Efficacy of transdermal nitroglycerin combined with etodolac for the treatment of chronic post-thoracotomy pain: an open-label prospective clinical trial

Effects of Co-administration of Fentanyl and Nitroglycerin on Hemodynamic Responses During Intubation and Extubation: A Randomized Clinical Trial

PURPOSE

This study was conducted with the aim of investigating the effects of simultaneous administration of fentanyl and nitroglycerine on hemodynamic responses.

DESIGN

This randomized controlled trial was conducted with 50 patients undergoing elective inguinal hernia surgery.

METHODS

Patients were randomly divided into two groups. In one group, fentanyl (F) was administered 5 minutes before intubation and extubation. In the other group, in addition to F, sublingual nitroglycerine spray was administered 2 minutes before intubation and extubation. Systolic, diastolic, and mean blood pressure and heart rate were measured before, immediately after, and at 1, 3, and 5 minutes after both procedures.

FINDINGS

Systolic, diastolic, and mean blood pressure and heart rate were significantly lower in the group receiving fentanyl and nitroglycerine than in the group receiving fentanyl alone. In both groups, a reduction in hemodynamic variables was observed immediately after both procedures, up to 5 minutes later, but it was significantly reduced in the group receiving simultaneous administration of the two drugs.

CONCLUSIONS

Co-administration of nitroglycerine and fentanyl significantly weakened the hemodynamic responses and reflexes induced by intubation and extubation during the anesthesia process. Preventing these unwanted complications can lead to safer anesthesia for susceptible patients.

Effects of ketamine, granisetron and dexmedetomidine on postoperative shivering and hemodynamic changes after general anesthesia: a double-blind randomized clinical trial

Postoperative shivering is one of the most common complications of surgeries. The current research compared the effects of ketamine, granisetron, and dexmedetomidine on reducing postoperative shivering after general anesthesia. This double-blind clinical trial enrolled 148 patients (39.08 ± 5.99 years old) who had been admitted to Vali-Asr Hospital of Arak, Iran in 2019-2021. The study drugs, including dexmedetomidine, ketamine, granisetron and normal saline, were administered in corresponding groups 30 minutes before the end of surgery. The results showed that dexmedetomidine reduced mean arterial pressure and heart rate in patients. The lowest incidence of shivering was observed in the dexmedetomidine group and it increased the duration of recovery. Overall, dexmedetomidine is recommended to reduce postoperative shivering after general anesthesia, but the increase in duration of recovery should be considered.

Nitroglycerin Plus Morphine on Iv Patient Controlled Analgesia for Abdominal Surgery: The Effect on Postoperative Pain

Background

Some studies have reported the effect of nitroglycerin on the reduction of pain after surgery.

Objectives

The primary goal of the current study was to evaluate the addition of nitroglycerin (as a nitric oxide donor) to morphine in patient-controlled analgesia. Besides, its effects on the reduction of pain and stability in hemodynamic indices after abdominal surgery are also investigated.

Methods

The current study was performed on 60 patients as candidates for abdominal surgery. Morphine (0.75 mg/mL) and nitroglycerin plus morphine (morphine 0.5 mg/mL + TNG 15 μg/mL) infusions were used for control and case groups, respectively, with the same induction of anesthesia. The severity of postoperative pain, hemodynamic indices of systolic blood pressure, diastolic pressure, heart rate, respiratory rate, and nausea were measured after surgery (immediately, 2, 6, 12, and 24 hours after surgery).

Results

The pain score decreased for both groups almost similarly. The mean systolic blood pressure was highly reduced in both groups. However, the mean diastolic blood pressure in the control group was considerably lower than that of the case group. Besides, the respiratory rate in the case group dramatically diminished and approached the normal value.

Conclusions

Combined administration of nitroglycerin and morphine had no synergistic effects on reducing postoperative pain. However, it led to more stable hemodynamic indices and improved breathing, without any side effects.

