A double-blind randomised controlled trial of paracetamol, diclofenac or the combination for pain relief after caesarean section

Model-Based Meta-Analysis Supporting the Combination of Acetaminophen and Topical Diclofenac in Acute Pain: A Therapy for Mild-to-Moderate Osteoarthritis Pain?

INTRODUCTION

Acetaminophen and topical diclofenac (AtopD) have complementary mechanisms of action and are therefore candidates for combination use in osteoarthritis (OA) pain. However, an evidence gap exists on their combination use in OA pain. This study aimed to assess the effects of this combination and compare its performance relative to monotherapies on pain score reduction and opioid-sparing effect by leveraging evidence from acute pain setting using a model-based meta-analysis (MBMA).

METHODS

A literature search was conducted using the MEDLINE database to identify randomized controlled trials (RCTs) studying the combination for acute pain. Subsequently, an MBMA of RCTs was implemented in conjunction with extrapolation principles to infer efficacy in the population of interest. Pain score reduction and opioid-sparing effect (OSE) were selected as the measures of efficacy.

RESULTS

A total of 11 RCTs encompassing 1396 patients were included. Exploratory evaluation revealed AtopD combination to show greater pain score reduction versus acetaminophen monotherapy. However, pain score reduction was more susceptible to confounding by opioid patient-controlled analgesia (PCA) than OSE. Therefore, a parsimonious MBMA evaluating OSE was developed from 5 of the 11 RCTs (n = 353 patients). The analysis revealed a statistically significant interaction coefficient, suggesting a reduction of 32% in opioid use with the combination versus acetaminophen monotherapy. Differences in the effect size of the combination were less conclusive versus diclofenac monotherapy.

CONCLUSION

Our results indicate greater pain reduction and opioid-sparing efficacy for the AtopD combination versus acetaminophen monotherapy. Given the similar pain pathways and mechanisms of action of the two drugs in acute and mild-to-moderate OA pain, comparable beneficial effects from the combination therapy may be anticipated following extrapolation to chronic OA pain. Prospective RCTs and real-world studies in OA pain are needed to confirm the differences in the efficacy of the combination treatment observed in our study.

Comparison of different nonsteroidal anti-inflammatory drugs for cesarean section: a systematic review and network meta-analysis

BACKGROUND

Cesarean section is associated with moderate to severe pain and nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly employed. The optimal NSAID, however, has not been elucidated. In this network meta-analysis and systematic review, we compared the influence of control and individual NSAIDs on the indices of analgesia, side effects, and quality of recovery.

METHODS

CDSR, CINAHL, CRCT, Embase, LILACS, PubMed, and Web of Science were searched for randomized controlled trials comparing a specific NSAID to either control or another NSAID in elective or emergency cesarean section under general or neuraxial anesthesia. Network plots and league tables were constructed, and the quality of evidence was evaluated with Grading of Recommendations Assessment, Development and Evaluation (GRADE) analysis.

RESULTS

We included 47 trials. Cumulative intravenous morphine equivalent consumption at 24 h, the primary outcome, was examined in 1,228 patients and 18 trials, and control was found to be inferior to diclofenac, indomethacin, ketorolac, and tenoxicam (very low quality evidence owing to serious limitations, imprecision, and publication bias). Indomethacin was superior to celecoxib for pain score at rest at 8-12 h and celecoxib + parecoxib, diclofenac, and ketorolac for pain score on movement at 48 h. In regard to the need for and time to rescue analgesia COX-2 inhibitors such as celecoxib were inferior to other NSAIDs.

CONCLUSIONS

Our review suggests the presence of minimal differences among the NSAIDs studied. Nonselective NSAIDs may be more effective than selective NSAIDs, and some NSAIDs such as indomethacin might be preferable to other NSAIDs.

Parenteral Ready-to-Use Fixed-Dose Combinations Including NSAIDs with Paracetamol or Metamizole for Multimodal Analgesia-Approved Products and Challenges

The combination of non-steroidal anti-inflammatory drugs (NSAIDs) with non-opioid analgesics is common in clinical practice for the treatment of acute painful conditions like post-operative and post-traumatic pain. Despite the satisfactory results achieved by oral analgesics, parenteral analgesia remains a key tool in the treatment of painful conditions when the enteral routes of administration are inconvenient. Parenteral ready-to-use fixed-dose combinations of non-opioid analgesics combinations, including NSAIDs and paracetamol or metamizole, could play a central role in the treatment of painful conditions by combining the advantages of multimodal and parenteral analgesia in a single formulation. Surprisingly, only in 2020, a parenteral ready-to-use fixed-dose combination of ibuprofen/paracetamol was launched to the market. This review aims to investigate the current availability of combinations of NSAIDs with paracetamol or metamizole in both European and American markets, and how the combination of such drugs could play a central role in a multimodal analgesia strategy. Also, we explored how the parenteral formulations of NSAIDs, paracetamol, and metamizole could serve as starting elements for the development of new parenteral ready-to-use fixed-dose combinations. We concluded that, despite the well-recognized utility of combining NSAIDs with paracetamol or metamizole, several randomized clinical trial studies demonstrate no clear advantages concerning their efficacy and safety. Future clinical trials specifically designed to assess the efficacy and safety of pre-formulated fixed-dose combinations are required to generate solid evidence about their clinical advantages.

Placenta accreta spectrum part I: anesthesia considerations based on an extended review of the literature

"Placenta accreta spectrum" (PAS) describes abnormal placental adherence to the uterine wall without spontaneous separation at delivery. Though relatively rare, PAS presents a particular challenge to anesthesiologists, as it is associated with massive peripartum hemorrhage and high maternal morbidity and mortality. Standardized evidence-based PAS management strategies are currently evolving and emphasize: "PAS centers of excellence", multidisciplinary teams, novel diagnostics/pharmaceuticals (especially regarding hemostasis, hemostatic agents, point-of-care diagnostics), and novel operative/interventional approaches (expectant management, balloon occlusion, embolization). Though available data are heterogeneous, these developments affect anesthetic management and must be considered in planed anesthetic approaches. This two-part review provides a critical overview of the current evidence and offers structured evidence-based recommendations to help anesthesiologists improve outcomes for women with PAS. This first part discusses PAS management in centers of excellence, multidisciplinary care team, anesthetic approach and monitoring, surgical approaches, patient safety checklists, temperature management, interventional radiology, postoperative care and pain therapy. The diagnosis and treatment of hemostatic disturbances and preoperative prepartum anemia, blood loss, transfusion management and postpartum venous thromboembolism will be addressed in the second part of this series.

Opioid dispensing after Cesarean delivery in British Columbia: a historical cohort analysis from 2004 to 2019

Purpose

To describe postdischarge opioid dispensing after Cesarean delivery (CD) in 49 hospitals in British Columbia (BC) and assess opportunities for opioid stewardship.

Methods

Using the BC Ministry of Health’s Hospital Discharge Abstract Database, we linked 135,725 CDs performed in 2004–2016 and 30,919 CDs performed in 2017–2019 (length of stay ≤ four days) by deidentified Personal Health Numbers to data on medications dispensed from all BC community pharmacies (PharmaNet). We excluded patients with cancer and those to whom opioids have been dispensed in the year before. We measured trends in annual percentages of patients dispensed opioids within seven days (opioid rate), with 95% confidence intervals (CIs), stratified by hospital and opioid type, adjusted for length of stay, and for autocorrelation within hospital using generalized linear modeling.

Results

The opioid dispensation rate dropped from 31% (95% CI, 30 to 33) in 2004 to 16% (95% CI, 15 to 17) in 2016, where it remained through 2019. Five hospitals showed steep reductions from over 40% to under 10% within two to three years, but in most hospitals the opioid dispensation rate decreased slowly—11 had little reduction and three showed increases. Codeine dispensing dropped from 31% in 2004–2008 by 4% per year, while tramadol and hydromorphone dispensing rose. After 2015, rates were stable (hydromorphone, 8%; tramadol, 6%; codeine, 3%; and oxycodone, 0.5%).

Conclusion

After Health Canada’s 2008 warning against codeine use by breastfeeding mothers, post-CD opioid dispensing declined disjointedly across BC hospitals. Rates did not decrease further after the opioid overdose epidemic was declared a public health emergency in BC in 2016. The present study highlights opportunities for quality improvement and opioid stewardship through monitoring using administrative databases.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12630-022-02271-8.

