Nalbuphine versus meperidine for post-operative analgesia: a double-blind comparison using the patient controlled analgesic technique

Nalbuphine by PCA-pump for analgesia following hysterectomy: bolus application versus continuous infusion with bolus application

The analgesic properties of the partial agonist-antagonist nalbuphine in the postoperative period are well known. When used for patient-controlled analgesia (PCA) the effectiveness of this substance is comparable to that of morphine or tramadol. However, the optimal programme for administration of nalbuphine in PCA-pumps has not been investigated. In particular, the combination of bolus administration vs bolus administration plus continuous basal administration is disputable. We hypothesized that the administration of an extra basal rate of nalbuphine in addition to the patient- triggered bolus administration and supplemental doses of diclofenac when required, would lead to a significant improvement in analgesia, without affecting the differences in vital signs and side effects. After approvement by the institutional ethics committee, 50 female patients (ASA I or II) scheduled for elective hysterectomy were included in a prospective, single-blinded study and randomized either into bolus-continuous (BC-)group (3 mg base rate/h, 1 mg bolus, 20 min lock out) or bolus (B-)group (no base rate, 1 mg bolus, 10 min lock out). During the observation period (up to 24 h postoperative) vital parameters, extent of analgesia (10-step VAS), and vigilance (5-step scale) were registered. Groups were compared by using unpaired Student t-test. A p<0.05 was considered to be significant. No differences were found in demographic data or vital parameters (MAP, PaO2, PaCO2, respiratory rate, heart rate, peripheral SaO2) during the observation period. Vital parameters showed no pathological changes in any group. With an identical rate of requirement for diclofenac (32 and 36%), analgesia in BC-group showed a decrease in VAS from 4.28+/-2.11 to 2.04+/-1.21 and from 3.64+/-2.20 to 2.08+/-0.96 in B-group. Vigilance was only marginally diminished in both groups. No serious side effects were found in either group. The consumption of nalbuphine (mg) was significantly higher in BC-group (70.28+/-13.85 vs. 47.44+/-22.99;p =0.0002) when compared to B-group. Subjective rating of effectiveness by the patients was similar in both groups. The two administration settings of nalbuphine by PCA pump have shown to be equally effective in the treatment of postoperative pain following hysterectomy. However, as the total amount of nalbuphine was significantly lower in B-group, the use of this administration schedule should be encouraged.

Intrathecal morphine (ITM) for postoperative pain control in children: a comparison with nalbuphine patient controlled analgesia (PCA)

This is a retrospective study covering the ten-year period 1984-1993. Single shot spinal morphine (ITM) is compared with PCA nalbuphine for postoperative pain relief in children having abdominal or thoracic procedures. The records of 52 patients meeting selection criteria were examined. Nursing and physician notations were reviewed for hourly pain assessments, evidence of associated complications, respiratory depression, nausea and or vomiting, pruritus, and urinary retention. ITM provided significantly better pain relief (2.2 h in pain) during the first 24 h postoperatively than PCA nalbuphine (9.2 h in pain). With the exception of urinary retention which was significantly more frequent following ITM (58.6%) compared to PCA nalbuphine (8.7%), narcotic related complications were not different between the two groups. No difference in duration of hospital stay or ICU stay could be demonstrated. We conclude that ITM provides better pain relief, without more serious complications, than PCA nalbuphine. We recommend it as a safe, effective technique to treat postoperative pain in children following thoracic or upper abdominal procedures.

Post-operative intravenous continuous analgesia: comparison of buprenorphine, fentanyl and nalbuphine

Continuous intravenous infusions of fentanyl, buprenorphine or nalbuphine were investigated to provide pain relief for patients after major abdominal surgery. Buprenorphine (n = 23) was given as a loading dose of 5 micrograms kg-1 and infused at 0.8 micrograms kg-1 h-1. Fentanyl (n = 20) was given as a loading dose of 2 micrograms kg-1 and infused at 0.7 micrograms kg-1 h-1. Nalbuphine (n = 21) was given as a loading dose of 200 micrograms kg-1 and infused at 80 micrograms kg-1 h-1. The infusion rate was increased when analgesia was inadequate, and decreased if respiratory depression occurred. Mean doses were respectively 0.74 +/- 0.15 microgram kg-1 h-1 buprenorphine, 0.68 +/- 0.18 microgram kg-1 h-1 fentanyl, 83 +/- 21 micrograms kg-1 h-1 nalbuphine. Titration of continuous intravenous infusion of buprenorphine and fentanyl provided better analgesia than nalbuphine with smaller doses than those reported in similar studies allowing spontaneous breathing.

