Emetic effects of morphine and piritramide

Pain levels and patient comfort after lower limb arthroplasty comparing i.v. patient-controlled analgesia, continuous peripheral nerve block and neuraxial analgesia: a retrospective cohort analysis of clinical routine data

BACKGROUND

Insufficient pain control after lower limb arthroplasty results in delayed recovery and increased risk for pain chronicization. The ideal kind of analgesia is still discussed controversially. We conducted a retrospective analysis of single-center routine data from a German university hospital, including patients receiving either total hip (THA) or knee arthroplasty (TKA).

METHODS

All patients received general anesthesia. Patients undergoing THA received either continuous epidural ropivacaine infusion (0.133%, Epi) or patient-controlled analgesia (PCA) with the Wurzburg Pain Drip (tramadol, metamizole and droperidol, WPD) or with piritramide (Pir). After TKA, patients received either continuous femoral nerve block (ropivacaine 0.2%, PNB) or Pir.

RESULTS

The analyzed cohort comprised 769 cases. Use of WPD after THA (n = 333) resulted in significantly reduced Numeric Rating Scale (NRS) values at rest, compared to Epi (n = 48) and Pir (n = 72) (.75 [IQR 1.14] vs. 1.17 [1.5], p = .02 vs. 1.47 [1.33], p < .0001) as well as maximum NRS scores (2.4 [1.7] vs. 3.29 [1.94], p < .001 vs. 3.32 [1.76], p < .0001). Positive feedback during follow-up visits was significantly increased in patients with a WPD PCA (p < .0001), while negative feedback (senso-motoric weakness/technical problems/nausea/dizziness/constipation) was particularly increased in Epi patients and lowest in those with WPD (p < .0001). After TKA, Pir (n = 131) resulted in significantly reduced NRS values at rest, compared to PNB (n = 185) (1.4 [1.4] vs. 1.6 [1.68], p = .02). Positive feedback was increased in patients with a Pir PCA in comparison with PNB (p = .04), while negative feedback was increased in PNB patients (p = .04). Overall, WPD presented with the lowest rate of any complications (8.7%), followed by Pir (20.2%), PNB (27.6%) and Epi (31.3%) (p < .001).

CONCLUSIONS

In the assessed population, the use of a WPD PCA after THA offered better pain control and patient comfort in comparison with continuous epidural or piritramide-based analgesia. After TKA, the use of a Pir PCA provided superior analgesia and a lower complication rate compared to continuous PNB.

Therapeutic Suggestions During General Anesthesia Reduce Postoperative Nausea and Vomiting in High-Risk Patients – A Post hoc Analysis of a Randomized Controlled Trial

Postoperative nausea and vomiting (PONV) are one of the most adverse events after general anesthesia, a distressing experience, and pose a risk to the patient. Despite advances in drug prophylaxis and PONV treatment, the incidence remains high and additional non-pharmacological treatments are needed. In this post hoc analysis of a recently published double-blind multicenter randomized controlled trial on the efficacy of intraoperative therapeutic suggestions on postoperative opioid dosage, we analyzed the effects of intraoperative therapeutic suggestions on PONV. We focus on patients with a high risk of PONV (Apfel risk score of 3–4) and distinguished early (first two postoperative hours) and delayed PONV (2–24 h). A total of 385 patients with a moderate or high risk for PONV were included. The incidence of early and delayed PONV was reduced (22.7–18.3 and 29.9–24.1%, respectively), without statistical significance, whereas in high-risk patients (n = 180) their incidence was nearly halved, 17.2 vs. 31.2% (p = 0.030) and 20.7 vs. 34.4% (p = 0.040), corresponding to a number needed to treat of 7 to avoid PONV. In addition, there was a significant reduction in PONV severity. In a multivariate logistic regression model, assignment to the control group (OR 2.2; 95% CI: 1.1–4.8) was identified as an independent predictor of the occurrence of early PONV. Our results indicate that intraoperative therapeutic suggestions can significantly reduce the incidence of PONV in high-risk patients. This encourages the expansion of therapeutic suggestions under general anesthesia, which are inexpensive and virtually free of side effects.

Clinical Trial Registration: German Clinical Trials Register, https://drks.de, registration number: DRKS00013800.

Aspiration in lethal drug abuse-a consequence of opioid intoxication

AIMS

The primary objective of this study was to investigate whether the fatalities of opioid abuse are not only related to respiratory depression but also as a result of other side effects such as emesis, delayed gastric emptying, a reduction of the cough reflex, and impaired consciousness leading to the aspiration of gastric contents, a finding regularly observed in drug-related deaths.

DESIGN

A retrospective exploratory study analyzing heroin/morphine/methadone-related deaths submitted to court-ordered autopsy.

SETTING

Center for Forensic Medicine, Medical University of Vienna, Austria (2010-2015).

