[Prolonged mydriasis caused by Lamaline]

Atropine derivatives. The presence of atropine derivatives in numerous combined medicines is often ignored or reflected. A case report of prolonged bilateral non reactive mydriasis with "cycloplegia", linked with the utilisation of a therapeutic dose of Lameline suppositories raises the question of individual susceptibility, with particular ocular sensitivity. This urge one not to ignore the presence of these products and to respect the contraindications, even with minute doses.

[Remarks on some analgesics used in the pain clinic]

The mechanism of action of aspirin as an analgesic is an inhibition of biosynthesis of prostaglandins. Thus the site of action has been believed to be peripheral. However, when aspirin is injected intra- thecally, it produces an analgesic effect. Aspirin has a membrane-stabilizing effect and it is used locally for the treatment of post- herpetic neuralgia. Epidural opioids are frequently used for the management of post-operative pain or cancer pain. Pharmacokinetic studies have shown that delayed respiratory depression results from migration of morphine in the cerebrospinal fluid to the brain. Peak concentrations of morphine near the brain stem occur about 3 hours after lumbar epidural injection, whereas lipophilic opioids such as meperidine, peak concentration occur within 30 to 60 minutes. The clearance from cerebrospinal fluid of lipophilic opioids is more rapid than that of morphine. Besides opioids, alpha 2 receptor agonists such as clonidine also have analgesic action when administered into the epidural space. Somatostatin is one of many neuropeptides found in the spinal cord. It has dual action: a mediation of thermal nociception and a general antinociceptive action. When somatostatin is administered intrathecally or epidurally, it produces analgesic effect and its efficacy appears to be equal to that of morphine.

Intercostal blockade and pulmonary function after cholecystectomy

Sixty-six patients undergoing cholecystectomy were randomly allocated to receive either intercostal blockade with bupivacaine supplemented with papaveretum or papaveretum alone for postoperative analgesia. Both groups were similar regarding distribution of sex, age, and weight. These two groups were compared. Patients who did not have intercostal blockade required postoperative analgesia sooner. There was no significant difference, however, in the total consumption of papaveretum. Both groups experienced similar degrees of pain, and there were no differences in postoperative pulmonary function. We conclude that although single intercostal blockade is an effective analgesic, it does not improve pain relief and does not improve pulmonary function after cholecystectomy when compared with a regimen of on-demand, intramuscularly administered papaveretum.

A comparison of rectal diclofenac with intramuscular papaveretum or placebo for pain relief following tonsillectomy

A controlled investigation was conducted to compare the effectiveness of diclofenac and papaveretum in the prevention of pain and restlessness after tonsillectomy in children. Sixty children between 3 and 13 years of age were randomly allocated to receive rectal diclofenac 2 mg/kg, intramuscular papaveretum 0.2 mg/kg or no medication immediately after induction of anaesthesia. Pain and appearance were assessed 1, 3 and 6 hours postoperatively, and the following morning. The assessments were double-blind and performed by the same observer. No significant differences in postoperative pain were found between the groups at any time. The use of diclofenac was associated with a significantly more rapid return to calm wakefulness and had significantly less effect upon respiratory rate. Consumption of paracetamol on the day of operation was significantly less in the diclofenac group. Diclofenac may offer advantages compared to papaveretum with regard to safety and convenience for use in the treatment of pain after tonsillectomy in children.

Gastric emptying: a study to compare the effects of intrathecal morphine and i.m. papaveretum analgesia

Gastric emptying was studied in two groups of 10 patients who underwent elective cholecystectomy. The groups were comparable for age, weight and duration of operation. Gastric emptying was measured with a radioisotopic technique using Tc99m-DTPA (diethylene triamine pentaacetic acid) before, and 24 h after, surgery. Analgesia was provided by intrathecal morphine 0.8 mg alone (group A) or by i.m. papaveretum 10 mg, administered as required, plus one additional dose 1 h before the postoperative measurement (group B). Control gastric emptying rates were not significantly different in the two groups (mean +/- SD: A = 76.6 +/- 23.0 ml; B = 81.8 +/- 16.3 ml in 30 min). After surgery, gastric emptying was significantly greater in group A (42.9 +/- 35.6 ml) than in group B (11.0 +/- 27.9 ml) (P less than 0.05).

