Comparison of the morphine-sparing effects of diclofenac sodium and ketorolac tromethamine after major orthopedic surgery

Transdermal buprenorphine patch as an adjunct to multimodal analgesia after total joint arthroplasty: a retrospective cohort study

Background

Total hip arthroplasty or total knee arthroplasty (THA/TKA) is often associated with varying degrees of pain. In recent years, transdermal buprenorphine (TDB) patch has shown encouraging results for acute postoperative pain control in orthopedic surgery. The aim of our study was to investigate the efficacy and safety of the combination of TDB patch and nonsteroidal anti-inflammatory drugs (NSAIDs) as a multimodal analgesic regimen after THA/TKA.

Methods

Patients who underwent THA and TKA between January 2022 and January 2023 were reviewed. Three postoperative analgesic regimens were selected: Group A (flurbiprofen 50 mg and tramadol 37.5 mg/acetaminophen 325 mg), Group B (flurbiprofen 50 mg and TDB 5 mg), and Group C (Parecoxib 40 mg and TDB 5 mg). The primary outcomes were the Wong-Baker face pain scale revision (FPS-R) scores and the rate of sleep disturbances. Secondary outcomes of the study included the proportion of patients with postoperative pain relief rates categorized as 0%, <50%, ≥50%, and 100%.

Results

The dynamic FPS-R pain scores on day 3 after surgery in Group B were significantly lower than those in Group A for THA (P < 0.017). The dynamic FPS-R pain scores were lowest in Group C on day 2 and 3 after THA and TKA (P < 0.017). Rate of sleep disturbances was significantly lower in Group B for THA and in Group C for TKA, respectively, compared with that in Group A (P < 0.017). The proportion of dynamic pain relief rate ≥50% in Group C was statistically higher than that in Group A for THA (P < 0.017). Rate of adverse reactions among three groups for THA and TKA was not statistically different (P > 0.05).

Conclusion

This study suggests that the combination of TDB patch and NSAIDs is safe and effective for postoperative analgesia after THA/TKA.

Modern Perioperative Pain Management Strategies to Minimize Opioids after Total Knee Arthroplasty

Total Knee Arthroplasty is associated with significant postoperative pain that can limit functional outcomes and patient satisfaction. In recent years, the standard of care for postoperative pain management has reduced reliance on opioids in favor of multimodal analgesia. These regimens consist of systemic medications such as COX-2 inhibitors, acetaminophen, corticosteroids, and gabapentinoids, as well as regional and local approaches such as peripheral nerve blocks and local infiltrative analgesics. Newer therapies, such as cryoneurolysis, are still being studied but have shown promising results. Additional studies are needed to determine the ideal pain regimen that will optimize pain control and eliminate the need for postoperative opioids.

Consensus Guidelines on Interventional Therapies for Knee Pain (STEP Guidelines) from the American Society of Pain and Neuroscience

Knee pain is second only to the back as the most commonly reported area of pain in the human body. With an overall prevalence of 46.2%, its impact on disability, lost productivity, and cost on healthcare cannot be overlooked. Due to the pervasiveness of knee pain in the general population, there are no shortages of treatment options available for addressing the symptoms. Ranging from physical therapy and pharmacologic agents to interventional pain procedures to surgical options, practitioners have a wide array of options to choose from - unfortunately, there is no consensus on which treatments are "better" and when they should be offered in comparison to others. While it is generally accepted that less invasive treatments should be offered before more invasive ones, there is a lack of agreement on the order in which the less invasive are to be presented. In an effort to standardize the treatment of this extremely prevalent pathology, the authors present an all-encompassing set of guidelines on the treatment of knee pain based on an extensive literature search and data grading for each of the available alternative that will allow practitioners the ability to compare and contrast each option.

Identification of Risk Factors for Acute Kidney Injury from Intravenous Ketorolac in Geriatric Trauma Patients

BACKGROUND

Ketorolac is an effective analgesic but the potential for acute kidney injury (AKI) is concerning, particularly in geriatric "G-60 trauma" patients. The objectives of this study are to report the incidence of AKI in patients who receive ketorolac, identify risk factors for AKI, and develop a risk factor-guided algorithm for safe utilization.

METHODS

This retrospective cohort study included trauma patients age 60 years and older who received intravenous ketorolac. The primary endpoint was the incidence of AKI.

RESULTS

Among 316 patients evaluated, the incidence of AKI was 2.5%. Patients with AKI received more nephrotoxins, had more comorbidities, and higher use of loop diuretics or vasopressors. Loop diuretic therapy and number of comorbidities were independent predictors of AKI.

CONCLUSIONS

Risk for AKI with ketorolac was low, being more prevalent with comorbidities or receipt of loop diuretics.

An Update on Multimodal Pain Management After Total Joint Arthroplasty

➤

Multimodal analgesia has become the standard of care for total joint arthroplasty as it provides superior analgesia with fewer side effects than opioid-only protocols.

➤

Systemic medications, including nonsteroidal anti-inflammatory drugs, acetaminophen, corticosteroids, and gabapentinoids, and local anesthetics via local infiltration analgesia and peripheral nerve blocks, are the foundation of multimodal analgesia in total joint arthroplasty.

➤

Ideally, multimodal analgesia should begin preoperatively and continue throughout the perioperative period and beyond discharge.

➤

There is insufficient evidence to support the routine use of intravenous acetaminophen or liposomal bupivacaine as part of multimodal analgesia protocols.

Pain Score Assessment Using Single-Dose IV Ketorolac Only, After External Dacryocystorhinostomy: A Randomized Double/Triple-Blind Placebo-Controlled Trial

PURPOSE

To assess efficacy of intravenous (IV) ketorolac for postoperative pain control after external dacryocystorhinostomy.

METHOD

Fifty-five patients from January to April 2019 were randomized, to a double-blind prospective interventional study. Intervention arm received IV ketorolac (60 mg/2 ml) immediately post-op, control received IV saline bolus. Pain assessment was done with numerical rating scale pre- and postinjection (day 0) and on day 1. Requirement for analgesics and antiemetics was recorded.

RESULTS

Total 55 patients (11 men and 44 women) with mean age 49.93 ± 16.29 years were included in the study. Twenty-four (43.6%) patients received IV ketorolac and 31 (56.4%) received placebo. Mann-Whitney U test showed mean rank score for pain scale was significantly lower in intervention arm versus control arm, assessed postinjection (16.69 vs. 36.76 respectively, p = .000) and at day 1 (21.08 vs. 33.35 respectively, p = .003).

CONCLUSION

IV ketorolac significantly lowers self-reported pain score following external dacryocystorhinostomy with reduced requirement of analgesic and antiemetic medications.