The efficacy of pentazocine + diclofenac versus paracetamol + diclofenac for post- caesarean section analgesia

Background

The most common major obstetric procedure is caesarean section (CS) and one of the greatest concerns for women after CS is to have optimal pain relief.

Aim

This study aims to compare the efficacy of pentazocine + diclofenac and paracetamol + diclofenac on post-operative analgesia after CS.

Methodology

This was a single-blind, randomised trial. Pregnant women that had CS were randomized into two groups. Group A received intramuscular pentazocine + rectal diclofenac postoperatively. Group B received intramuscular paracetamol + rectal diclofenac postoperatively. Post-operative pain was assessed by numeric rating scale at 1 h after the surgery, at 6 h, 12 h and 24 h. The result obtained was analysed using SPSS Version 22 and P < 0.05 was considered statistically significant.

Results

The median pain scores in both groups ranged from 2 to 3 across all periods of assessment. The pain relief was slightly better in the pentazocine + diclofenac group with no significant difference in the pain score between the two groups at all periods of assessment. The satisfaction level was good in 66.3% and 69.5% of the participants in the pentazocine + diclofenac and paracetamol + diclofenac group respectively but the difference was not statistically significant (χ² = 4.14, P = 0. 12). Nausea, vomiting and drowsiness were significantly more in the pentazocine + diclofenac combination (P < 0.001).

Conclusion

Both combination of analgesics provided adequate analgesia but pentazocine + diclofenac combination had better pain relief but was more associated with side effects.

The Current Consideration, Approach, and Management in Postcesarean Delivery Pain Control: A Narrative Review

Optimal postoperative analgesia has a significant impact on patient recovery and outcomes after cesarean delivery. Multimodal analgesia is the core principle for cesarean delivery and pain management. For a standard analgesic regimen, the use of long-acting neuraxial opioids (e.g., morphine) and adjunct drugs, such as scheduled acetaminophen and nonsteroidal anti-inflammatory drugs, is recommended unless contraindicated. Oral or intravenous opioids should be reserved for breakthrough pain. In addition to the aforementioned use of multimodal analgesia, preoperative evaluation is critical to individualize the analgesic regimen according to the patient requirements. Risk factors for severe postoperative pain or analgesia-related adverse effects will require modifications to the standard analgesic regimen (e.g., the use of ketamine, gabapentinoids, or regional anesthetic techniques). Further investigation is required to determine analgesic drugs or dose alterations based on preoperative predictions for patients at risk of severe pain. Outcomes beyond pain and analgesic use, such as functional recovery, should be determined to evaluate analgesic treatment protocols.

A retrospective audit of pain assessment and management post-caesarean section at New Somerset Hospital in Cape Town, South Africa

Background

The most common major surgical procedure performed worldwide is the caesarean section (CS). Effective pain management is a priority for women undergoing this procedure, to reduce the incidence of persistent pain (a risk factor for postpartum depression), as well as optimise maternal-neonatal bonding and the successful establishment of breastfeeding. Multimodal analgesia is the gold standard for post-CS analgesia. At present, no perioperative pain management protocols could be identified for the management of patients presenting for CS at regional hospitals in South Africa. This audit aimed to review the folders of patients who underwent CS, with particular reference to perioperative pain management guidelines for CS.

Methods

A descriptive, retrospective, cross-sectional audit was conducted. Three hundred folders (10% of the annual number of caesarean procedures performed) from New Somerset Hospital, a regional hospital in Cape Town, South Africa were reviewed.

Results

The women were a mean age of 30 years (standard deviation [s.d.]: 6.2). Median gravidity was 3 (interquartile range [IQR]: 2–3) and parity was 1 (IQR: 1–2); 52% had previously undergone a CS. In 93.3% cases, spinal anaesthesia was employed for CS. Pain assessment was poor, with only 55 (18%) patients having their pain assessed on the day of the operation. Analgesia was prescribed in over 98% of the patients, however, medication was only administered as prescribed in 32.6%. Non-steroidal anti-inflammatory drugs (NSAIDs) were prescribed in < 5% of cases. None of the patients received a patient-controlled analgesia (PCA), transversus abdominis plane (TAP) block, or wound infusion catheter as supplementary strategies.

Conclusion

Pain management for post-CS patient at this hospital is lacking. There is the need for the implementation of a structured assessment tool to improve administration of analgesics in these patients. In addition, the reasons for the omission of NSAIDs from the analgesia regimen requires investigation. Hospital requires post-CS pain protocols to guide management especially in resource-limited settings.

[Perioperative analgesia with nonopioid analgesics : Joint interdisciplinary consensus-based recommendations of the German Pain Society, the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Surgery]

BACKGROUND

Nonopioid analgesics are frequently used for perioperative analgesia; however, insufficient research is available on several practical issues. Often hospitals have no strategy for how to proceed, e.g., for informing patients or for the timing of perioperative administration of nonopioid analgesics.

METHODS

An expert panel representing the German national societies of pain, anaesthesiology and intensive care medicine and surgery developed recommendations for the perioperative use of nonopioid analgesics within a formal, structured consensus process.

RESULTS

The panel agreed that nonopioid analgesics shall be part of a multimodal analgesia concept and that patients have to be informed preoperatively about possible complications and alternative treatment options. Patients' history of pain and analgesic intake shall be evaluated. Patients at risk of severe postoperative pain and possible chronification of postsurgical pain shall be identified. Depending on the duration of surgery, nonopioid analgesics can already be administered preoperatively or intraoperatively so that plasma concentrations are sufficient after emergence from anesthesia. Nonopioid analgesics or combinations of analgesics shall be administered for a limited time only. An interdisciplinary written standard of care, comprising the nonopioid analgesic of choice, possible alternatives, adequate dosing and timing of administration as well as surgery-specific policies, have to be agreed upon by all departments involved. At discharge, the patient's physician shall be informed of analgesics given and those necessary after discharge. Patients shall be informed of possible side effects and symptoms and timely discontinuation of analgesic drugs.

CONCLUSION

The use of nonopioid analgesics as part of a perioperative multimodal concept should be approved and established as an interdisciplinary and interprofessional concept for the adequate treatment of postoperative pain.

[Perioperative analgesia with nonopioid analgesics : Joint interdisciplinary consensus-based recommendations of the German Pain Society, the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Surgery]

BACKGROUND

Nonopioid analgesics are frequently used for perioperative analgesia; however, insufficient research is available on several practical issues. Often hospitals have no strategy for how to proceed, e.g., for informing patients or for the timing of perioperative administration of nonopioid analgesics.

METHODS

An expert panel representing the German national societies of pain, anaesthesiology and intensive care medicine and surgery developed recommendations for the perioperative use of nonopioid analgesics within a formal, structured consensus process.

RESULTS

The panel agreed that nonopioid analgesics shall be part of a multimodal analgesia concept and that patients have to be informed preoperatively about possible complications and alternative treatment options. Patients' history of pain and analgesic intake shall be evaluated. Patients at risk of severe postoperative pain and possible chronification of postsurgical pain shall be identified. Depending on the duration of surgery, nonopioid analgesics can already be administered preoperatively or intraoperatively so that plasma concentrations are sufficient after emergence from anesthesia. Nonopioid analgesics or combinations of analgesics shall be administered for a limited time only. An interdisciplinary written standard of care, comprising the nonopioid analgesic of choice, possible alternatives, adequate dosing and timing of administration as well as surgery-specific policies, have to be agreed upon by all departments involved. At discharge, the patient's physician shall be informed of analgesics given and those necessary after discharge. Patients shall be informed of possible side effects and symptoms and timely discontinuation of analgesic drugs.

CONCLUSION

The use of nonopioid analgesics as part of a perioperative multimodal concept should be approved and established as an interdisciplinary and interprofessional concept for the adequate treatment of postoperative pain.

[Perioperative analgesia with nonopioid analgesics : Joint interdisciplinary consensus-based recommendations of the German Pain Society, the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Surgery]

Hintergrund

Nichtopioidanalgetika werden bei vielen Patienten zur perioperativen Analgesie eingesetzt. Zu einigen praktischen Fragen beim Einsatz von Nichtopioidanalgetika liegen z. T. nur wenig Informationen aus Studien vor, und in Krankenhäusern existieren häufig keine Konzepte zum Vorgehen, z. B. zur Patientenaufklärung und zum Zeitpunkt der perioperativen Gabe.

