprofen tending to have lower pain scores than the other groups.