Psychological factors influencing post-operative pain and analgesic consumption

The personality factors, post-operative pain experience and analgesic requirements after minor oral surgery under general anaesthesia of 103 patients are presented. Psychiatric morbidity, neuroticism and anxiety were related to increased pain which tended to persist longer than normal. Trait anxiety also correlated with simple analgesic consumption, and neuroticism was weakly associated with Omnopon requirements. Thus, regular analgesics prescribed for at least 3 days will anticipate the needs of such patients. Despite higher levels of anxiety and neuroticism, women did not complain of more pain or require more analgesia than men in this study. There was also no overall correlation between post-operative pain experience and analgesic requirements. Therefore analgesic tablet consumption cannot be used as a measure of pain control.

Unusual opioid withdrawal syndrome. A case-report

In a patient with advanced cancer, neurosurgery relieved severe pain that had been uncontrolled by very high doses of opioids. On reduction of opioid dosage he had visual and auditory hallucinations and showed deterioration of consciousness progressing to coma. Naloxone worsened his mental state whereas morphine restored it to normal. This syndrome may be related to opioid withdrawal at receptors other than the mu receptors that have been linked to analgesia and drug abuse.

Human immunodeficiency virus infection in heterosexual intravenous drug users in San Francisco

To investigate the risk of infection with the human immunodeficiency virus (HIV) in San Francisco, the prevalence of antibodies to HIV was determined in 281 heterosexual intravenous drug users recruited from community-based settings. Ten per cent of subjects had ELISA and Western blot confirmed seropositivity for antibodies (95 per cent CI 6.8-14.2 per cent). Analysis of behavioral factors revealed an increased risk of seropositivity in addicts who reported regularly sharing needles when injecting, particularly those sharing with two or more persons (odds ratio = 5.43; 95 per cent CI 1.08-52.5). Blacks and Latinos also had a greater prevalence of seropositivity than Whites, and this finding persisted after adjustment for needle sharing (adjusted odds ratio = 2.8; 95 per cent CI .84-8.59). Seropositivity was not associated with age, sex, duration of drug use, or history of prostitution. These data indicate that a new epidemic of AIDS (acquired immunodeficiency syndrome) in intravenous drug users, similar to that which has occurred among homosexuals in San Francisco, is possible. The relatively low seroprevalence in 1985 provides health officials an important opportunity to intervene and attempt to prevent widespread infection of drug users with HIV.

Renal failure does not impair the metabolism of morphine

The pharmacokinetics of morphine were measured using gas chromatography-mass spectrometry (GCMS) with specific ion monitoring after the intramuscular administration of papaveretum to four patients with renal failure (one anephric) and three normals. The apparent t1/2 of absorption and t1/2 of elimination were significantly shorter in the patients with renal failure (P less than 0.05). Morphine glucuronides are eliminated slowly in these patients as expected. Renal failure does not impair the elimination of morphine.

Caudal analgesia for perianal surgery. A comparison between bupivacaine and diamorphine

Seventy-three patients undergoing elective perianal surgery were randomly divided into a control group, a group who received a caudal injection of 20 ml bupivacaine 0.5% plain and a group who received diamorphine 2.5 mg in 10 ml normal saline by caudal injection; a comparison was then made of postoperative analgesia requirements. The bupivacaine group had better analgesia than the control group for the first 8 hours, after which there was no difference. The diamorphine group had better analgesia than the control group for the first 24 hours postoperatively. Side effects were less in the diamorphine group than the control, or the bupivacaine group. In particular, 41% of the bupivacaine group complained of some degree of urinary retention and one patient required temporary catheterisation. It is concluded that caudal diamorphine gives good postoperative analgesia for perianal operations, particularly when motor blockade is not wanted by the surgeon.

Intramuscular midazolam premedication in small children. A comparison with papaveretum and hyoscine

Midazolam 0.2 mg/kg was compared as an intramuscular premedication in small children with papaveretum and hyoscine 0.4 and 0.008 mg/kg. Midazolam produced satisfactory sedation and anxiolysis and in the early postoperative period patients were significantly more awake (p less than 0.05).