Methodik

Eine Expertengruppe der beteiligten Fachgesellschaften hat konsensbasierte Empfehlungen zum perioperativen Einsatz von Nichtopioidanalgetika erarbeitet und in einem strukturierten formalen Konsensusprozess verabschiedet.

Ergebnisse

Die Arbeitsgruppe stimmt überein, dass Nichtopioidanalgetika Bestandteil eines perioperativen multimodalen Analgesiekonzepts sein sollen und Patienten präoperativ über Nutzen, Risiken und alternative Behandlungsmöglichkeiten aufgeklärt werden sollen. Die präoperative Patienteninformation und -edukation soll auch eine Schmerz- und Analgetikaanamnese umfassen und Patienten mit Risikofaktoren für starke Schmerzen und eine Schmerzchronifizierung sollen identifiziert werden. Unter Berücksichtigung von Kontraindikationen können Nichtopioidanalgetika abhängig von der Operationsdauer auch schon prä- oder intraoperativ gegeben werden, um nach Beendigung der Anästhesie ausreichende Plasmakonzentrationen zu erzielen. Nichtopioidanalgetika oder Kombinationen von (Nichtopioid‑)Analgetika sollen nur für einen begrenzten Zeitraum gegeben werden. Ein gemeinsam erarbeiteter abteilungsübergreifender Behandlungsstandard mit dem Nichtopioidanalgetikum erster Wahl, weiteren Therapieoptionen sowie adäquaten Dosierungen, ergänzt durch eingriffsspezifische Konzepte, soll schriftlich hinterlegt werden. Bei Entlassung aus dem Krankenhaus soll der nachbehandelnde Arzt zu perioperativ gegebenen und aktuell noch eingenommenen Analgetika schriftliche Informationen erhalten. Patienten sollen zu möglichen Nebenwirkungen der Analgetika und ihrer Symptome, die auch nach Krankenhausentlassung auftreten können, und die befristete Einnahmedauer informiert werden.

Schlussfolgerung

Die Anwendung von Nichtopioidanalgetika soll als Bestandteil eines perioperativen multimodalen Analgesiekonzepts mit klaren Vorgaben zu Indikationen, Kontraindikationen, Dosierungen und Behandlungsdauer in einem abteilungsübergreifenden Behandlungsstandard schriftlich hinterlegt werden.

Zusatzmaterial online

Die Offenlegung von Interessen ist in der Online-Version dieses Artikels (10.1007/s00104-021-01421-w) enthalten.

Analgesia After Cesarean Delivery in the United States 2008-2018: A Retrospective Cohort Study

BACKGROUND

Optimizing analgesia after cesarean delivery is a priority and requires balancing adequate pain relief with the risk of analgesics-associated adverse effects. Current recommendations are for use of a multimodal, opioid-sparing analgesic regimen that includes neuraxial morphine combined with scheduled nonsteroidal anti-inflammatory drugs (NSAIDs) and scheduled acetaminophen. Furthermore, recent studies recommend scheduled acetaminophen with as-needed opioids in lieu of acetaminophen-opioid combination drugs to reduce opioid consumption and optimize analgesia. However, the extent of utilization of this recommended regimen in the United States is unclear. We therefore performed this retrospective study to evaluate postoperative analgesic regimens utilized after cesarean delivery under neuraxial anesthesia, examine variability across institutions, evaluate changes over time in postoperative analgesic practice, and examine factors associated with the use of neuraxial morphine and of multimodal analgesia.

METHODS

This retrospective cohort study was approved by the Duke University Institutional Review Board. Parturients who underwent cesarean delivery under neuraxial anesthesia from 2008 to 2018 were included. Data were extracted from a nationwide inpatient administrative-financial database (Premier Inc, Charlotte, NC) and included parturient characteristics, comorbidities, hospital characteristics, and charges for administered medications. The primary outcome was the postoperative analgesic regimen utilized during hospitalization, including utilization of neuraxial morphine and of multimodal analgesia for postoperative pain control. We also examined the factors associated with the use of neuraxial morphine and of the multimodal regimen incorporating neuraxial morphine, NSAIDs, and acetaminophen.

RESULTS

Data from 804,752 parturients were analyzed. Of this cohort, 75.8% received neuraxial morphine, 93.2% received NSAIDs, 28.4% received acetaminophen, and 81.3% received acetaminophen-opioid combination drugs. Only 6.1% received the currently recommended regimen of neuraxial morphine with NSAIDs and acetaminophen, with this percentage increasing from 1.3% in 2008 to 15.0% in 2018. On the other hand, 58.9% received neuraxial morphine, NSAIDs, and an acetaminophen-opioid combination drug, with this regimen being utilized in 57.0% of cases in 2008 and 58.1% in 2018. The hospital in which the patient was treated accounted for 54.7% of the variation in receipt of neuraxial morphine and 41.2% in the variation in receipt of multimodal analgesia with neuraxial morphine, NSAIDs, and acetaminophen, with this variability in receipt of neuraxial morphine and of multimodal analgesia being largely independent of patient characteristics.

CONCLUSIONS

Relatively few parturients received the currently recommended multimodal analgesic regimen of neuraxial morphine with NSAIDs and acetaminophen after cesarean delivery. Additionally, the majority received acetaminophen-opioid combination drugs rather than plain acetaminophen. Further studies should investigate the implications for patient outcomes.

Safety in Acute Pain Medicine-Pharmacologic Considerations and the Impact of Systems-Based Gaps

Objective

In the setting of an expanding prevalence of acute pain medicine services and the aggressive use of multimodal analgesia, an overview of systems-based safety gaps and safety concerns in the setting of aggressive multimodal analgesia is provided below.

Setting

Expert commentary.

Methods

Recent evidence focused on systems-based gaps in acute pain medicine is discussed. A focused literature review was conducted to assess safety concerns related to commonly used multimodal pharmacologic agents (opioids, nonsteroidal anti-inflammatory drugs, gabapentanoids, ketamine, acetaminophen) in the setting of inpatient acute pain management.

Conclusions

Optimization of systems-based gaps will increase the probability of accurate pain assessment, improve the application of uniform evidence-based multimodal analgesia, and ensure a continuum of pain care. While acute pain medicine strategies should be aggressively applied, multimodal regimens must be strategically utilized to minimize risk to patients and in a comorbidity-specific fashion.

Systemic adjunct analgesics for cesarean delivery: a narrative review

It is critical to adequately treat postoperative cesarean delivery pain. The use of parenteral or neuraxial opioids has been a mainstay, but opioids have side effects that can be troubling and the opioid crisis in the United States has highlighted the necessity to utilize analgesics other than opioids. Other analgesic options include neuraxial analgesics, nerve blocks such as the transversus abdominis plane block, and non-opioid parenteral and oral medications. The goal of this article is to review non-opioid systemic analgesic adjuncts following cesarean delivery, focusing on their efficacy and side effects as well as their impact on reduction of opioid requirements after surgery.

Oral Diclofenac Potassium Versus Intravenous Acetaminophen in Acute, Isolated, Closed-Limb Trauma

Pain control is an important concern in limb trauma. The most ideal agent for this purpose varies among different hospitals. The objective of this study was to compare the analgesic effect of oral diclofenac potassium versus intravenous acetaminophen in patients with limb trauma. This was a double-blind randomized clinical trial conducted on 60 adult patients. Oral diclofenac potassium (50 mg) was given in Group D, and intravenous acetaminophen (1 g in 500 ml normal saline over 20 min) was administered in Group A. Patients' pain scores (visual analogue scale) were recorded and compared at baseline, 5, 15, 30, 60 min, and 4 hr after drug administration. The mean age was 42.62 ± 15.42 and 38.04 ± 17.48 years in Group A and Group D, respectively. No significant change was observed between the 2 groups (p = 0.11). In this study, both drugs could decrease the pain score effectively and safely in isolated limb trauma.