The Efficacy and Safety of Nonsteroidal Anti-Inflammatory Drugs in Total Joint Arthroplasty: Systematic Review and Direct Meta-Analysis

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) have become widely used to manage perioperative pain following total joint arthroplasty (TJA). The purpose of our study is to evaluate the efficacy and safety of NSAIDs in support of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Management.

METHODS

Databases including MEDLINE, EMBASE, and the Cochrane Central Registry of Controlled Trials were searched for studies published prior to November 2018 on NSAIDs in TJA. Studies included after a systematic review evaluated through direct comparisons and/or meta-analysis, including qualitative and quantitative heterogeneity testing, to evaluate effectiveness and safety of NSAIDs.

RESULTS

After critical appraisal of 2921 publications, 25 articles represented the best available evidence for inclusion in the analysis. Oral selective cyclooxygenase (COX)-2 and non-selective NSAIDs and intravenous ketorolac safely reduce postoperative pain and opioid consumption during the hospitalization for primary TJA. Administration of an oral selective COX-2 NSAID reduced postoperative opioid consumption after discharge from TKA.

CONCLUSION

Strong evidence supports the use of an oral selective COX-2 or non-selective NSAID and intravenous ketorolac as adjunctive medications to manage postoperative pain during the hospitalization for TJA. Although no safety concerns were observed, prescribers need to remain vigilant when prescribing NSAIDs.

Intravenous ketorolac is associated with reduced mortality and morbidity after open abdominal aortic aneurysm repair

OBJECTIVES

The role of non-steroidal anti-inflammatory drugs in aortic aneurysm disease has been debated. Animal studies demonstrated that intrathecal ketorolac reduces the inflammatory response associated with aortic clamping. However, no human-subject study evaluated this association. Therefore, we sought to explore the effects of ketorolac use in open abdominal aortic aneurysm repair.

METHODS

The Premier Healthcare Database (June 2009-March 2015) was inquired to capture patients who underwent open abdominal aortic aneurysm repair for non-ruptured abdominal aortic aneurysm, identified via International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Intravenous ketorolac was coded as any or none. Outcomes were in-hospital mortality, cardiac, respiratory, renal, neurological, and hemorrhagic complications. Multivariable logistic regression coarsened exact matching followed by conditional fixed-effect regression modeling were performed.

RESULTS

A total of 6394 patients were identified (ketorolac: 806; 12.6%). Patients who received ketorolac were younger and less likely to have hypertension (76.1% vs. 79.3%), diabetes mellitus (12.5% vs. 17.4%), or chronic kidney disease (8.3% vs. 21.4%; all p values ≤ .033). There was no significant difference in medication use including oral non-steroidal anti-inflammatory drugs and malignant or musculoskeletal diseases. Mortality, respiratory, and renal complications were less prevalent with ketorolac (2.5% vs. 4.9%, 25.2% vs. 34.6%, 10.0% vs. 21.1%; p ≤ .002). Ketorolac was associated with lower adjusted odds for those events: 0.58 (0.36-0.93), 0.53 (0.42-0.68), and 0.72 (0.60-0.86), respectively (all p values ≤ .025). There was no association with neurological, cardiac, or hemorrhagic complications. The findings were replicated by coarsened exact matching analysis.

CONCLUSION

This study demonstrated 40% mortality reduction with intravenous ketorolac following open abdominal aortic aneurysm repair. The survival benefit could be due to its anti-inflammatory and opioid-sparing properties. This is evident by its protective effect against respiratory outcomes. The lack of association with the classical non-steroidal anti-inflammatory drugs-related cardiac and hemorrhagic complication could be attributable to the short-term use of ketorolac compared with non-steroidal anti-inflammatory drugs chronic use.

Diclofenac Versus Ketorolac for Pain Control After Primary Total Joint Arthroplasty: A Comparative Analysis

Introduction As total hip arthroplasty (THA) and total knee arthroplasty (TKA) transition to outpatient settings, appropriate pain management remains a challenge. Nonsteroidal anti-inflammatory drugs (NSAIDs) may subvert the need for postoperative opioids. This study evaluated: 1) total opioid consumption; 2) postoperative pain intensity; 3) discharge destination; 4) length of stay (LOS); and 5) THA and TKA patients' satisfaction in receiving adjunctive intravenous (IV) diclofenac or ketorolac. Methods In this retrospective cohort study, patients scheduled to undergo primary THA or TKA by a single surgeon between March 2017 and April 2018 were identified. Patients were stratified based on the receipt of IV diclofenac (THA: n = 25; TKA: n = 51) or IV ketorolac (THA: n = 28; TKA: n = 32) in addition to the standard pain management regimen. Student's t-testing and Chi-square were used to analyze continuous and categorical variables, respectively. Results TKA diclofenac patients had lower opioid consumption 12 hours postoperatively (p: 0.037). TKA patients in the diclofenac cohort were discharged to home less often (p: 0.025). Both diclofenac cohorts had greater patient satisfaction than the ketorolac cohorts (p: <0.05). There was no significant difference between groups in postoperative pain intensity at 24 or 48 hours or in the length of stay (p: >0.05 for all). Conclusion This study demonstrated that both TKA and THA patients treated with IV diclofenac had no difference in postoperative pain intensity while THA patients had no difference in opioid consumption relative to those treated with IV ketorolac. Further comparison of IV NSAIDs with other IV pain medications may provide broader insight into the ideal management for postoperative pain for this widening patient population.

Comparison of analgesic effects of intravenous and intranasal ketorolac in patients with mandibular fracture-A Randomized Clinical Trial

Background

Similarity of pharmacokinetics of intranasal ketorolac to the intravenous form and other advantages have promoted its application. This study compared the analgesic effects of intravenous and intranasal ketorolac in patients undergoing mandibular fracture surgery.

Material and Methods

In this clinical trial study, Sixty-four patients with unilateral mandibular fracture were divided randomly into two groups. In group 1, 30 mg of intravenous (IV) ketorolac was injected every 8 hours and in group 2, intranasal (IN) ketorolac spray was used as a 100-µL puff in each nostril (31.5 mg) every 6 hours. After each patient regained consciousness, pain intensity was measured based on visual analogue scale for 48 hours. Finally, the total dose of the opioid analgesic agent (pethidine) and the time for the first request for an analgesic agent were recorded for each patient, and their means were compared in each group with proper statistical tests.

Results

Mean pain intensity of patients at baseline was significantly higher than that at other intervals and then, it decreased significantly (P<0.001). Furthermore, 2, 4, 6 and 8 hours after surgery, mean pain intensity in the IN group was significantly lower than that in the IV group (P<0.05). In the IN group, dose of antinociceptive medicine was slightly higher and the time to request it was shorter than the other group, but it was not statistically significant (P >0.05).