[Patient-controlled analgesia]

Patient controlled analgesia (PCA) is a drug delivery system aimed to control acute pain using negative feedback technology in a closed loop system in which the patient plays an active role. It overcomes the inadequacies of traditional analgesic protocols due to marked differences in pharmacokinetic and dynamy of analgesis between patients. Moreover, doctors and nurses frequently underprescribe opioids in patients with severe pain for fear of dangerous side-effects. A safe and effective delivery of these drugs on patient demand can be achieved using various delivery systems, modes and dosing parameters. Most devices provide both demand dosing, where a constant predetermined dose is self administered, and constant rate infusion plus demand dosing, where the minimum administration rate is determined by the doctor, but can be supplemented by patient demand. Morphine sulphate remains the drug most commonly used in PCA therapy, but meperidine hydrochloride, alfentanil, nalbuphine and buprenorphine are also sometimes administered. The doctor determines the incremental dose per demand, the lockout interval, and the maximum dose per time unit, possibly also the loading dose and the minimum dose rate when a continuous flow is used. PCA provides improved analgesia, which is immediate and independent of nurse availability. This technique decreases opioid requirements, and the required total amounts are lowered. PCA gives patients both behavioural and decisional control. They can titrate the analgesic dose in such a way as to balance pain relief with the degree of side-effects, the patient is willing to tolerate. Patients often choose less than the available total dose of analgesic. The risks consists in the usual opioid side-effects, mainly respiratory depression. These may be due to mechanical problems, machine failure, or user incidents (misprogramming, or miscalculation of doses). Standards help to ensure consistent care and avoid errors that can occur even with handwritten orders. The principles of demand analgesia are now being investigated using other agents, such as local anaesthetics, and other routes of administration, mainly epidural injection. In most patients, even in children, PCA can replace intramuscular injections, which are the standard route for opioid administration. Today PCA and spinal opioids are the two main methods of analgesia for postoperative pain management.

[Comparison of nalbuphine and pentazocine in the treatment of postoperative pain by self-administration]

The side-effects of two opioid agonist-antagonists, nalbuphine and pentazocine, were assessed when used for patient-controlled postoperative analgesia. Forty ASA I or II patients scheduled for upper abdominal surgery were randomly allocated to two equal groups. The anaesthetic technique was the same for all the patients: premedication with atropine and diazepam, induction with thiopentone and suxamethonium and maintenance with fentanyl, pancuronium, nitrous oxide and halothane. Patient-controlled computer assisted analgesia (On-Demand Analgesia Computer) was started in the recovery room at least 2 h after the last administration of fentanyl. The parameters used were: a routine hourly dose (the half of that received during the previous hour), with on demand delivery of nalbuphine (15 micrograms.kg-1) or pentazocine (45 micrograms.kg-1) aliquots respectively, with a refractory period between two demands of 4 min and a total hourly maximum dose of 16 mg and 48 mg respectively. The following parameters were measured before the start of self-administration, and every hour afterwards for 24 h: systolic (Pasys) and diastolic blood pressures, heart rate, pressure-rate product (PRP), respiratory rate, end-tidal CO2 and pain (by way of a three point scale). Analgesia was assessed on a four-point scale every 6 h. The total doses of nalbuphine and pentazocine administered were 94 +/- 43 mg and 251 +/- 150 mg respectively. The only parameters significantly different between the two groups were Pasys and PRP, being higher in the pentazocine group. There were no significant differences in the side-effects (drowsiness, nausea, vomiting, headache, amnesia, logorrhoea and urine retention). All patients in both groups were satisfied with this technique.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison of nalbuphine and meperidine in treatment of postoperative pain

The analgesic efficacy and side effect profile of nalbuphine 20 mg IV and of nalbuphine 40 mg IV were compared to those of meperidine 75 mg IM in the immediate postoperative period. Pain intensity, pain relief, additional analgesic requirements and the overall acceptability of the treatment were recorded for 150 patients. No significant differences were found between the groups for any of the efficacy variables. Peak analgesic effects occurred at 15 minutes in both nalbuphine groups and at 30 minutes in the meperidine group. The mean time to additional analgesic medication was approximately 207 minutes in each group. The incidence of nausea and vomiting with meperidine was 22 per cent (95 per cent confidence interval 10 to 34 per cent) and with nalbuphine 20 mg the incidence was two per cent (95%CI -2 to 6 per cent). This difference was significant (p less than 0.01). The difference between nalbuphine 40 mg (10 per cent, 95%CI 1 to 19 per cent) and meperidine, was not considered statistically significant (p = 0.17). The analgesic efficacy of nalbuphine 20 mg was indistinguishable from that of nalbuphine 40 mg and from that of meperidine 75 mg. The significantly lower incidence of nausea and vomiting with nalbuphine is a major advantage for a recovery room analgesic.