Analgesic Effect and Potential Cumulative Benefit from Caudal Epidural D5W in Consecutive Participants with Chronic Low-Back and Buttock/Leg Pain

Objectives: Chronic low-back pain (CLBP) participants in a prior controlled study reported short-term pain relief after caudal epidural injection of 5% dextrose (D5W). This study assessed whether repeated caudal epidural injections of D5W results in serial short-term diminution of CLBP and progressive long-term decrease in pain and disability.

Design: Prospective uncontrolled study.

Settings/Location: Outpatient pain clinic.

Subjects: Adults with CLBP with radiation to gluteal or leg areas.

Interventions: Caudal epidural injection of 10 mL of D5W (without anesthetic) every 2 weeks for four treatments and then as needed for 1 year.

Outcome measures: Numerical Rating Scale (NRS, pain, 0–10 points), Oswestry Disability Index (ODI, disability, %), and fraction of participants with ≥50% reduction in NRS score. Analysis by intention to treat.

Results: Participants (n = 32, 55 ± 9.8 years old, nine female) had moderate-to-severe CLBP (6.5 ± 1.2 NRS points) for 11.1 ± 10.8 years. They received 5.5 ± 2.9 caudal D5W injections through 12 months of follow-up. The data capture rate for analysis was 94% at 12 months for NRS and ODI outcome measures, with 6% carried forward by intention to treat. A consistent pattern of analgesia was demonstrated after D5W injection. Compared with baseline status, NRS and ODI scores improved by 3.4 ± 2.3 (52%) and 18.2 ± 16.4% (42%) points, respectively. The fraction of participants with 50% reduction in NRS-based pain was 21/32 (66%).

Conclusion: Epidural D5W injection, in the absence of anesthetic, resulted in consistent postinjection analgesia and clinically significant improvement in pain and disability through 12 months for most participants. The consistent pattern postinjection analgesia suggests a potential sensorineural effect of dextrose on neurogenic pain.

The Analgesic Efficacy of Nonsteroidal Anti-inflammatory Agents (NSAIDs) in Patients Undergoing Cesarean Deliveries: A Meta-Analysis

BACKGROUND AND OBJECTIVES

Postoperative pain after cesarean delivery, which accounts for approximately 1 in 3 live births in the United States, can be severe in many patients. Nonsteroidal anti-inflammatory agents (NSAIDs) are potent analgesics that are effective in the treatment of postoperative pain. In this meta-analysis, we assessed the analgesic efficacy of NSAIDs in postoperative cesarean delivery patients.

METHODS

An electronic literature search of the Library of Medicine's PubMed, Cochrane CENTRAL, Scopus, and EMBASE databases was conducted in May 2013 and updated in January 2015 (Appendix, Supplemental Digital Content 1, http://links.lww.com/AAP/A174). Searches were limited to randomized controlled trials. The primary outcome variable was visual analog scale or numerical rating scale pain scores. Secondary outcomes included cumulative postoperative opioid consumption and opioid-related adverse effects (drowsiness/sedation, nausea, and vomiting). Data extraction was performed independently by 2 reviewers. Extracted data were input into Review Manager.

RESULTS

Twenty-two randomized controlled trials compared a NSAID (n = 639) to a control (n = 674). Patients in the NSAID group versus control reported lower pain scores at 12 hours (P = 0.003) and at 24 hours (P < 0.001). Subgroup analysis showed a significant difference in pain scores at 24 hours, with patients receiving NSAIDs via intravenous/intramuscular (P < 0.001) route, but not the oral (P = 0.39) or rectal routes (P = 0.99). Significantly lower average pain scores were reported for pain with movement at 24 hours in the NSAID group (P = 0.001). Patients in the NSAID group versus controls consumed significantly less opioids (P < 0.001) and had significantly less drowsiness/sedation (P = 0.03), but there was no significant difference between the groups with regard to nausea or vomiting (P = 0.48 and P = 0.17, respectively).

CONCLUSIONS

The perioperative use of NSAIDs in cesarean delivery patients will result in a significantly lower pain scores, less opioid consumption, and less drowsiness/sedation but no difference in nausea or vomiting compared to those who did not receive NSAIDs. Further research should address the optimal NSAID regimen and examine the effect of improved analgesia on patient-centered outcomes such as patient satisfaction and quality of breastfeeding.

Perinatal and neonatal use of paracetamol for pain relief

Paracetamol (acetaminophen) is the most widely used drug to treat pain or fever in pregnant women or neonates, but its pharmacokinetics (PK) and pharmacodynamics (PD) warrant a focused analysis. During pregnancy, there is an important increase in paracetamol clearance. Consequently, it is reasonable to anticipate that the analgesic effect of paracetamol will decrease faster, whereas higher doses may result in even higher oxidative toxic metabolites. Therefore, most peripartal PD data relate to multimodal analgesia strategies. In neonates, weight/size is the most relevant covariate of paracetamol PK. This resulted in proposed dosing regimens containing higher doses than currently prescribed in the label for term neonates. Using adequate dosing, paracetamol is a poor procedural analgesic, is effective for mild-to-moderate pain, and has morphine-sparing effects. Short-term safety has been well documented, and there is active research investigating the potential association between paracetamol exposure and atopy, fertility, and neurobehavior.

Taking advantage of CTAB micelles for the simultaneous electrochemical quantification of diclofenac and acetaminophen in aqueous media

Cetyltrimethylammonium bromide hemimicelles, formed on the surfaces of a carbon paste electrode, selectively adsorbed diclofenac molecules from a neutral aqueous solution containing acetaminophen, allowing simultaneous quantification of both drugs.

Short Term Analgesic Effects of 5% Dextrose Epidural Injections for Chronic Low Back Pain: A Randomized Controlled Trial

Background

Hypertonic dextrose injection (prolotherapy) is reported to reduce pain including non-surgical chronic low back pain (CLBP), and subcutaneous injection of 5% dextrose is reported to reduce neurogenic pain, hyperalgesia and allodynia. The mechanism in both cases is unclear, though a direct effect of dextrose on neurogenic pain has been proposed. This study assessed the short-term analgesic effects of epidural 5% dextrose injection compared with saline for non-surgical CLBP.

Methods

Randomized double-blind (injector, participant) controlled trial. Adults with moderate-to-severe non-surgical low back pain with radiation to gluteal or leg areas for at least 6 months received a single epidurogram-confirmed epidural injection of 10 mL of 5% dextrose or 0.9% saline using a published vertical caudal injection technique. The primary outcome was change in a numerical rating scale (NRS, 0 - 10 points) pain score between baseline and 15 minutes; and 2, 4, and 48 hours and 2 weeks post-injection. The secondary outcome was percentage of participants achieving 50% or more pain improvement at 4 hours.

Results and Conclusions

No baseline differences existed between groups; 35 participants (54 ± 10.7 years old; 11 female) with moderate-to-severe CLBP (6.7 ± 1.3 points) for 10.6 ± 10.5 years. Dextrose participants reported greater NRS pain score change at 15 minutes (4.4 ± 1.7 vs 2.4 ± 2.8 points; P = 0.015), 2 hours (4.6 ± 1.9 vs 1.8 ± 2.8 points; P = 0.001), 4 hours (4.6 ± 2.0 vs 1.4 ± 2.3 points; P < 0.001), and 48 hours (3.0 ± 2.3 vs 1.0 ± 2.1 points; P = 0.012), but not at 2 weeks (2.1 ± 2.9 vs 1.2 ± 2.4 points; P = 0.217). Eighty four percent (16/19) of dextrose recipients and 19% (3/16) of saline recipients reported ≥ 50% pain reduction at 4 hours (P < 0.001). These findings suggest a neurogenic effect of 5% dextrose on pain at the dorsal root level; waning pain control at 2 weeks suggests the need to assess the effect of serial dextrose epidural injections in a long-term study with robust outcome assessment.

The Effects of Diclofenac Suppository and Intravenous Acetaminophen and their Combination on the Severity of Postoperative Pain in Patients Undergoing Spinal Anaesthesia During Cesarean Section

INTRODUCTION

The main tasks of postoperative care are postoperative pain and complications control which play an important role in accelerating the recovery of patient's general condition.

AIM

This study was performed in order to compare the effects of diclofenac suppository, intravenous acetaminophen and their combination on the severity of postoperative pain in patients undergoing spinal anaesthesia for cesarean section in Sayyad Shirazi teaching Hospital, Gorgon, Iran.