Conclusions

Application of intranasal ketorolac spray decreased pain after mandibular fracture surgery, especially at 8-hour interval after surgery, decreasing the need for opioids.

Key words:Ketorolac, intranasal, intravenous, mandibular fracture.

Perioperative Considerations for the Patient with Opioid Use Disorder on Buprenorphine, Methadone, or Naltrexone Maintenance Therapy

As part of a national effort to combat the current US opioid epidemic, use of currently Food and Drug Administration-approved drugs for the treatment of opioid use disorder/opioid addiction (buprenorphine, methadone, and naltrexone) is on the rise. To provide optimal pain control and minimize the risk of relapse and overdose, providers need to have an in-depth understanding of how to manage these medications in the perioperative setting. This article reviews key principles and discusses perioperative considerations for patients with opioid use disorder on buprenorphine, methadone, or naltrexone.

Evaluation of the safety and efficacy of an intravenous nanocrystal formulation of meloxicam in the management of moderate-to-severe pain after bunionectomy

Objective

This randomized, double-blind, placebo-controlled study evaluated the safety and efficacy of an intravenous (IV) nanocrystal formulation of meloxicam in subjects with moderate-to-severe pain following a standardized unilateral bunionectomy.

Methods

Fifty-nine subjects aged 18–72 years were randomized to receive doses of either 30 mg (n=20) or 60 mg (n=20) meloxicam IV or placebo (n=19), administered once daily as bolus IV injections over 15–30 seconds (two or three doses). Safety, the primary objective, was assessed by physical examination, clinical laboratory tests, and the incidence of adverse events (AEs). Efficacy was evaluated by examining summed pain intensity differences over the first 48 hours (SPID₄₈) using analysis of covariance models. Use of opioid rescue analgesic agents was evaluated.

Results

Generally, AEs were mild-to-moderate in intensity, and their incidence was similar across the three treatment groups. No serious AEs were reported; there were no withdrawals due to AEs, including injection-related AEs. The estimated effect size for SPID₄₈ versus placebo was 1.15 and 1.01 for meloxicam IV doses 30 mg and 60 mg, respectively (P≤0.01). Both doses produced significantly greater pain reductions versus placebo (P≤0.05) at all evaluated times/ intervals during the 48-hour period. The proportions of subjects with ≥30% and ≥50% overall reduction in pain from baseline after 6 and 24 hours were significantly higher with meloxicam IV 30 mg doses versus placebo, but not with meloxicam IV 60 mg doses. The time to first use of rescue medication was significantly longer versus placebo with meloxicam IV 60 mg (P<0.05), but not with meloxicam IV 30 mg doses.

Conclusion

Meloxicam IV was generally safe and well tolerated in subjects with moderate-to-severe post-bunionectomy pain. Once-daily administration of meloxicam IV 30 mg and 60 mg exhibited rapid onset of analgesia (as early as 15 minutes) with maintenance of analgesic effect for two consecutive 24-hour periods.

Perioperative pain management following total joint arthroplasty: A review and update to an institutional pain protocol

As the rate of total joint arthroplasty increases with the aging population of the United States, new focus on decreasing opioid use through the development of multimodal pain regimens (MPRs) is becoming an important area of research. MPRs use different agents and modes of delivery in order to synergistically address pain at many levels of the pain pathway. MPRs include a combination of acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), gabapentinoids, opioids (short- and long-acting), spinal/epidural analgesia, regional nerve blocks, and local anesthetics. This review summarizes the available literature on major components of MPRs shown to be effective in the total joint arthroplasty population. Finally, the authors' preferred method for pain control in the TJA population is reviewed.

Comparison of Pain Relief from Different Intravenous Doses of Ketorolac after Reduction of Mandibular Fractures

Introduction

Pain is an unpleasant feeling due to tissue destruction, which disturbs an individual's daily routines even at its lowest levels. The majority of surgeons and anaesthesiologists are increasingly trying to administer non-opioid analgesics because excessive use of opioids after surgery results in patient dissatisfaction.

Aim

To evaluate the analgesic effect of intravenous injection of different doses of ketorolac at different intervals in patients undergoing surgery for unilateral fractures of the mandible.

Materials and Methods

In the present randomized clinical trial (March 2016 to January 2017, in Tabriz Imam Reza Treatment/Educational Center), 50 patients were assigned to five groups with simple randomization method. In Group 1 and 2, immediately before the induction of general anaesthesia 30 and 60 mg of ketorolac and in Group 3 and 4, immediately before termination of surgery 30 and 60 mg of ketorolac was injected intravenously. In Group 5, ketorolac was not administered. After each patient regained complete consciousness, the severity of pain was determined using VAS up to 24 hours at baseline and at 2, 4, 6, 12 and 24-hours intervals. The total dose of the opioid analgesic agent (morphine-pethidine) and the time for the first request for an analgesic agent were recorded for each patient and their means were compared in each group with suitable statistical tests.

Results

The patients in Group 5 and 4 exhibited the highest and lowest mean pain scores (5.03±0.9 and 3.5±1), respectively. ANOVA for repeated measures and post-hoc Tukey tests showed significant differences only between Group 3 and 5 (p=0.002) and Group 4 and 5 (p=0.001), with no significant differences between the other groups (p>0.005). The highest dose of the analgesic agent was in Group 5 (5.3±1.4 mg) and the lowest dose was recorded in Group 4 (1.6±0.6 mg). Patients in the control group received significantly higher doses compared to the other groups (p<0.05). The patients in Group 1 and 2 received higher doses of analgesics compared to Group 3 and 4 (p<0.05). The longest time for the request for the first dose of analgesic agent after surgery was 73.4±12.03 minutes in Group 4 The patients in the control group had requested analgesics after surgery at a significantly shorter time compared to the patients in all the study groups (p<0.05). The patients in Group 1 and 2 had requested analgesics at a shorter time after surgery compared to the subjects in Group 3 and 4 (p<0.05).

Conclusion

Intravenous administration of 30 and 60 mg of ketorolac, immediately before termination of surgery, decreases the pain severity and the need for opioid analgesics after surgery.

Postoperative opioid sparing with injectable hydroxypropyl-β-cyclodextrin-diclofenac: pooled analysis of data from two Phase III clinical trials

Purpose

Use of nonopioid analgesics (including nonsteroidal anti-inflammatory drugs) for postoperative pain management can reduce opioid consumption and potentially prevent opioid-related adverse events. This study examined the postoperative opioid-sparing effect of repeated-dose injectable diclofenac formulated with hydroxypropyl-β-cyclodextrin (HPβCD)-diclofenac.