PARTICIPANTS

Two hundred thirty-four autopsy cases were included in the study: morphine (n = 200), heroin (n = 11), and methadone (n = 23) intoxication.

FINDINGS

Analyses revealed that 41.88% of all deceased showed aspiration of gastric contents with equal gender distribution (p = 0.59). Aspiration was more frequent in younger deceased (χ² = 8.7936; p = 0.012) and in deceased with higher body mass index (BMI) (χ² = 6.2441; p = 0.044). Blood opioid concentration was lower in deceased with signs of aspiration than in non-aspirators (p = 0.013). Toxicological evaluation revealed a high degree of concomitant substance abuse (91%)-benzodiazepines (61.6%) and/or alcohol (21.8%).

CONCLUSIONS

There are lower opioid concentrations in deceased with signs of aspiration, a fact which strongly points to aspiration as alternative cause of death in opioid-related fatalities. Furthermore, this study highlights the common abuse of slow-release oral morphine in Vienna and discusses alternative medications in substitution programs (buprenorphine/naloxone or tamper-resistant slow-release oral morphine preparations), as they might reduce intravenous abuse and opioid-related deaths.

Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative)

The main remit of the European Society for Paediatric Anaesthesiology (ESPA) Pain Committee is to improve the quality of pain management in children. The ESPA Pain Management Ladder is a clinical practice advisory based upon expert consensus to help to ensure a basic standard of perioperative pain management for all children. Further steps are suggested to improve pain management once a basic standard has been achieved. The guidance is grouped by the type of surgical procedure and layered to suggest basic, intermediate, and advanced pain management methods. The committee members are aware that there are marked differences in financial and personal resources in different institutions and countries and also considerable variations in the availability of analgesic drugs across Europe. We recommend that the guidance should be used as a framework to guide best practice.

Economic and clinical burden of opioid-induced nausea and vomiting

Opioids are the standard of care for treating moderate-to-severe pain; however, their efficacy can be limited by adverse events (AEs), including nausea and vomiting. Opioid-induced nausea and vomiting (OINV) is an inherent adverse effect of opioid treatment, exerting effects centrally and peripherally. Opioid-related AEs can impact treatment adherence and discontinuation, which can result in inadequate pain management. OINV may persist long-term, negatively affecting patient functional outcomes, physical and mental health, patient satisfaction, and overall costs of treatment. Multiple factors may contribute to OINV, including activation of opioid receptors in the chemoreceptor trigger zone, vestibular apparatus, and gastrointestinal tract. Prophylactic or early treatment with antiemetics may be appropriate for patients who are at high risk for OINV.

Consensus guidelines for the management of postoperative nausea and vomiting

The present guidelines are the most recent data on postoperative nausea and vomiting (PONV) and an update on the 2 previous sets of guidelines published in 2003 and 2007. These guidelines were compiled by a multidisciplinary international panel of individuals with interest and expertise in PONV under the auspices of the Society for Ambulatory Anesthesia. The panel members critically and systematically evaluated the current medical literature on PONV to provide an evidence-based reference tool for the management of adults and children who are undergoing surgery and are at increased risk for PONV. These guidelines identify patients at risk for PONV in adults and children; recommend approaches for reducing baseline risks for PONV; identify the most effective antiemetic single therapy and combination therapy regimens for PONV prophylaxis, including nonpharmacologic approaches; recommend strategies for treatment of PONV when it occurs; provide an algorithm for the management of individuals at increased risk for PONV as well as steps to ensure PONV prevention and treatment are implemented in the clinical setting.

Opioid induced nausea and vomiting

Opioids are broad spectrum analgesics that are an integral part of the therapeutic armamentarium to combat pain in the palliative care population. Unfortunately, among the adverse effects of opioids that may be experienced along with analgesia is nausea, vomiting, and/or retching. Although it is conceivable that in the future, using combination agents (opioids combined with agents which may nullify emetic effects), currently nausea/vomiting remains a significant issue for certain patients. However, there exists potential current strategies that may be useful in efforts to diminish the frequency and/or intensity of opioid-induced nausea/vomiting (OINV).

[Postoperative pain management after minimally invasive hysterectomy: thoracic epidural analgesia versus intravenous patient-controlled analgesia]

BACKGROUND

In view of the development of innovative and non-traumatic surgical techniques, postoperative pain management should be carried out depending on the invasiveness of the intervention. In the present study two analgesic strategies were compared in patients undergoing minimally invasive hysterectomy: epidural analgesia (EDA) and intravenous patient-controlled analgesia (iv-PCA).