MATERIALS AND METHODS

This was a double-blind clinical trial on 90 patients undergoing cesarean section. The patients were randomly divided into three groups, group A: 100 mg diclofenac suppository, group B: 1000 mg intravenous acetaminophen, group C: 100 mg diclofenac suppository and 500 mg intravenous acetaminophen. The same spinal anaesthesia circumstances were applied for all the participants. At the end of surgery, pain severity was assessed according to VAS scale at different times. Data were then analysed by SPSS 18 statistical software.

RESULTS

The mean age of participants was (28.27±6.07). There was significant difference between the mean pain scores of the three groups before the intervention (p=0.018), which was considered as co-variate. This difference was more notable between the combination of acetaminophen - diclofenac group and diclofenac alone. After the intervention, significant difference was observed in mean pain severity between acetaminophen group and the combination group and also between diclofenac and the combination group. During the study, the least mean pain severity was found in the combination group and the highest was observed in the diclofenac group.

CONCLUSION

Results of this study indicates a significant effect of concomitant use of intravenous acetaminophen and diclofenac suppository on pain severity reduction and reducing the need for repeated doses of narcotics and prolonging the postoperative analgesia.

Analgesic efficacy of intrathecal fentanyl during the period of highest analgesic demand after cesarean section: A randomized controlled study

Cesarean section (CS) is one of the most common surgical procedures in female patients. We aimed to evaluate the postoperative analgesic efficacy of intrathecal fentanyl during the period of greatest postoperative analgesic demand after CS. This period was defined by detailed analysis of patient-controlled analgesia (PCA) usage.This double-blind, placebo-controlled, parallel-group randomized trial included 60 parturients who were scheduled for elective CS. Participants received spinal anesthesia with bupivacaine supplemented with normal saline (control group) or with fentanyl 25 μg (fentanyl group). To evaluate primary endpoints, we measured total pethidine consumption over the period of greatest PCA pethidine requirement. For verification of secondary endpoints, we recorded intravenous PCA requirement in other time windows, duration of effective analgesia, pain scores assessed by visual analog scale, opioid side effects, hemodynamic changes, neonatal Apgar scores, and intraoperative pain.Detailed analysis of hour-by-hour PCA opioid requirements showed that the greatest demand for analgesics among patients in the control group occurred during the first 12 hours after surgery. Patients in the fentanyl group had significantly reduced opioid consumption compared with the controls during this period and had a prolonged duration of effective analgesia. The groups were similar in visual analog scale, incidence of analgesia-related side effects (nausea/vomiting, pruritus, oversedation, and respiratory depression), and neonatal Apgar scores. Mild respiratory depression occurred in 1 patient in each group. Fewer patients experienced intraoperative pain in the fentanyl group (3% vs 23%; relative risk 6.8, 95% confidence interval 0.9-51.6).The requirement for postoperative analgesics is greatest during the first 12 hours after induction of anesthesia in patients undergoing CS. The addition of intrathecal fentanyl to spinal anesthesia is effective for intraoperative analgesia and decreases opioid consumption during the period of the highest analgesic demand after CS, without an increase in maternal or neonatal side effects. We recommend using intrathecal fentanyl for CS in medical centers not using morphine or other opioids intrathecally at present.

Patient-controlled oral analgesia versus nurse-controlled parenteral analgesia after caesarean section: a randomised controlled trial

We assessed the effectiveness of early patient-controlled oral analgesia compared with parenteral analgesia in a randomised controlled non-inferiority trial of women undergoing elective caesarean section under regional anaesthesia. Seventy-seven women received multimodal paracetamol, ketoprofen and morphine analgesia. The woman having patient-controlled oral analgesia were administered four pillboxes on the postnatal ward containing tablets and instructions for self-medication, the first at 7 h after the spinal injection and then three more at 12-hourly intervals. Pain at rest and on movement was evaluated using an 11-point verbal rating scale at 2 h and then at 6-hourly intervals for 48 h. The pre-defined non-inferiority limit for the difference in mean pain scores (patient-controlled oral analgesia minus parenteral) was one. The one-sided 95% CI of the difference in mean pain scores was significantly lower than one at all time-points at rest and on movement, demonstrating non-inferiority of patient-controlled oral analgesia. More women used morphine in the patient-controlled oral analgesia group (22 (58%)) than in the parenteral group (9 (23%); p = 0.002). The median (IQR [range]) number of morphine doses in the patient-controlled oral analgesia group was 2 (1-3 [1-7]) compared with 1 (1-1 [1-2]); p = 0.006) in the parenteral group. Minor drug errors or omissions were identified in five (13%) women receiving patient-controlled oral analgesia. Pruritus was more frequent in the patient-controlled oral analgesia group (14 (37%) vs 6 (15%) respectively; p = 0.03), but no differences were noted for other adverse events and maternal satisfaction. After elective caesarean section, early patient-controlled oral analgesia is non-inferior to standard parenteral analgesia for pain management, and can be one of the steps of an enhanced recovery process.

The Assessment of Addition of Either Intravenous Paracetamol or Diclofenac Suppositories to Patient-Controlled Morphine Analgesia for Postgastrectomy Pain Control

Background:

Major surgical procedures, such as gastrectomy, result in extensive postoperative pain, which can lead to increased morbidity, discomfort and dissatisfaction among the patients.

Objectives:

The aim of this study was to evaluate the effect of adding diclofenac suppositories or intravenous paracetamol, on morphine consumption and on the quality of postgastrectomy pain control.

Patients and Methods:

This randomized double blinded clinical trial was carried out in 90 patients with gastric cancer, who were candidates for gastrectomy, which were divided into three similar groups. The patients were transferred to an intensive care unit after the operation and received patient-controlled analgesia (PCA) with morphine, morphine PCA plus intravenous paracetamol 1 g, every 6 hours, and morphine PCA plus diclofenac suppositories, 100 mg every 8 hours. The patients were evaluated for up to 24 hours after the operation for the severity of pain, alertness, and opioid complications.

Results:

There was no significant difference in pain scores among the three groups (P values, after extubation, at 2, 4, 6, 12, 18 and 24 hours were 0.72, 0.19, 0.21, 0.66, 0.54, 0.56, and 0.25, respectively), although morphine consumption was greater in the morphine group, compared with the other two groups (21.4 ± 7.7 mg in morphine group vs. 14.3 ± 5.8 mg in morphine-paracetamol group and 14.3 ± 3.9 in morphine-diclofenac group; P = 0.001). In morphine group, during the first 24 hours, the patients had lower levels of consciousness (P values, after extubation, at 2, 4, 6, 12, 18 and 24 hour were 0.6, 0.95, 0.28, 0.005, 0.027, 0.022 and 0.004 respectively), even though the incidence of complications was similar among the three groups.

Conclusions:

In this study, intravenous paracetamol or diclofenac suppositories, administered for postgastrectomy pain control, decreased morphine consumption by almost 32% and also improved alertness. Nevertheless, the amount of opioids did not affect the incidence of complications.

Disposition of cimicoxib in plasma and milk of whelping bitches and in their puppies

BACKGROUND

Caesarean section of bitches is a well recognized painful condition in dogs and it can be classified as a soft tissue surgery. Cimicoxib, a newly registered NSAID in European Union has a claim for the relief of pain in peri-operative conditions. However, in case of caesarean section, the main concerns of using NSAIDs are the transfer of the drugs into milk and its impact on the suckling pups. Thus, the aim of the present work was to evaluate the transfer of cimicoxib into the milk of 6 lactating bitches after a single oral administration of the drug on day 0 (just after whelping) and on day 28 at the target dose of 2 mg/kg. Another aim of the study was to evaluate the transfer of the drug from the milk into the suckling pups. Blood and milk samples were collected from the bitches after each administration on day 0 and day 28 and blood samples were drawn from the pups after suckling on day 28.