Patients and methods

Pooled data from two double-blind, randomized, placebo- and active comparator-controlled Phase III trials were analyzed. Patients received HPβCD-diclofenac, placebo, or ketorolac by intravenous injection every 6 hours for up to 5 days following abdominal/pelvic or orthopedic surgery. Rescue opioid use was evaluated from the time of first study drug administration to up to 120 hours following the first dose in the overall study population and in subgroups defined by baseline pain severity, age, and HPβCD-diclofenac dose.

Results

Overall, 608 patients received ≥1 dose of study medication and were included in the analysis. While 93.2% of patients receiving placebo required opioids, the proportion of patients requiring opioids was significantly lower for patients receiving HPβCD-diclofenac (18.75, 37.5, or 50 mg) or ketorolac (P<0.005 for all comparisons). Mean cumulative opioid dose and number of doses were significantly lower among patients receiving HPβCD-diclofenac versus placebo for the 0–24 through 0–120 hour time periods (P<0.0001), as well as versus ketorolac for the 0–72 through 0–120 hour time periods (P<0.05). HPβCD-diclofenac significantly reduced opioid consumption versus placebo in subgroups based on baseline pain severity (moderate, severe) and age (<65 years, ≥65 years) from the 0–24 hour period onward. When compared to ketorolac, HPβCD-diclofenac also significantly reduced cumulative opioid consumption among patients with moderate baseline pain (0–72 through 0–120 hours) and opioid dose number among patients ≥65 years old (0–24 through 0–120 hours).

Conclusion

HPβCD-diclofenac can reduce postoperative opioid requirements. As this analysis was not powered to compare opioid-related adverse event rates, follow-up studies examining the clinical impact of HPβCD-diclofenac’s opioid sparing are warranted.

Acute Pain Management

Acute pain management is improving steadily over the past few years, but training and professional education are still lacking in many professions. Untreated or undertreated acute pain could have detrimental effects on the patient in terms of comfort and recovery from trauma or surgery. Acute undertreated pain can decrease a patient's vascular perfusion, increase oxygen demand, suppress the immune system, and possibly risk increased incidence of venous thrombosis. Although acute postoperative pain needs to be managed aggressively, patients are most vulnerable during this period for developing adverse effects, and therefore, patient assessment and careful drug therapy evaluation are necessary processes in therapeutic planning. Acute pain management requires careful and thorough initial assessment and follow-up reassessment in addition to frequent dosage adjustments, and managing analgesic induced side effects. Analgesic selection and dosing must be based on the patient's past and recent analgesic exposure. There is no single acute pain management regimen that is suitable for all patients. Analgesics must be tailored to the individual patient.

Double-blind, randomized, double-dummy clinical trial comparing the efficacy of ketorolac trometamol and naproxen for acute low back pain

Background

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most common type of medication used in the treatment of acute pain. Ketorolac trometamol (KT) is a nonnarcotic, peripherally acting nonsteroidal anti-inflammatory drug with analgesic effects comparable to certain opioids.

Objective

The aim of this study was to compare the efficacy of KT and naproxen (NA) in the treatment of acute low back pain (LBP) of moderate-to-severe intensity.

Patients and methods

In this 10-day, Phase III, randomized, double-blind, double-dummy, noninferiority trial, participants with acute LBP of moderate-to-severe intensity as determined through a visual analog scale (VAS) were randomly assigned in a 1:1 ratio to receive sublingual KT 10 mg three times daily or oral NA 250 mg three times daily. From the second to the fifth day of treatment, if patient had VAS >40 mm, increased dosage to four times per day was allowed. The primary end point was the reduction in LBP as measured by VAS. We also performed a post hoc superiority analysis.

Results

KT was not inferior to NA for the reduction in LBP over 5 days of use as measured by VAS scores (P=0.608 for equality of variance; P=0.321 for equality of means) and by the Roland–Morris Disability Questionnaire (P=0.180 for equality of variance test; P=0.446 for equality of means) using 95% confidence intervals. The percentage of participants with improved pain relief 60 minutes after receiving the first dose was higher in the KT group (24.2%) than in the NA group (6.5%; P=0.049). The most common adverse effects were heartburn, nausea, and vomiting.

Conclusion

KT is not inferior in efficacy and delivers faster pain relief than NA.

Comparison of the anti-inflammatory effect of dexamethasone and ketorolac in the extractions of third molars

This double-blind, split-mouth, and randomized study was aimed to compare the efficacy of dexamethasone and ketorolac tromethamine, through the evaluation of pain, edema, and limitation of mouth opening. Thirty-four individuals aged 18-26 years, having bilateral mandibular third molars, in a similar position, were selected. Two different surgical procedures were performed on the same individual by the single surgeon. For an extraction, the individual received 1 capsule of 10 mg ketorolac tromethamine 1 h before surgery and every 8 h for 2 days. For the extraction of the contralateral side, the individual received 1 capsule of 8 mg dexamethasone 1 h before surgery and 1 placebo capsule every 8 h for 2 days. Sodium metamizol, 500 mg, was given as rescue medication in postoperative. Pain was assessed by the Visual Box Scale-11 points (BS-11) at 24 h postoperative. Edema (metric measurement) and the maximum mouth opening (interincisal) were recorded in the pre-operative, 24 h, 48 h, 72 h and 7 days postoperatively. The results showed that both therapeutic treatments used were effective in the postoperative, and there were no statistically significant differences between the groups for the pain and edema variables. However, for the limitation of mouth opening, 24 h and 7 days postoperatively, the dexamethasone group had a lower limitation of mouth opening, behaving better than the ketorolac for this variable in these periods. Due also to the higher margin of safety, the use of dexamethasone as a single dose becomes a more suitable alternative for use in routine surgical extractions of third molars.

Analgesic management of acute pain in the opioid-tolerant patient

PURPOSE OF REVIEW

The management of acute pain in the opioid-tolerant patient is an area in perioperative medicine that is growing, as the use of opioids for chronic noncancer pain has been tolerated in the USA. Adding to this population is an increase in opioid abusers, addicts and those in recovery and maintenance programmes. These patients will continue to present for surgery and with acute pain that anaesthesiologists and other members of the healthcare team must become more adept at managing.

RECENT FINDINGS

This review covers some of the strategies that may be used by practitioners in the management of acute pain in the opioid-tolerant patient. It is important to collect a detailed history of opioid and drugs of abuse, including the timing of the last dose in order to avoid precipitation of withdrawal. The use of multimodal anaesthetic and analgesic strategies is important for both patient safety and satisfaction and can enhance recovery and discharge home.