The effectiveness of nalbuphine and hydroxyzine for the emergency treatment of severe headache

The present treatment for acute attacks of headache is empiric. Intramuscular nalbuphine (Nubain) and hydroxyzine (Vistaril) were assessed for pain relief in a prospective, double-blind clinical trial. Ninety-four patients were assigned randomly to treatment groups receiving nalbuphine 10 mg, nalbuphine 10 mg plus hydroxyzine 50 mg, hydroxyzine 50 mg, or placebo. The treatment groups were found to be adequately homogenous with regard to age, sex, type and duration of headaches, and history of prior narcotic use. All data were analyzed by one-way analysis of variance. Patients who had headaches diagnosed as other than classic migraine had significantly greater pain relief with nalbuphine compared to placebo (P less than .01). The combination of nalbuphine and hydroxyzine was not significantly more effective than other treatment groups. In 20 patients with classic migraine, none of the treatment regimens significantly outperformed placebo. There were no clinically significant adverse effects attributed to the study drugs. These findings are similar to others that showed a lack of efficacy of kappa receptor agonists in classic migraineurs. Nalbuphine appears to be clinically useful in other types of severe headache. This study does not support the routine addition of hydroxyzine for presumed synergistic effect.

Analgesic and gastrointestinal effects of nalbuphine--a comparison with pethidine

A double-blind comparison of some analgesic and gastrointestinal effects of nalbuphine and pethidine was performed in 28 women undergoing laparoscopic sterilisation. The opioid was given as an initial loading dose prior to the induction of general anaesthesia and further doses were given on demand in the postoperative period to achieve and maintain adequate pain relief. Gastric emptying in the immediate postoperative period was also assessed in each patient by measuring the rate of absorption of orally administered paracetamol. Nalbuphine was equally effective as pethidine as a postoperative analgesic, but may have been a less effective supplement to anaesthesia in the doses used in this study. Gastric emptying was profoundly depressed in all patients irrespective of which analgesic was used.

Patient-controlled analgesia with nalbuphine, a new narcotic agonist-antagonist, for the treatment of postoperative pain

Patient-controlled analgesia (PCA, intravenous self-application of narcotics) has been studied during the early postoperative period in 40 ASA I-III patients recovering from elective major and minor surgery (20 abdominal and 20 orthopaedic operations). Doses of 3.7 mg of the new agonist-antagonist opioid analgesic nalbuphine were available on demand, whenever the patients felt that pain relief was necessary, delivered by a microprocessor-controlled injection pump (On-Demand Analgesia Computer, ODAC) in response to use of a patient-controlled manual switch. The maximum dose/h was set at 28.2 mg, with a refractory time of 1 minute between successful demands. A continuous nalbuphine infusion (0.44 mg X h-1) was administered in addition in order to prevent obstruction of the catheter. The duration of the PCA period was 17.9 (0.4-28.0) h (median, range). During that time, 13.3 (1-45) demands per patient were recorded, resulting in median individual nalbuphine consumptions of 51.3 (8.1-1050.5) micrograms X kg-1 X h-1. Self-administration was characterized by considerable intra- and inter-individual variability. Following abdominal surgery significantly more nalbuphine was needed compared to orthopaedic patients, but it resulted in poorer pain relief. There were no statistically significant differences in drug requirements or pain scores between the sexes. Overall efficacy and patient acceptance proved to be good. When compared with previous conventional postoperative analgesia, the effectiveness of PCA was judged superior by about 57% of patients. Side effects (nausea, sweating) occurred in about 10% of patients but were usually of minor intensity. No serious circulatory or respiratory problems were observed during the period of PCA. Patient-controlled analgesia is a promising technique for the treatment of acute pain and for clinical pain research.

Newer methods of delivery of opiates for relief of pain

Successful pain management using opiates requires both an analgesic with sufficient intrinsic activity and an effective administration system. Most instances of unsatisfactory pain control, however, are due to failure to achieve and maintain adequate blood concentrations of the chosen drug. Newer techniques of administration aim to overcome this problem. Oral opiate therapy with conventional or sustained-release formulations of morphine provide good control of terminal cancer pain provided that a regular dosing pattern is established and reviewed according to the patient's needs. This represents a significant departure from the traditional 'as required' prescription of this type of drug. In the management of acute severe pain, sublingual and intravenous opiates--self-administered as needed, or given by mandatory dosing schedules--have also been shown to overcome the limitations of intermittent intramuscular injections. A further novel development, stemming from basic neuroscience research, is the selective application of opiates to the spinal cord via the epidural or intrathecal route. This controversial technique has led to major improvements in treatment of some types of acute and chronic pain.