RESULTS

All bitches whelped without any complication and gave birth to 38 pups. After administration on D0, the mean observed plasma Cmax in bitches was 0.5323 μg/mL and the mean area under the concentration-time curve extrapolated to the infinity, AUCINF, was 2.411 μg.h/mL. After administration on D28, only AUCINF was significantly higher with a value of 3.747 μg.h/mL. In milk, after administration on D0, the mean observed Cmax was 0.9974 μg/mL and the mean area under the concentration-time curve until the last measurable time point, AUClast, was 4.205 μg.h/mL. Out of 24 sampled pups on D28, only 2 animals had a sample with very low cimicoxib concentrations slightly above the limit of quantification (0.01 μg/mL).

CONCLUSION

The presented data show that cimicoxib given by oral route to lactating bitches at a single dose of 2 mg/kg had a high transfer rate into the milk with a milk to plasma ratio of 1.7 to 1.9. The transfer rate to the suckling pups was low and no clinical abnormalities were detected in both bitches and pups.

Diclofenac is more effective for post-operative analgesia in patients undergoing lower abdominal gynecological surgeries: A comparative study

Aim:

The present study aimed to compare the efficacy of injectable diclofenac intramuscularly (IM), injection paracetamol intravenously (IV), or a combination of both to provide post-operative analgesia in patients undergoing lower abdominal gynecological surgeries.

Materials and Methods:

A total of 90 female patients (American Society of Anesthesiologists I and II), aged 20-50 years, scheduled for elective total abdominal hysterectomy with or without bilateral salpingo-oophorectomy were randomized to receive 75 mg diclofenac IM 8 hourly (Group D) or 1 g paracetamol IV 8 hourly (Group P) or a combination of both 8 hourly (Group PD) for 24 h post-operative period from the start of surgery. The primary outcome measured was the requirement of rescue analgesic (tramadol), the secondary outcomes measured included visual analog score (VAS) for pain, time until first rescue analgesic administration, patient satisfaction score and any side effects.

Results:

The requirement of rescue analgesic was significantly lower in Groups D and PD compared to Group P. Mean (standard deviation) tramadol requirement during 24 h was 56.67 (62.60) mg, 20.00 (40.68) mg and 20.00 (40.68) mg in the Groups P, D and PD respectively. Less number of patients in Groups D and PD (20% in both the groups) required rescue analgesic compared to Group P (50%). The VAS showed a significant decrease in Groups D and PD compared to Group P between 4 and 12 h post-operatively. However, Group PD showed no significant difference when compared to Group D alone.

Conclusion:

Injection diclofenac IM is more effective than paracetamol IV in terms of rescue analgesic requirement, but the combination of diclofenac IM and paracetamol IV provides no added advantage over diclofenac IM alone.

Oral analgesia for relieving post-caesarean pain

BACKGROUND

Oral analgesia is a convenient and widely used form of pain relief following caesarean section. It includes various medications used at different doses alone or in adjunction to other form of analgesia.

OBJECTIVES

To determine the effectiveness, safety and cost-effectiveness of oral analgesia for post-caesarean pain relief.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2014) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs). Cluster-randomised trials were eligible for inclusion but none were identified. Quasi-randomised and cross-over trials were not eligible for inclusion.Interventions included oral medication given to women for post-caesarean pain relief compared with oral medication, or placebo/no treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed for inclusion all the potential studies and independently assessed trial quality, extracted the data using the agreed data extraction form, and checked them for accuracy.

MAIN RESULTS

Eight small trials involving 962 women (out of 13 included trials) contributed data to the analysis, of which only four trials had low risk of bias.None of the included studies reported on 'adequate pain relief', which is one of this review's primary outcomes. 1. Opiod analgesics versus placeboBased on one trial involving 120 women, the effect of opioids versus placebo was not significant in relation to the need for additional pain relief (primary outcome) (risk ratio (RR) 0.33, 95% confidence interval (CI) 0.06 to 1.92), and the effect in terms of adverse drug effects outcomes was also uncertain (RR 6.58, 95% CI 0.38 to 113.96).Low (75 mg) and high (150 mg) doses of tramadol had a similar effect on the need for additional pain relief (RR 0.67, 95% CI 0.12 to 3.78 and RR 0.14, 95% CI 0.01 to 2.68, respectively, one study, 80 women). 2. Non-opioid analgesia versus placeboThe confidence interval for the lower requirement for additional analgesia (primary outcome) with the non-opioid analgesia group was wide and includes little or no effect (average RR 0.70, 95% CI 0.48 to 1.01, six studies, 584 women). However, we observed substantial heterogeneity due to the variety of non-opioid drugs used (I(2) = 85%). In a subgroup analysis of different drugs, only gabapentin use resulted in less need for additional pain relief (RR 0.34, 95% CI 0.23 to 0.51, one trial, 126 women). There was no difference in need for additional pain relief with the use of celexocib, ibuprofen, ketoprofen, naproxen, paracetamol. Maternal drug effects were more common with the use of non-opioid analgesics (RR 11.12, 95% CI 2.13 to 58.22, two trials, 267 women).Gabapentin 300 mg (RR 0.25, 95% CI 0.13 to 0.49, one study, 63 women) and 600 mg (RR 0.44, 95% CI 0.27 to 0.71, one study, 63 women) as well as ketoprofen 100 mg (RR 0.55, 95% CI 0.39 to 0.79, one study 72 women) were both more effective than placebo with respect to the need for additional pain relief. However, the 50 mg ketoprofen group and the placebo group did not differ in terms of the number of women requiring additional pain relief (RR 0.82, 95% CI 0.64 to 1.07, one study, 72 women). 3. Combination analgesics versus placeboOur pooled analysis for the effect of combination analgesics on the need for additional pain relief was RR 0.70 (95% CI 0.35 to 1.40, three trials, 242 women, I(2) = 69%). When comparing different drugs within the combination oral analgesics versus placebo comparison we observed subgroup differences (P = 0.05; I² = 65.8%). One trial comparing paracetamol plus codeine versus placebo resulted in fewer women requiring additional pain relief (RR 0.44, 95% CI 0.23 to 0.82, one trial, 65 women). However, there were no differences in the the number of women requiring additional pain relief when comparing paracetamol plus oxycodone versus placebo, or paracetamol plus propoxyphene (RR 1.00, 95% CI 0.78 to 1.28, one trial, 96 women and RR 0.65, 95% CI 0.11 to 3.69, one trial, 81 women, respectively).Maternal drug effects were more common in combination analgesics group versus placebo (RR 13.18, 95% CI 2.86 to 60.68, three trials, 252 women). 4. Opioid analgesics versus non-opioid analgesicsThe confidence interval for the effect on additional pain relief between opioid and non-opioid drugs was very wide (RR 0.51, 95% CI 0.07 to 3.51, one trial, 121 women). Side effects were more common with the use opioids versus non-opioids analgesics (RR 2.32, 95% CI 1.15 to 4.69, two trials 241 women). 5. Opioid analgesics versus combination analgesicsThere was no difference in need for additional pain relief in opioid analgesics versus combination analgesics based on one study involving 121 women comparing tramadol and paracetamol plus propoxyphene (RR 0.51, 95% CI 0.07 to 3.51). Maternal adverse effects also did not differ between the two groups (RR 6.74, 95% CI 0.39 to 116.79). 6. Non-opioid versus combination analgesicsThe need for additional pain relief was greater in the group of women who received non-opoid analgesics (RR 0.87, 95% CI 0.81 to 0.93, one trial, 192 women) compared with the group of women who received combination analgesics. Secondary outcomes not reported in the included studiesNo data were found on the following secondary outcomes: number of days in hospital post-operatively, re-hospitalisation due to incisional pain, fully breastfeeding on discharge, mixed feeding at discharge, incisional pain at six weeks after caesarean section, maternal post partum depression, effect (negative) on mother and baby interaction and cost of treatment.

AUTHORS' CONCLUSIONS

Eight trials with 962 women were included in the analysis, but only four trials were of high quality. All the trials were small. We carried out subgroup analysis for different drugs within the same group and for high versus low doses of the same drug. However, the relatively few studies (one to two trials) and numbers of women (40 to 136) limits the reliability of these subgroup analyses.Due to limited data available no conclusions can be made regarding the safest and the most effective form of oral analgesia for post-caesarean pain. Further studies are necessary.