Chronic postsurgical pain: current evidence for prevention and management

Chronic postsurgical pain (CPSP) is an unwanted adverse event in any operation. It leads to functional limitations and psychological trauma for patients, and leaves the operative team with feelings of failure and humiliation. Therefore, it is crucial that preventive strategies for CPSP are considered in high-risk operations. Various techniques have been implemented to reduce the risk with variable success. Identifying the risk factors for each patient and applying a timely preventive strategy may help patients avoid the distress of chronic pain. The preventive strategies include modification of the surgical technique, good pain control throughout the perioperative period, and preoperative psychological intervention focusing on the psychosocial and cognitive risk factors. Appropriate management of CPSP patients is also necessary to reduce their suffering. CPSP usually has a neuropathic pain component; therefore, the current recommendations are based on data on chronic neuropathic pain. Hence, voltage-dependent calcium channel antagonists, antidepressants, topical lidocaine and topical capsaicin are the main pharmacological treatments. Paracetamol, NSAIDs and weak opioids can be used according to symptom severity, but strong opioids should be used with great caution and are not recommended. Other drugs that may be helpful are ketamine, clonidine, and intravenous lidocaine infusion. For patients with failed pharmacological treatment, consideration should be given to pain interventions; examples include transcutaneous electrical nerve stimulation, botulinum toxin injections, pulsed radiofrequency, nerve blocks, nerve ablation, neuromodulation and surgical management. Physical therapy, cognitive behavioral therapy and lifestyle modifications are also useful for relieving the pain and distress experienced by CPSP patients.

Does the Use of Nitroglycerin Patch Improve Local Anaesthetic Effects in Bier's Block? A Double-Blind Placebo Controlled Study

Aim

The aim of the study was to assess the nitroglycerin patch as a new additive to Bier's block and its impact on the effects and dose of lidocaine.

Methods

Forty patients of each sex belonging to ASA I or II underwent elective tendon repair surgeries of the forearm and hand. The patients were divided into two equal groups as follows: Group C received only lidocaine (1.5 mg/kg, 0.25%) and Group N received lidocaine (1.5 mg/kg, 0.25%) + 5 mg transcutaneous nitroglycerin patch. Onset and recovery times for sensory and motor block, visual analogue scale (VAS) scores for bandage pain, postoperative VAS score, analgesic requirements, patients' satisfaction, and surgeons' opinion were recorded.

Results

Sensory block onset time was shorter in Group N (3.80 ± 1.0) than that in Group C (5.72 ± 1.46), and motor block onset time was shorter in Group N (10.72 ± 1.93) than that in Group C (13.56 ± 1.26). Sensory block recovery time was prolonged in Group N (10.56 ± 1.12) than Group C (6.88 ± 1.45), recovery time of motor block was prolonged in Group N (13.04 ± 1.57) than Group C (11.96 ± 1.72). Bandage pain had lower VAS scores in Group N. Postoperative VAS scores showed significant differences between both groups at the following points of measurement: 30 minutes, 1 hour, and 4 hours after bandage deflation. Postoperative analgesic effect was the longest in Group N (187.20 ± 60.79 min) than Group C (51.60 ± 25.28 min). Patients' satisfaction and surgeons' opinion were better in Group N than Group C.

Conclusion

Supplementation of Bier's block with transcutaneous nitroglycerin patch reduces the lidocaine dose, the sensory and motor block onset times, VAS scores, and analgesic consumption intra- and postoperatively. Length of the block recovery times for the sensory and motor effects, duration of postoperative analgesic effect, and the first time to analgesic requirement improved the quality of Bier's block with better patients' satisfaction and surgeons' opinion and had no adverse effects.

Evaluating the quality of intravenous regional anesthesia following adding dexamethasone to lidocaine

Objectives:

The quality of anesthesia in intravenous regional anesthesia (IVRA) has been evaluated in many studies so far. This study was designed to evaluate the effects of adding the dexamethasone to lidocaine on the quality of IVRA.

Materials and Methods:

A double-blind clinical trial was set up involving 50 hand surgery candidates, 20 to 55 years old, and with American Society of Anesthesiologists class of I and II. Patients were randomly allocated into two groups of 25 cases and received either 3 mg/kg of lidocaine (control group) or 3 mg/kg of lidocaine plus 8 mg of dexamethasone (study group). The onset and recovery times from sensory and motor blocks, the starting time of tourniquet pain, the amount of narcotics needed during patients’ recovery, and probable side-effects were all compared between the two groups.