SUMMARY

There is a need for more high-level evidence-based guidelines to help practitioners achieve the best care of this growing high-risk population of patients.

Preventive analgesia in hip or knee arthroplasty: a systematic review

OBJECTIVE

To analyze the efficacy and safety of preventive analgesia in patients undergoing hip or knee arthroplasty due to osteoarthritis.

METHODS

A systematic literature review was performed, using a defined a sensitive strategy on Medline, Embase and Cochrane Library up to May 2013. The inclusion criteria were: patients undergoing knee and/or hip arthroplasty, adults with moderate or severe pain (≥4 on a Visual Analog Scale). The intervention, the use (efficacy and safety) of pharmacological treatment (preventive) close to surgery was recorded. Oral, topical and skin patch drugs were included. Systematic reviews, meta-analysis, controlled trials and observational studies were selected.

RESULTS

A total of 36 articles, of moderate quality, were selected. The patients included were representative of those undergoing knee and/or hip arthroplasty in Spain. They had a mean age >50 years, higher number of women, and reporting moderate to severe pain (≥4 on a Visual Analog Scale). Possurgical pain was mainly evaluated with a Visual Analog Scale. A wide variation was found as regards the drugs used in the preventive protocols, including acetaminophen, classic NSAID, Cox-2, opioids, corticosteroids, antidepressants, analgesics for neuropathic pain, as well as others, such as magnesium, ketamine, nimodipine or clonidine. In general, all of them decreased post-surgical pain without severe adverse events.

CONCLUSIONS

The use or one or more pre-surgical analgesics decreases the use of post-surgical drugs, at least for short term pain.

The Effect of Perioperative Ketorolac on the Clinical Failure Rate of Meniscal Repair

Background:

There has been recent interest in the effect of nonsteroidal anti-inflammatory medications on musculoskeletal healing. No studies have yet addressed the effect of these medications on meniscal healing.

Hypothesis:

The administration of ketorolac in the perioperative period will result in higher rates of meniscal repair clinical failure.

Study design:

Cohort study; Level of evidence, 3.

Methods:

A total of 110 consecutive patients underwent meniscal repair at our institution between August 1998 and July 2001. Three patients were lost to follow-up, and the remaining 107 (mean age, 15.9 ± 4.4 years) had a minimum 5-year follow-up (mean follow-up, 5.5 years). Thirty-two patients (30%) received ketorolac perioperatively. The primary outcome measure was reoperation for continued symptoms of meniscal pathology. Asymptomatic patients were evaluated by the International Knee Documentation Committee (IKDC) Subjective Knee Form, Short Form–36 (SF-36) Health Survey, and Knee Outcome Osteoarthritis Score (KOOS).

Results:

Kaplan-Meier survivorship revealed no difference in reoperation rates with and without the administration of perioperative ketorolac (P = .95). There was an overall failure rate of 35% (37/107 patients), with a 34% failure rate in patients receiving ketorolac (11/32 patients). Multivariable Cox regression confirmed that age, duration of symptoms, meniscal tear type, fixation technique, concurrent anterior cruciate ligament repair, and ketorolac usage did not have an impact on the rate of failure (P > .05 for all; ketorolac use, P > .50). Female sex (P = .04) and medial location (P = .01) were predictive of an increased risk for reoperation.

Conclusion:

Failure of meniscal repair was not altered with the administration of perioperative ketorolac. Further work studying the effects of longer term anti-inflammatory use after meniscal repair is necessary before stating that this class of medications has no effect on meniscal healing.

Clinical Relevance:

Results of this study suggest that nonsteroidal anti-inflammatory ketorolac can be administered perioperatively during a meniscal repair procedure to harness its benefits of decreased narcotic requirement, decreased pain, and shorter length of hospital stay without negatively influencing the long-term outcome of the surgery.

Do nonsteroidal anti-inflammatory drugs affect the outcome of arthroscopic Bankart repair?

To achieve pain control after arthroscopic shoulder surgery, nonsteroidal anti-inflammatory drugs (NSAIDs) are a complement to other analgesics. However, experimental studies have raised concerns that these drugs may have a detrimental effect on soft tissue-to-bone healing and, thus, have a negative effect on the outcome. We wanted to investigate if there are any differences in the clinical outcome after the arthroscopic Bankart procedure for patients who received NSAIDs prescription compared with those who did not. 477 patients with a primary arthroscopic Bankart procedure were identified in the Norwegian shoulder instability register and included in the study. 32.5% received prescription of NSAIDs post-operatively. 370 (78%) of the patients answered a follow-up questionnaire containing the Western Ontario Shoulder Instability index (WOSI). Mean follow-up was 21 months. WOSI at follow-up were 75% in the NSAID group and 74% in the control group. 12% of the patients in the NSAID group and 14% in the control group reported recurrence of instability. The reoperation rate was 5% in both groups. There were no statistically significant differences between the groups. Prescription of short-term post-operative NSAID treatment in the post-operative period did not influence on the functional outcome after arthroscopic Bankart procedures.

Analgesic efficacy and safety of a novel injectable formulation of diclofenac compared with intravenous ketorolac and placebo after orthopedic surgery: a multicenter, randomized, double-blinded, multiple-dose trial

OBJECTIVES

A novel injectable formulation of diclofenac, Dyloject, utilizes hydroxypropyl-β-cyclodextrin (HPβCD) as a solubilizing agent, allowing dosing as a small-volume intravenous bolus for postoperative pain. In this test of the efficacy and safety of HPβCD diclofenac, we hypothesized that HPβCD diclofenac would relieve moderate and severe pain after orthopedic surgery.

PATIENTS AND METHODS

Adults 18 to 85 years old with moderate and severe pain within 6 hours after surgery were randomized to HPβCD diclofenac, ketorolac tromethamine, or placebo, and stratified by risk cohort. The HPβCD diclofenac non-high-risk cohort dose was 37.5 mg, the high-risk cohort received 18.75 mg, and patients ≥95 kg received 50 mg. The ketorolac dose was 30 mg in the non-high-risk and high-weight cohorts and 15 mg in the high-risk cohort. Rescue intravenous morphine was given for pain as needed. Efficacy was measured by the sum of pain intensity differences (SPID).

RESULTS

Mean SPID scores of 277 patients were significantly better with HPβCD diclofenac and ketorolac than with placebo (P<0.0001), across all risk cohorts (P<0.05). HPβCD diclofenac was associated with better SPID scores, faster onset of analgesia, and significantly lower opioid requirement (P<0.008) than ketorolac. In patients more than or equal to 65 years, HPβCD diclofenac was associated with significantly better analgesic efficacy (P=0.05), and lower opioid requirement versus ketorolac. The incidence of treatment-related adverse events was similar across groups.