A randomised controlled trial of opioid only versus combined opioid and non-steroidal anti inflammatory analgesics for pain relief in the first 48 hours after Caesarean section

Background:

Post-Caesarean section pain is complex in nature, requiring a combination of pharmacological and non-pharmacological methods. Effective management of postoperative pain will reduce postoperative morbidity, hospital stay and cost. The objective of this study was to compare the clinical effectiveness and adverse effects of a combination of non-selective cyclooxygenase (COX) inhibitor (Diclofenac sodium 50 mg) and opioid (Pentazocine 60 mg) to opiod only (Pentazocine 60 mg) for pain management after Caesarean section (CS) at Aminu Kano Teaching Hospital (AKTH).

Materials and Methods:

This was a randomised double-blind controlled study conducted at AKTH, Kano, Nigeria. A total of 166 patients scheduled to undergo either emergency or elective Caesarean section were studied. Group I received a combination of COX inhibitor and opiod while Group II received opiod only for pain management after CS.

Results:

The average age of the patients was 28.35 years (SD ± 6.426) in the group I and 26.9(SD ± 6.133) in group II. The mean parity was 3.27(SD ± 2.67) and 2.75(SD ± 2.14) while the mean gestational age at admission was 37.68(SD ± 2.69) and 38.18(SD ± 2.63) weeks in the first and second groups, respectively. Comparison of the level of pain experienced and patients satisfaction during the first 48 hours postoperatively revealed that the level of pain was statistically significantly less and patient's satisfaction significantly better in group I compared to group II (P-value 0.00001).

Conclusion:

The use of combined compared to single agent analgesia is safe, significantly reduced pain and improved patient satisfaction after a caesarian section (CS).

A randomised controlled trial of parecoxib, celecoxib and paracetamol as adjuncts to patient-controlled epidural analgesia after caesarean delivery

The benefit of combining non-opioid analgesics with neuraxial opioids for analgesia after caesarean delivery has not been clearly established. Larger doses of paracetamol or cyclooxygenase-2 inhibitors have not been evaluated. A randomised, double blind, double-dummy, parallel group placebo-controlled clinical trial was conducted among women having elective caesarean delivery under spinal anaesthesia, followed by pethidine patient-controlled epidural analgesia. Patients received placebos (group C); intravenous parecoxib 40 mg then oral celecoxib 400 mg at 12 hours (group PC); intravenous paracetamol 2 g then oral 1 g six-hourly (group PA); or these regimens combined (group PCPA). The primary outcome was 24-hour postoperative patient-controlled epidural pethidine use and the main secondary outcome was postoperative pain. One hundred and thirty-eight women were recruited but 27 subsequently met exclusion criteria, leaving 111 who were randomised, allocated and analysed by intention-to-treat (n=23, 30, 32 and 26 in groups C, PC, PA and PCPA respectively). There were no differences between groups for pethidine consumption, based on either intention-to-treat (median 365, 365, 405 and 360 mg in groups C, PC, PA and PCPA respectively, P=0.84) or per protocol analysis (17 major violations). Dynamic pain scores did not differ between groups but requirement for, and dose of, supplementary oral tramadol was least in group PCPA (incidence 23% versus 48%, 70% and 58% in groups C, PC and PA respectively, P=0.004). The addition of regular paracetamol, cyclooxygenase-2 inhibitors or both to pethidine patient-controlled epidural post-caesarean analgesia did not provide a pethidine dose-sparing effect during the first 24 hours.

Analgesic Efficacy of Diclofenac and Paracetamol vs. Meperidine in Cesarean Section

Background:

One of the most important complications in cesarean surgery is postoperative pain, and different ways have been proposed to control it.

Objectives:

The purpose of this study was to determine the efficacy of Diclofenac and Paracetamol combination in comparison with Meperidine on postoperative pain after cesarean surgery.

Patients and Methods:

One hundred and twenty women candidates for elective cesarean section under spinal anesthesia categorized as ASA class I were selected and randomly assigned to receive either Diclofenac suppository at the end of the operation and thereafter 1 gram infused bolus of Paracetamol (group A), or 20 mg bolus of Meperidine after transition to recovery room (group B) to control postoperative pain.

Results:

Postoperative pain was present in recovery in 38.3% and 23.3% in groups B and A, respectively (P = 0.009). Postoperative pain was seen after six hours of operation in 38.7% and 16.7% in groups B and A, respectively (P = 0.010). Postoperative pain was present after 12 hours of operation in 38.3% and 15% in groups B and A, respectively (P = 0.002). The additive Meperidine use was the same between the two groups in recovery (P > 0.05). The additive Meperidine use was seen after six hours of operation in 26.7% and 6.7% in groups B and A, respectively (P = 0.013). The additive Meperidine use was seen after 12 hours of operation in 16.7% and none of the patients in groups B and A, respectively (P = 0.004). The frequency of drug adverse effects was the same between the two groups (P > 0.05).

Conclusions:

Totally, according to the obtained results it may be concluded that Paracetamol and Diclofenac combination would have a better efficacy in postoperative pain control and need reduction to additive analgesia compared to Meperidine.

Comparison of patient-controlled analgesia versus continuous infusion of tramadol in post-cesarean section pain management

AIM

To evaluate and compare analgesic efficacy, drug consumption and patient satisfaction with the i.v. patient-controlled and continuous infusion modes of administration of tramadol.

METHODS

A total of 40 pregnant women in American Society of Anesthesiologists physical status classification system risk classes I-II scheduled for cesarean section were randomized into two groups to receive treatment in single-blind fashion. Patients in both groups received tramadol as an i.v. infusion 15 min before the end of surgery under general anesthesia for cesarean section. In the post-anesthesia care unit, the 20 patients allocated to group I were given i.v. tramadol in patient-controlled anesthesia (PCA), while the 20 other patients assigned to group II received it as a continuous infusion. Pain visual analog scores (VAS), mean arterial pressure (MAP), heart rate, total tramadol consumption, sedation scores, side-effects (nausea/vomiting) and patient satisfaction were evaluated seven times in the course of the first postoperative 24 h. The Mann-Whitney U-test and Friedman's anova were used for the statistical treatment of data.

RESULTS

VAS, sedation scores and nausea/vomiting scores were similar in both groups (P > 0.05). The 24-h tramadol consumption was significantly lower in group I (420.15 ± 66.58 mg) than in group II (494.00 ± 29.45 mg), while patient satisfaction was significantly higher in group I (P < 0.05).

CONCLUSION

While tramadol administration by either of the methods used may ensure efficient early postoperative anesthesia in cesarean section patients, i.v. PCA may be preferred because of the lower drug consumption and higher patient satisfaction associated with it.

Multimodal postcesarean delivery analgesia

Cesarean deliveries can be associated with moderate to severe postoperative pain. Appropriate management of pain is important because it results in better patient satisfaction, earlier mobilization, and improved maternal-infant bonding. There are many individual options for treatment of pain; however, multimodal analgesic therapy has become the mainstay of treatment. In this article, the epidemiology of postcesarean delivery pain, pain mechanisms, and the multiple options available to providers for treatment of postoperative pain are discussed.

The effects of indomethacin, diclofenac, and acetaminophen suppository on pain and opioids consumption after cesarean section

BACKGROUND

Cesarean section is one of the common surgeries of women. Acute post-operative pain is one of the recognized post-operative complications.

AIMS

This study was planned to compare the effects of suppositories, indomethacin, diclofenac and acetaminophen, on post-operative pain and opioid usage after cesarean section.

MATERIALS AND METHODS

In this double-blind clinical trial study, 120 candidates of cesarean with spinal anesthesia and American Society of Anesthesiologists (ASA) I-II were randomly divided into four groups. Acetaminophen, indomethacin, diclofenac, and placebo suppositories were used in groups, respectively, after operation and the dosage was repeated every 6 h and pain score and opioid usage were compared 24 h after the surgery. The severity of pain was recorded on the basis of Visual Analog Scale (VAS) and if severe pain (VAS > 5) was observed, 0.5 mg/kg intramuscular pethidine had been used.

STATISTICAL ANALYSIS USED

The data were analyzed in SPSS software version 15 and analytical statistics such as ANOVA, Chi-square, and Tukey's honestly significant difference (HSD) post-hoc.

RESULTS

Pain score was significantly higher in control group than other groups, and also pain score in acetaminophen group was higher than indomethacin and diclofenac. The three intervention groups received the first dose of pethidine far more than control group and the distance for diclofenac and indomethacin were significantly longer (P < 0.001). The use of indomethacin, diclofenac, and acetaminophen significantly reduces the amount of pethidine usage in 24 h after the surgery relation to control group.