Results:

No significant differences were detected concerning age, gender, length of surgery and the mean time of starting of tourniquet pain between the two groups. The mean times of both sensory (P = 0.002) and motor (P = 0.004) blocks onset were significantly shorter in the study group. The mean time of recovery from sensory block was significantly longer in the study group (P = 0.01). The average amount of narcotics needed during the recovery was significantly lower in the study group (P = 0.01). No side-effect was detected.

Conclusion:

We conclude that adding the dexamethasone to lidocaine can improve the quality of anesthesia in IVRA.

[Lidocaine alleviates propofol related pain much better than metoprolol and nitroglycerin]

BACKGROUND AND OBJECTIVES

Injection pain after propofol administration is common and may disturb patients' comfort. The aim of this study was to compare effectiveness of intravenous (iv) nitroglycerin, lidocaine and metoprolol applied through the veins on the dorsum of hand or antecubital vein on eliminating propofol injection pain.

METHOD

There were 147 patients and they were grouped according to the analgesic administered. Metoprolol (n=31, Group M), lidocaine (n=32, Group L) and nitroglycerin (n=29, Group N) were applied through iv catheter at dorsum hand vein or antecubital vein. Pain was evaluated by 4 point scale (0 - no pain, 1 - light pain, 2 - mild pain, 3 - severe pain) in 5, 10, 15 and 20th seconds. ASA, BMI, patient demographics, education level and the effect of pathways for injection and location of operations were analyzed for their effect on total pain score.

RESULTS

There were no differences between the groups in terms of total pain score (p=0.981). There were no differences in terms of total pain score depending on ASA, education level, location of operation. However, lidocaine was more effective when compared with metoprolol (p=0.015) and nitroglycerin (p=0.001) among groups. Although neither lidocaine nor metoprolol had any difference on pain management when applied from antecubital or dorsal hand vein (p>0.05), nitroglycerin injection from antecubital vein had demonstrated statistically lower pain scores (p=0.001).

CONCLUSION

We found lidocaine to be the most effective analgesic in decreasing propofol related pain. We therefore suggest iv lidocaine for alleviating propofol related pain at operations.

Lidocaine alleviates propofol related pain much better than metoprolol and nitroglycerin

BACKGROUND AND OBJECTIVES

Injection pain after propofol administration is common and may disturb patients' comfort. The aim of this study was to compare effectiveness of intravenous (iv) nitroglycerin, lidocaine and metoprolol applied through the veins on the dorsum of hand or antecubital vein on eliminating propofol injection pain.

METHOD

There were 147 patients and they were grouped according to the analgesic administered. Metoprolol (n=31, Group M), lidocaine (n=32, Group L) and nitroglycerin (n=29, Group N) were applied through iv catheter at dorsum hand vein or antecubital vein. Pain was evaluated by 4 point scale (0 - no pain, 1 - light pain, 2 - mild pain, 3 - severe pain) in 5, 10, 15 and 20th seconds. ASA, BMI, patient demographics, education level and the effect of pathways for injection and location of operations were analyzed for their effect on total pain score.

RESULTS

There were no differences between the groups in terms of total pain score (p=0.981). There were no differences in terms of total pain score depending on ASA, education level, location of operation. However, lidocaine was more effective when compared with metoprolol (p=0.015) and nitroglycerin (p=0.001) among groups. Although neither lidocaine nor metoprolol had any difference on pain management when applied from antecubital or dorsal hand vein (p>0.05), nitroglycerin injection from antecubital vein had demonstrated statistically lower pain scores (p=0.001).

CONCLUSION

We found lidocaine to be the most effective analgesic in decreasing propofol related pain. We therefore suggest iv lidocaine for alleviating propofol related pain at operations.