DISCUSSION

HPβCD diclofenac is safe and efficacious for acute moderate and severe pain after orthopedic surgery and significantly spares morphine use.

Sublingual ketorolac versus sublingual tramadol for moderate to severe post-traumatic bone pain in children: a double-blind, randomised, controlled trial

OBJECTIVES

To assess the effectiveness of sublingual ketorolac versus sublingual tramadol in reducing the pain associated with fracture or dislocation of extremities in children.

PATIENTS AND METHODS

A double-blind, randomised, controlled, non-inferiority trial was conducted in the paediatric emergency department of a research institute. One hundred and thirty-one children aged 4-17 years with suspected bone fracture or dislocation were enrolled. Eligible children were randomised to ketorolac (0.5 mg/kg) and placebo, or to tramadol (2 mg/kg) and placebo by sublingual administration, using a double-dummy technique. Pain was assessed by the patients every 20 min, for a maximum period of 2 h, using the McGrath scale for patients up to 6 years of age, and the Visual Analogue Scale for those older than 6 years of age.

RESULTS

The mean pain scores fell significantly from eight to four and five in the ketorolac and tramadol groups, respectively, by 100 min (Wilcoxon sign rank test, p<0.001). The mean pain scores for ketorolac were lower than those for tramadol, but these differences were not significant at any time point (Mann-Whitney U Test, p values: 0-20 min: 0.167; 20-40 min: 0.314; 40-60 min: 0.223; 60-80 min: 0.348; 80-100 min: 0.166; 100-120 min: 0.08). The rescue dose of paracetamol-codeine was administered in 2/60 children in the ketorolac group versus 8/65 in the tramadol group (Fisher exact test, p=0.098). There were no statistically significant differences between the two groups in the frequency of adverse effects.

CONCLUSIONS

Both sublingual ketorolac and tramadol were equally effective for pain management in children with suspected fractures or dislocations.

A novel injectable formulation of diclofenac compared with intravenous ketorolac or placebo for acute moderate-to-severe pain after abdominal or pelvic surgery: a multicenter, double-blind, randomized, multiple-dose study

BACKGROUND

Injectable formulations of diclofenac have long been available in Europe and other countries. These formulations use a default dose of 75 mg of diclofenac delivered IV over 30 to 120 minutes or as an IM injection. A novel formulation of injectable diclofenac sodium, Dyloject®, is solubilized with hydroxypropyl β-cyclodextrin (HPβCD) so that it can be given IV or IM in a small volume bolus. In this multicenter, multiple-dose, multiple-day, randomized, double-blind, parallel-group phase 3 study, we investigated whether lower doses of HPβCD diclofenac delivered as a small volume bolus would be effective for the management of acute pain after abdominal or pelvic surgery.

METHODS

Adults with moderate and severe pain, defined as ≥50 mm on a 0 to 100 mm visual analog scale, within 6 hours after surgery were randomly assigned (1:1:1:1 ratio) to receive HPβCD diclofenac, 18.75 mg or 37.5 mg; ketorolac tromethamine 30 mg; or placebo. Patients in all treatment arms received a bolus IV injection every 6 hours until discharged. They were observed for at least 48 h, and for up to 5 days. Rescue IV morphine was available any time, up to a total of 7.5 mg over a 3-hour period. The primary efficacy measure was the sum of pain intensity differences from 0 to 48 hours after study drug initiation.

RESULTS

Three hundred thirty-one patients received ≥1 dose of study drug. Over the first 48 hours, both IV HPβCD diclofenac doses, as well as ketorolac, produced significant reductions in pain intensity over placebo (all P < 0.05), as well as significant reductions in the need for rescue morphine administration. Both doses of HPβCD diclofenac, as well as ketorolac, significantly reduced rescue morphine dosages, as compared to placebo (P < 0.0001), and time to rescue morphine administration was significantly increased by treatment with 18.75 mg diclofenac and ketorolac. The overall incidence of treatment-related adverse events was 20.2%. No treatment-related serious adverse events were reported in either diclofenac dose group, whereas only 1 was reported in the ketorolac group.

CONCLUSIONS

For patients with acute moderate and severe pain after abdominal or pelvic surgery, repeated 18.75 mg and 37.5 mg doses of HPβCD diclofenac provided significant analgesic efficacy, as compared to placebo. Significant analgesic efficacy was also provided by the active comparator ketorolac. Both HPβCD diclofenac and ketorolac significantly reduced the need for opioids.

Pain management after surgery: a brief review

Proper pain management, particularly postoperative pain management, is a major concern for clinicians as well as for patients undergoing surgery. Although many advances have been made in the field of pain management, particularly during the past decades, not all patients achieve complete relief from postoperative pain. In this paper, we have emphasized the importance of postoperative analgesia and discussed the new developments in this field.

Acute postoperative pain management in the older patient

Acute pain management in the older adult is both challenging and rewarding. This review addresses the difficulty with assessment of pain in the older adult, variations in the pain experience of older adults, physiological differences between the young and old, changes in pharmacokinetics and pharmacodynamics with age, and useful pharmacological treatments for acute pain in older adults. It then presents a few representative cases of pain management in older adults. The goal of this review is to provide relevant information that can be used to manage acute postoperative pain in the older adult.

Perioperative single dose ketorolac to prevent postoperative pain: a meta-analysis of randomized trials

BACKGROUND

Preventive analgesia using non-opioid analgesic strategies is recognized as a pathway to improve postoperative pain control while minimizing opioid-related side effects. Ketorolac is a nonsteroidal antiinflammatory drug frequently used to treat postoperative pain. However, the optimal dose and route of administration for systemic single dose ketorolac to prevent postoperative pain is not well defined. We performed a quantitative systematic review to evaluate the efficacy of a single dose of perioperative ketorolac on postoperative analgesia.

METHODS

We followed the PRISMA statement guidelines. A wide search was performed to identify randomized controlled trials that evaluated the effects of a single dose of systemic ketorolac on postoperative pain and opioid consumption. Meta-analysis was performed using a random-effects model. Effects of ketorolac dose were evaluated by pooling studies into 30- and 60-mg dosage groups. Asymmetry of funnel plots was examined using Egger regression. The presence of heterogeneity was assessed by subgroup analysis according to the route of systemic administration (IV versus IM) and the time of drug administration (preincision versus postincision).