CONCLUSIONS

Considering the significant decreasing pain score and opioid usage especially in indomethacin and diclofenac groups rather than control group, it is suggested using of indomethacin and diclofenac suppositories for post-cesarean section analgesia.

Nonsteroidal anti-inflammatory drugs during pregnancy and the initiation of lactation

Nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin, which are available as "over-the counter" medications in most countries, are widely used by both pregnant and lactating women. They are popular non-opioid analgesics for the treatment of pain after vaginal and operative delivery. In addition, NSAIDs are used for tocolysis in premature labor, and low-dose aspirin has a role in the prevention of preeclampsia and recurrent miscarriage in antiphospholipid syndrome. NSAIDs and aspirin may affect fertility and increase the risk of early pregnancy loss. In the second trimester their use is considered reasonably safe, but has been associated with fetal cryptorchism. In the third trimester, NSAIDs and aspirin are usually avoided because of significant fetal risks such as renal injury, oligohydramnios, constriction of the ductus arteriosus (with potential for persistent pulmonary hypertension in the newborn), necrotizing enterocolitis, and intracranial hemorrhage. Maternal administration or ingestion of most NSAIDs results in low infant exposure via breastmilk, such that both cyclooxygenase-1 and cyclooxygenase-2 inhibitors are generally considered safe, and preferable to aspirin, when breastfeeding.

[Single-dose intraincisional levobupivacaine infiltration in caesarean postoperative analgesia: a placebo-controlled double-blind randomized trial]

OBJECTIVES

The efficacy of single-dose intraincisional infiltration with levobupivacaine in postoperative analgesia and chronic pain after caesarean sections is unknown.

STUDY

A placebo-controlled double-blind randomized trial.

PATIENTS AND METHODS

After ethical approval, and written inform consent, 140 women scheduled for a caesarean section were randomly assigned and received 30mL of levobupivacaine 0.5% (L group) or saline (placebo-P group) into their wound. The primary endpoint was morphine consumption (using intravenous morphine patient-controlled analgesia) for the first 24h after surgery. At 1h to 48h, side effects, pain at rest and pain 2months later were recorded.

RESULTS

All included patients had similar demographic and surgical characteristics. The morphine consumption was significantly lower in the L group at h6, h8 and h12 (considering both total intake and each request). At h4, the mean total morphine consumption was 25 (12) mg in the L group versus 31 (14) mg in the P group (P=0.05). Time until discharge and side effects including nausea-vomiting (14 vs 20%), wound scar complications (6 vs 8%) and chronic pain after 2months (25% in both groups complained of small pain, and 75% no pain) were similar between the two groups (P>0.05).

CONCLUSION

Single-dose local infiltration of levobupivacaine 0.5% reduced opioid requirement at 12h, with no difference after 24h. www.clinicaltrials.com, number: NCT00621907.

Diclofenac-tramadol vs. diclofenac-acetaminophen combinations for pain relief after caesarean section

BACKGROUND

We compared the analgesic efficacy of diclofenac-acetaminophen combination with diclofenac-tramadol combination to optimize multimodal post-operative analgesia in women undergoing caesarean section.

METHODS

In this randomized, double-blind, parallel-group controlled trial, 204 women undergoing caesarean section under spinal anaesthesia with bupivacaine received rectal suppository diclofenac 100 mg (8 hourly till 24 h) plus either intravenous acetaminophen (1 g 6 hourly) or tramadol (75 mg 6 hourly) post-operatively. The primary outcome measure was the summed pain intensities during the entire observation period, calculated as the sum of time-weighted pain intensity scores as an area under the curve (AUC). Secondary outcome was the use of rescue analgesic, administered if the patient's numeric rating scale (NRS) scores ≥  4.

RESULTS

The overall pain score for the entire observation period measured as AUC was significantly lower in the diclofenac-tramadol group. However, diclofenac-tramadol combination produced Bonferroni-corrected statistically significant lower NRS pain scores only on movement at 24 h. Rescue analgesic consumption was comparable between the groups (13% vs. 12%, P = 0.872). Overall, the pain scores were low in both of the groups across various time intervals (median NRS scores 0-2 for pain both at rest and on movement), indicating satisfactory pain control in both groups. Side effects were few and comparable, except nausea (significantly more in tramadol group than acetaminophen group, 15% vs. 2%, P = 0.001).

CONCLUSION

Both diclofenac-tramadol and diclofenac-acetaminophen combinations can achieve satisfactory post-operative pain control in women undergoing caesarean section. The diclofenac-tramadol combination was overall more efficacious but associated with higher incidence of post-operative nausea.

Obesity and Obstetric Anaesthesia

Obesity is increasing in the population as a whole, and especially in the obstetric population, among whom pregnancy-induced physiological changes impact on those already present due to obesity. In particular, changes in the cardiovascular and respiratory systems during pregnancy further alter the physiological effects and comorbidities of obesity. Obese pregnant women are at increased risk of diabetes, hypertensive disorders of pregnancy, ischaemic heart disease, congenital malformations, operative delivery, postpartum infection and thromboembolism. Regional analgesia and anaesthesia is usually preferred but may be challenging. Obese pregnant women appear to have increased morbidity and mortality associated with caesarean delivery and general anaesthesia for caesarean delivery in particular, and more anaesthesia-related complications. This article summarises the physiological and pharmacological implications of obesity and pregnancy and describes the issues surrounding the management of these women for labour and delivery.

Postoperative analgesia with parecoxib, acetaminophen, and the combination of both: a randomized, double-blind, placebo-controlled trial in patients undergoing thyroid surgery

BACKGROUND

We assessed the analgesic efficacy of parecoxib, acetaminophen, and the combination of both compared with placebo in patients undergoing elective thyroid or parathyroid surgery.

METHODS

We randomized 140 patients to receive one of the following i.v. treatments using a double-blinded double-dummy technique: placebo, 80 mg 24 h(-1) parecoxib, 5 g 24 h(-1) acetaminophen, or 80 mg parecoxib plus 5 g acetaminophen. We provided rescue analgesia with piritramide delivered by a patient-controlled analgesia device. We measured opioid consumption and pain intensity over 24 h after operation.

RESULTS

Patient characteristic data, anaesthetic, and surgical characteristics of the patients in the four groups were similar. Parecoxib, acetaminophen, and the combination significantly reduced opioid requirements during 24 h after surgery [mean (sd) 12.5 (10.9) mg for parecoxib, 14.2 (12.3) mg for acetaminophen, and 11.9 (10.7) mg for combination] compared with placebo [23.5 (15.3) mg, P<0.05]. However, the combination of parecoxib and acetaminophen did not have any advantage over individual drugs in terms of opioid consumption in our trial (P>0.05).

CONCLUSIONS

Parecoxib and acetaminophen effectively reduce postoperative opioid requirements after thyroid or parathyroid surgery. The combination of these drugs is not associated with a further reduction in opioid consumption.

Current world literature

This bibliography is compiled by clinicians from the journals listed at the end of this publication. It is based on literature entered into our database between 1 February 2008 and 31 January 2009 (articles are generally added to the database about two and a half months after publication). In addition, the bibliography contains every paper annotated by reviewers; these references were obtained from a variety of bibliographic databases and published between the beginning of the review period and the time of going to press. The bibliography has been grouped into topics that relate to the reviews in this issue.

Analgesia after caesarean delivery

As the number of women giving birth by caesarean increases throughout most of the developed world, so too is research into postoperative pain relief for these women. Like most other post-surgical populations, the new mother needs effective pain relief so that she can mobilise early but she also has the added responsibility of needing to care for her newborn baby. There is no 'gold standard' for post-caesarean pain management; the number of options is large and the choice of method is at least partly determined by drug availability, regional and individual preferences, resource limitations and financial considerations. Most methods rely on opioids, supplemented with anti-inflammatory analgesics, nerve blocks or other adjunctive techniques. The aim of this review is to detail commonly used opioid-based methods and to review the evidence supporting non-opioid methods, when incorporated into a multimodal approach to post-caesarean pain management. Areas of promising research are also discussed.