Peri- and postanalgesic properties of lidokain, lornoxicam, and nitroglycerine combination at intravenous regional anesthesia

Background. This study was conducted to compare and evaluate the effect of adding lornoxicam or nitroglycerine as adjuncts to lidocaine in intravenous regional anesthesia (IVRA). Methods. 60 patients were randomly separated into three groups, lidocaine group (group L), lidocaine + lornoxicam group (group LL), and lidocaine + lornoxicam + transdermal nitroglycerine group (group LL-N). Hemodynamic parameters, sensory and motor blocks onset, and recovery times were recorded. Analgesic consumption for tourniquet pain and postoperative period were recorded. Results. Sensory block onset times and motor block onset times were shorter in the LL-N and LL groups compared with L group. Sensory block recovery time and motor block recovery time were prolonged in the LL and LL-N groups compared with group L. The amount of fentanyl required for tourniquet pain was less in group LL and group LL-N when compared with group L. VAS scores of tourniquet pain were higher in group L compared with the other study groups. Postoperative VAS scores were higher for the first 4 hours in group L compared with the other study groups. Conclusion. The adjuvant drugs (lornoxicam or TNG) when added to lidocaine in IVRA were effective in improving the overall quality of anesthesia, reducing tourniquet pain, increasing tourniquet tolerance, and improving the postoperative analgesia.

Combination pharmacotherapy for the treatment of neuropathic pain in adults

BACKGROUND

Pharmacotherapy remains an important modality for the treatment of neuropathic pain. However, as monotherapy current drugs are associated with limited efficacy and dose-related side effects. Combining two or more different drugs may improve analgesic efficacy and, in some situations, reduce overall side effects (e.g. if synergistic interactions allow for dose reductions of combined drugs).

OBJECTIVES

This review evaluated the efficacy, tolerability and safety of various drug combinations for the treatment of neuropathic pain.

SEARCH METHODS

We identified randomised controlled trials (RCTs) of various drug combinations for neuropathic pain from CENTRAL, MEDLINE, EMBASE and handsearches of other reviews and trial registries. The most recent search was performed on 9 April 2012.

SELECTION CRITERIA

Double-blind, randomised studies comparing combinations of two or more drugs (systemic or topical) to placebo and/or at least one other comparator for the treatment of neuropathic pain.

DATA COLLECTION AND ANALYSIS

Data extracted from each study included: proportion of participants a) reporting ≥ 30% pain reduction from baseline OR ≥ moderate pain relief OR ≥ moderate global improvement; b) dropping out of the trial due to treatment-emergent adverse effects; c) reporting each specific adverse effect (e.g. sedation, dizziness) of ≥ moderate severity. The primary comparison of interest was between study drug(s) and one or both single-agent comparators. We combined studies if they evaluated the same drug class combination at roughly similar doses and durations of treatment. We used RevMan 5 to analyse data for binary outcomes.

MAIN RESULTS

We identified 21 eligible studies: four (578 participants) evaluated the combination of an opioid with gabapentin or pregabalin; two (77 participants) evaluated an opioid with a tricyclic antidepressant; one (56 participants) of gabapentin and nortriptyline; one (120 participants) of gabapentin and alpha-lipoic acid, three (90 participants) of fluphenazine with a tricyclic antidepressant; three (90 participants) of an N-methyl-D-aspartate (NMDA) blocker with an agent from a different drug class; five (604 participants) of various topical medications; one (313 participants) of tramadol with acetaminophen; and another one (44 participants) of a cholecystokinin blocker (L-365,260) with morphine. The majority of combinations evaluated to date involve drugs, each of which share some element of central nervous system (CNS) depression (e.g. sedation, cognitive dysfunction). This aspect of side effect overlap between the combined agents was often reflected in similar or higher dropout rates for the combination and may thus substantially limit the utility of such drug combinations. Meta-analysis was possible for only one comparison of only one combination, i.e. gabapentin + opioid versus gabapentin alone. This meta-analysis involving 386 participants from two studies demonstrated modest, yet statistically significant, superiority of a gabapentin + opioid combination over gabapentin alone. However, this combination also produced significantly more frequent side effect-related trial dropouts compared to gabapentin alone.