RESULTS

Thirteen randomized clinical trials with 782 subjects were included. The weighted mean difference (95% confidence interval [CI]) of combined effects showed a difference for ketorolac over placebo for early pain at rest of -0.64 (-1.11 to -0.18) but not at late pain at rest, -0.29 (-0.88 to 0.29) summary point (0-10 scale). Opioid consumption was decreased by the 60-mg dose, with a mean (95% CI) IV morphine equivalent consumption of -1.64 mg (-2.90 to -0.37 mg). The opioid-sparing effects of ketorolac compared with placebo were greater when the drug was administered IM compared with when the drug was administered IV, with a mean difference (95% CI) IV morphine equivalent consumption of -2.13 mg (-4.1 to -0.21 mg). Postoperative nausea and vomiting were reduced by the 60-mg dose, with an odds ratio (95% CI) of 0.49 (0.29-0.81).

CONCLUSIONS

Single dose systemic ketorolac is an effective adjunct in multimodal regimens to reduce postoperative pain. Improved postoperative analgesia achieved with ketorolac was also accompanied by a reduction in postoperative nausea and vomiting. The 60-mg dose offers significant benefits but there is a lack of current evidence that the 30-mg dose offers significant benefits on postoperative pain outcomes.

A double-blind placebo-controlled comparison of a novel formulation of intravenous diclofenac and ketorolac for postoperative third molar extraction pain

Dyloject is a novel formulation of diclofenac intended for intravenous (IV) administration. This formulation employs the solubilizing agent hydroxypropyl-β-cyclodextrin to permit bolus IV administration. The efficacy and safety of 5 dose levels of IV diclofenac were compared with IV ketorolac and placebo following third molar extraction. This was a single-dose, randomized, double-blind, placebo- and comparator-controlled, parallel-group study. A total of 353 subjects with moderate to severe pain received placebo; ketorolac 30 mg; or IV diclofenac 3.75, 9.4, 18.75, 37.5, or 75 mg (N  =  51 for all groups, except N  =  47 for ketorolac). The primary endpoint was total pain relief over 6 hours (TOTPAR6) as measured by the visual analog scale (VAS). Secondary endpoints included multiple measures of pain intensity and relief; patient global evaluation; and times to pain relief and rescue medication. Dropouts and adverse effects (AEs) were also monitored. IV diclofenac was superior to placebo as measured by TOTPAR6 (P < .0001 for all doses except 3.75 mg, for which P  =  .0341). IV diclofenac 3.75 mg was statistically superior to placebo for TOTPAR2 and TOTPAR4. IV diclofenac at both 37.5 and 75 mg was superior to placebo (P < .05) at the earliest (5 minute) assessments of pain intensity and pain relief, but ketorolac was not. The proportion of patients reporting 30% or greater pain relief at 5 minutes was significantly greater after IV diclofenac 37.5 and 75 mg than after ketorolac 30 mg or placebo. Secondary endpoints confirmed the primary findings. Treatment-related AEs were generally mild to moderate and were typical for nonsteroidal anti-inflammatory drugs (NSAIDs). The more rapid onset of action of IV diclofenac compared with the reference injectable NSAID ketorolac suggests additional clinical benefit. If confirmed in larger series, these findings may improve the safety and efficacy of postoperative NSAID analgesia.

A pharmacokinetic analysis of diclofenac potassium soft-gelatin capsule in patients after bunionectomy

The clinical utility of diclofenac potassium, a nonsteroidal anti-inflammatory drug, may be lessened by inconsistent gastrointestinal absorption. Diclofenac potassium liquid filled soft-gelatin capsule (DPSGC) is an investigational formulation that uses ProSorb dispersion technology to facilitate rapid and consistent gastrointestinal absorption. In this study, the pharmacokinetic (PK) properties of DPSGC are investigated and compared with a commercially available oral diclofenac potassium tablet in patients after primary unilateral first metatarsal bunionectomy. In an open-label, randomized study, 53 patients received ProSorb-D 12.5 mg (the liquid equivalent of DPSGC), DPSGC 25 mg, DPSGC 50 mg, or immediate-release diclofenac potassium 50-mg tablet administered every 8 hours for a 24-hour inpatient period followed by 7 days of outpatient dosing. Diclofenac steady-state PK was evaluated over an 8-hour sampling period 4 days after surgery. Delayed and/or multiple peaks in the diclofenac plasma concentration-time course profiles occurred more frequently with the commercially available oral diclofenac potassium 50-mg tablet than with the other DPSGC formulations. PK data for ProSorb-D 12.5-mg liquid, DPSGC 25 mg, DPSGC 50 mg, and diclofenac potassium 50-mg tablet revealed mean peak plasma concentrations (Cmax) of 302, 749, 1006, and 902 ng/mL, respectively, whereas area under the plasma concentration curve values were 316, 595, 1029, and 1166 ng-hour/mL, respectively. Mean times to Cmax (tmax) were 0.49, 0.63, 0.95, and 1.26 h, respectively. When compared with absorption characteristics of diclofenac potassium 50-mg tablet, DPSGC was more rapidly and consistently absorbed after bunionectomy. These characteristics should be advantageous when rapid pain relief is desired.

[Postoperative multimodal pain management : Cost-minimisation analysis from a hospital's point of view]

BACKGROUND

Adequate pain management after major surgery is important to improve patients' quality of life and to support the healing process. Since the cost for pain management is included in the DRG system for hospital reimbursement, hospitals should aim to provide adequate postoperative pain management at the lowest possible cost. In this study we compare two multimodal pain management schemes for postoperative pain management in a cost-minimisation analysis.

METHODS

In a decision analytic model two treatment regimes for postoperative pain management are compared in a cost-minimisation analysis: diclofenac + morphine vs paracetamol vs morphine. The study is performed from the perspective of a public hospital. Due to the short time horizon costs are not discounted.

RESULTS

Assuming comparable effectiveness for adequate postoperative pain management, the expected value in the decision tree model for the combination diclofenac + morphine is 13.37 EUR and for the combination paracetamol + morphine 32.23 EUR, respectively. The results are robust under various one- and two-way sensitivity analyses.

CONCLUSION

With no contraindications given the combination diclofenac + morphine is more cost-effective for postoperative pain management after major surgery compared to paracetamol + morphine.

[Pain therapy for the lower extremities]

Pain therapy after surgical procedures of the lower extremity is an important goal, whereas insufficient analgesia leads to an essential reduction of the patient's mobility and convalescence. If possible, regional anaesthetic and intrathecal procedures for pre-, intra- and postoperative analgesia should be used. Systemic analgesics should not be used preoperatively, whereas non-opioids and opioids are recommended postoperatively. Surgical options that adequately reduce pain are intra-articular injection of local anaesthetics alone or in combination with opioids and cooling and physiotherapeutic treatment regimens after joint procedures. There is no scientific rationale as an argument for inserting drains. The surgical approach depends more on the individual patient's anatomical characteristics. Whereas the regional analgesic regimen is more effective than systemic therapy, sufficient tools for pain reduction during surgical procedures of the lower extremity are at the orthopaedic surgeon's disposal, too.