When do patients given intrathecal morphine need postoperative systemic opiates?

A prospective, randomised study has compared the requirements for intramuscular papaveretum after cholecystectomy in patients given either 0.8 mg intrathecal morphine preoperatively or intravenous papaveretum peroperatively. Patients given intrathecal morphine required significantly less papaveretum during the first 48 hours after operation, but no significant difference in analgesic requirements was observed by 72 hours due to a continuing demand for papaveretum by these patients.

Sciatic nerve block for children. Sciatic nerve block by the anterior approach for postoperative pain relief

This study aimed to establish whether it was practical to perform sciatic nerve block by the anterior approach in a group of children of different ages and weights. A total of 82 blocks were performed of which 78 (95.2%) were judged to have been successful. The technique of the block differed slightly from that used in adult practice, in that great reliance was placed on the loss of resistance felt as the needle point passed through the thigh muscles into the sciatic neurovascular compartment. There were no immediate or late complications associated with this block in any of the patients. It is concluded that the block is easy to perform and can produce reliable postoperative analgesia for most common operations on the foot and ankle in paediatric practice.

The need for analgesic cover after ENT surgery--comparison of nefopam and papaveretum

Intra-operative intramuscular injections of either papaveretum 0.3 mg/kg or nefopam 0.4 mg/kg were given to alternate patients to promote smooth emergence from ENT anaesthesia in a consecutive series of 40 children. Observations over a period of 30 minutes following completion of surgery showed that emergence was satisfactory in 19 out of 20 children given papaveretum, and in 15 out of 20 children given nefopam. The study confirms that this indication for papaveretum is justifiably popular and that nefopam is a useful alternative mainly because it does not cause respiratory depression. There are no previous reports of the use of nefopam in children.

The pattern of postoperative analgesic administration in non-English speaking Asian women following caesarean section

A survey of postoperative analgesic administration to non-English speaking Asian women following Caesarean section has shown significant differences when compared to English speaking Caucasian women. The main differences demonstrated were that analgesia was utilised for a shorter period (mean of 16 hours) and that a smaller number of doses were given to the Asian group.

Neonatal methadone withdrawal. Effect of two treatment regimens

Thirty-one infants exposed to methadone in utero who required pharmacologic treatment for withdrawal symptoms were randomly assigned to a paregoric or phenobarbital treatment group. Seven infants had symptoms too mild to require treatment. Respiratory rate, blood pH, PCO2, systolic BP, and serum thyroxine concentrations were measured on the 4th, 7th, and 14th days of life. Platelet counts were performed on the seventh and 14th days of life, and urinary catecholamine excretion was measured on the sixth day of life. Rates of weight gain were recorded during the second and third weeks of life. With the exception of a slightly higher blood PCO2 level in the phenobarbital-treated infants on day 7, no significant intergroup differences were observed in the treated infants. Paregoric-treated infants required a significantly longer period of treatment than phenobarbital-treated infants (22 v 17 days). This may have been due, at least in part, to the prolonged half-life and relatively high blood levels of phenobarbital present after cessation of therapy.

Premedication for fibreoptic bronchoscopy

A randomised, double-blind trial of atropine, atropine plus papaveretum, and atropine plus diazepam given intramuscularly as premedication for fibreoptic bronchoscopy in 60 patients showed no difference between the three regimens as assessed by bronchoscopist or patient. Bronchoscopists frequently attributed a sedative action to atropine alone and their assessment of tolerance and sedation was more optimistic than that of the patients. In a second study comparing intravenous diazepam (10 mg) with saline, after prior intramuscular atropine (0.6 mg), both the bronchoscopists and the patients noted a significant sedative effect of diazepam, and coughing was reduced by diazepam.

Rapid and safe withdrawal of intravenous papaveretum after prolonged continuous infusion

A case is reported in which papaveretum was administered to a patient by continuous intravenous infusion for 60 days. Complete and rapid withdrawal of the narcotic analgesic at the end of that period, despite a massive established daily requirement, was relatively simple and apparently safe. Aspects of narcotic analgesic dependence as they pertain to the case are discussed and the prolonged administration of intravenous opiates with greater confidence by clinicians involved in the intensive therapy of similar patients is suggested.