AUTHORS' CONCLUSIONS

Multiple, good-quality studies demonstrate superior efficacy of two-drug combinations. However, the number of available studies for any one specific combination, as well as other study factors (e.g. limited trial size and duration), preclude the recommendation of any one specific drug combination for neuropathic pain. Demonstration of combination benefits by several studies together with reports of widespread clinical polypharmacy for neuropathic pain surely provide a rationale for additional future rigorous evaluations. In order to properly identify specific drug combinations which provide superior efficacy and/or safety, we recommend that future neuropathic pain studies of two-drug combinations include comparisons with placebo and both single-agent components. Given the apparent adverse impact of combining agents with similar adverse effect profiles (e.g. CNS depression), the anticipated development and availability of non-sedating neuropathic pain agents could lead to the identification of more favourable analgesic drug combinations in which side effects are not compounded.

Transdermal nitroglycerin as an adjuvant to patient-controlled morphine analgesia after total knee arthroplasty

BACKGROUND

Nitroglycerin (NTG) has been shown to be a useful adjunct for pain treatment without increasing adverse side effects. The effects of NTG on postoperative morphine consumption after knee replacement were evaluated.

METHODS

After undergoing total knee replacement, patients receiving patient-controlled morphine analgesia were randomly assigned to receive either an NTG or a placebo patch. The blinded investigator assessed each patient using a visual analogue scale at rest and while moving, as well as the patient's morphine requirements, sedation score, sleep quality, nausea and vomiting, vital signs and postoperative bleeding.

RESULTS

Two of the patients in the NTG group suffered postoperative myocardial infarctions after removal of the patch. Because of these two serious adverse effects, the study was stopped prematurely. In the subset of patients studied, NTG conferred no advantage over placebo in pain control (visual analogue scale at rest or during movement) and in satisfaction scores.

CONCLUSIONS

The use of NTG patches conferred no advantage over the use of placebo in patients receiving patient-controlled morphine analgesia after total knee replacement. Two myocardial infarcts occurred in this group. Therefore, the safety of postoperative NTG patch use for pain control must be questioned.

The Analgesic Effect of Nitroglycerin Added to Lidocaine on Intravenous Regional Anesthesia

We evaluated the analgesic effect of nitroglycerine (NTG) when added to lidocaine in IV regional anesthesia. Thirty patients undergoing hand surgery were randomly assigned to two groups. The control group (group C, n = 15) received a total dose of 40 mL with 3 mg/kg of lidocaine diluted with saline, and the NTG group (group NTG, n = 15) received an additional 200 mug NTG. Hemodynamic variables, tourniquet pain measured before and 1, 5, 10, 20, and 30 min after tourniquet inflation, and analgesic requirements were recorded during the operation. After the tourniquet deflation, at 1 and 30 min and 2 and 4 h, visual analog scale (VAS) score, time to first analgesic requirement, total analgesic consumption in the first 24 h after operation, and side effects were noted. Shortened sensory and motor block onset time (3.2 +/- 1.1 versus 4.5 +/- 1.2 min; P = 0.01 and 3.3 +/- 1.6 versus 5.2 +/- 1.8; P = 0.009 in group NTG and group C, respectively), prolonged sensory and motor block recovery times (6.8 +/- 1.6 versus 3.1 +/- 1.2 min P < 0.0001 and 7.3 +/- 1.3 versus 3.6 +/- 0.8 P < 0.0001 in group NTG and group C, respectively), shortened VAS scores of tourniquet pain (P = 0.023), and improved quality of anesthesia were found in group NTG (P < 0.05). VAS scores were lower in group NTG after tourniquet release and in the postoperative period (P = 0.001). First analgesic requirement time was longer in group NTG (225 +/- 74 min versus 39 +/- 33 min) than in group C (P < 0.0001). Postoperative analgesic requirements were significantly smaller in group NTG (P < 0.0001) but the side effects were similar in both groups. We conclude that the addition of NTG to lidocaine for IV regional anesthesia improves sensory and motor block, tourniquet pain, and postoperative analgesia without side effects.