Ketorolac and spinal fusion: does the perioperative use of ketorolac really inhibit spinal fusion?

STUDY DESIGN

Retrospective review.

OBJECTIVE

To evaluate the effect of postoperative use of ketorolac (Toradol) on spinal fusion in humans.

SUMMARY OF BACKGROUND DATA

The value of parenteral ketorolac in postoperative analgesia has been well documented across surgical specialties. However, some studies have shown that ketorolac may adversely affect osteogenic activity and fracture healing.

METHODS

A total of 405 consecutive patients who underwent primary lumbar posterolateral intertransverse process fusion with pedicle screw instrumentation were included in this retrospective study. A subtotal of 228 patients received Toradol after surgery for adjunctive analgesia. Each patient received a mandatory dose of 30 mg intravenously every 6 hours for 48 hours. The same surgeon performed the fusion procedure on all of these patients. Historical controls included 177 patients who did not receive Toradol after surgery. The minimum follow-up period was 24 months. Nonunions were diagnosed by analyzing sequential radiographs, flexion-extension radiographs, and computed tomography with multiplanar reconstructions. The gold standard of surgical exploration was performed in symptomatic patients with diagnostic ambiguity or nonunions diagnosed by imaging.

RESULTS

There were no smokers in the study population. Pseudarthrosis was identified in 12 of 228 patients (5.3%) who received Toradol after surgery, and in 11 of 177 patients (6.2%) who did not. There was no significant difference detected in the nonunion rates between the two groups (P > 0.05, chi2 method).

CONCLUSION

Use of ketorolac after spinal fusion surgery in humans, limited to 48 hours after surgery for adjunctive analgesia, has no significant effect on ultimate fusion rates.

A new knee surgery model in rats to evaluate functional measures of postoperative pain

INTRODUCTION

With the increase in the number of total knee surgeries being performed, postoperative analgesic management remains a challenge. We used a new animal knee surgery model to characterize pain-related behavior in the rat, and its therapeutic modulation with systemic and intrathecal drug treatment.

METHODS

Rats were anesthetized with isoflurane and an incision was made over the left knee to expose the patella tendon. The tendon was reflected aside and a 1.4-mm diameter, 0.5 mm deep hole was drilled in both the femur and tibia at 2 mm above and below the knee joint, respectively. The holes were filled with dental cement and the wound was closed. Sham surgery animals only had a skin incision. Some animals had previously been implanted with a lumbar intrathecal catheter for drug injection. At 24 h after surgery, animals received the following drugs systemically: i.p. morphine sulfate 0.3-1 mg/kg, i.p. ketorolac 2.5-20 mg/kg, p.o. celecoxib 10-50 mg/kg, i.p. ketamine hydrochloride 2.5-10 mg/kg, i.p. clonidine hydrochloride 25 microg/kg, p.o. pregabablin 10-20 mg/kg, or drug vehicle; or intrathecally: morphine sulfate 0.3-1 microg, ketorolac 4-80 microg, L-745,337 80 microg, pregabalin 15 microg, neostigmine 0.5 microg, or saline vehicle. Pain-related behavior was then assessed by recording exploratory spontaneous activity, in which vertical and horizontal light beam interruptions were automatically recorded to measure rearing activity and ambulation for 60 min. Data were compared using analysis of variance with the Tukey-B post hoc test.

RESULTS

The model demonstrated deficits in rearing and ambulation compared with sham skin incision control animals on postsurgery days 1-3. Systemic and intrathecal morphine improved rearing and ambulation, with knee surgery/ morphine rats displaying as much activity as sham skin incision/vehicle animals, whereas knee surgery/vehicle rats showed decreased activity. Systemic ketorolac 20 mg/kg improved rearing and ambulation, with knee surgery/ketorolac rats showing increased activity compared with knee surgery/vehicle animals. Intrathecal ketorolac 4-40 microg did not increase rearing or ambulation, but the 80 microg dose was effective. Other drugs tested, systemically or intrathecally, did not restore activity to normal levels.

CONCLUSION

This study presents a new simple, reproducible rat model to assess function and discomfort after knee surgery, and one that responds to therapeutic interventions. In this knee surgery model, both systemic and intrathecal administration of either morphine or ketorolac caused reversal of the deficits in rearing and ambulatory behavior at 24 h postsurgery.

Adenosine as a Non-Opioid Analgesic in the Perioperative Setting

Adenosine, a ubiquitous metabolic intermediate in the body, is involved in nearly every aspect of cell function, including neuromodulation and neurotransmission. Adenosine A(1) and A(2) receptors are widely distributed in the brain and spinal cord, and are a novel, non-opiate target for pain management. The potential of adenosine as a non-narcotic analgesic in anesthetized patients has been explored in clinical trials, including double-blind studies versus placebo and remifentanil infusion. These studies suggest that, compared to placebo or remifentanil, an intraoperative adenosine infusion stabilizes core hemodynamics and reduces the requirement for anesthesia during surgery. Further, adenosine improves postoperative recovery, as indicated by lower pain scores and less opioid consumption. The safety profile of adenosine has been well characterized based on use of currently approved adenosine products. The most common adverse events associated with its use include flushing, chest discomfort, dyspnea, headache, gastrointestinal discomfort, and lightheadedness. These effects are generally well tolerated and transient. Further studies are warranted to investigate the full potential of adenosine as a non-opioid analgesic in the perioperative setting.

The elderly patient and postoperative pain treatment

The management of postoperative pain in elderly patients can be a difficult task. Older patients have co-existing diseases and concurrent medications, diminished functional status and physiological reserve and age-related pharmacodynamic and pharmacokinetic changes. Pain assessment presents numerous problems arising from differences in reporting cognitive impairment and difficulties in measurement. The elderly are also at higher risk of adverse consequences from surgery and unrelieved or undertreated pain. Selection of analgesic therapy needs to balance the potential efficacy with the incidence of interactions, complications or side effects in the post-operative period. Drug titration in the post-anaesthesia care unit should be encouraged together with analgesia on request in the wards. Multimodal analgesia, using acetaminophen, non-steroidal anti-inflammatory drugs or other non opioid drugs, is the best way to decrease opioid consumption and thus opioid-related adverse events. Sophisticated analgesic methods like PCA, regional analgesia and PCEA are not contraindicated in the elderly but pain relief and side effects should be monitored.