MATERIAL AND METHODS

For this prospective case controlled study 60 women with benign uterine diseases undergoing vaginal hysterectomy (VH) or laparoscopically assisted vaginal hysterectomy (LAVH) were enrolled. Patients were divided for analysis into two groups (n=30 each) according to the postoperative analgesic strategy (EDA group versus iv-PCA group). A matched-pair analysis was applied (matching criteria: risk assessment, surgeon and age of patient) to minimize the differences between both groups. Patients were evaluated with respect to the extent of pain determined by a numeric rating scale (NRS 0-10 scale), analgesic consumption, rate of postoperative nausea and vomiting (PONV), mobilization from bed, oral intake of nutrition, complications, duration of stay in the recovery room as well as hospital stay and health-related quality of life (SF-36 Health Survey; collected before and 6 weeks after surgery).

RESULTS

Laparoscopically assisted removal of the uterus was carried out in 22 women and by vaginal hysterectomy in 38 women. No significant differences between the study groups were seen in the duration of surgery (iv-PCA 58 ± 25 min versus EDA 60 ± 26 min). Demographic data of both groups as well as intraoperative hemodynamic and respiratory parameters were comparable to a great extent. Compared to the iv-PCA group, women in the EDA group showed lower NRS values (p<0.01): recovery room admission 4.7 ± 2.5 iv-PCA vs. 0.9 ± 1.3 EDA, recovery room discharge 3.8 ± 1.8 iv-PCA vs. 1.0 ± 1.2 EDA, day of surgery at 8 p.m. 5.0 ± 2.1 iv-PCA vs. 1.8 ± 2.3 EDA and first postoperative day at 8 a.m. 3.5 ± 1.7 iv-PCA vs. 1.9 ± 2.2 EDA. In addition, less PONV (iv-PCA 9/30 vs. EDA 1/30, p<0.01), less shivering (iv-PCA 8/30 vs. EDA 2/30, p<0.05), reduced fatigue (iv-PCA 26/30 vs. EDA 9/30, p<0.05) and a lower consumption of analgesics were found. Average postoperative requirement for piritramide in the iv-PCA group was 7 mg (range 0-24 mg) on the day of surgery and 5 mg (0-39 mg) on the first postoperative day. In the EDA group no opiate medication was given postoperatively (p<0.01). Duration of stay in the recovery room was shorter in the EDA group (71 ± 32 min vs. 50 ± 13 min, p<0.05). Hospital stay was 5 days on average in both groups. There were no surgical complications or epidural catheter-related complications. Because of urinary retention catheterization of the bladder had to be made in 3 patients of the iv-PCA group and 13 patients of the EDA group (p<0.05). Furthermore, the possibility to take a shower postoperatively was restricted in the EDA group because the epidural catheter was in place and thereby hygiene concerns. Regarding the early oral nutritional intake as well as postoperative mobilization, no significant differences between groups were found. In comparison with the preoperative status, the results regarding health-related quality of life were significantly better for both groups after a follow-up of 6 weeks (p<0.01); however, this effect was especially pronounced in the EDA group (p<0.05).

CONCLUSIONS

To reduce the number of patients suffering from postoperative pain a procedure-specific pain management should be developed. The results of this study have shown that even in minimally invasive surgery, such as vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy there are some advantages for epidural analgesia compared to intravenous patient-controlled analgesia. In particular reduced pain intensity, lower need for analgesics and reduced occurrence of PONV can lead to excellent patient comfort, fast recovery as well as positive effects on health-related quality of life. However, there are also some disadvantages such as an increased rate of urinary retention and restriction of mobility.

Randomized, Double-Blind, Placebo-Controlled Study to Assess the Efficacy of Nonopioid Analgesics on Pain following Arthroscopic Knee Surgery

Purpose. In a randomized, double-blind trial, the efficacy of nonopioid analgesics on postoperative piritramide consumption was compared for pain relief during the first 24 h in patients recovering from arthroscopic knee surgery. Methods. 120 patients were treated with normal saline and/or one of the nonopioid analgesics (parecoxib, metamizole, paracetamol) in addition to piritramide using the PCA pump. Beginning in the postanesthesia care unit (PACU), patients were asked to quantify their pain experience at rest while piritramide consumption was recorded. Results. Piritramide consumption upon arrival in the PACU was high in all groups. However, cumulative consumption in the parecoxib group was significantly lower than that in the placebo group at 6 and 12 h after surgery. At discharge from the PACU, VAS scores dropped in all groups and were significantly lower in the parecoxib group. In the PACU, satisfaction of the patients was moderate and improved with time after surgery. Conclusions. There was statistically significant opioid-saving effect by administering parecoxib with better VAS scores and satisfaction level compared to placebo. The high pain score in the PACU in all groups immediately after recovering from remifentanil-based anesthesia would be prevented if local anesthetics were administered intra-articularly as part of a multimodal analgesic approach.

Efficacy of adding clonidine to intrathecal morphine in acute postoperative pain: meta-analysis

BACKGROUND

Clonidine may be used along with intrathecal morphine for single-dose postoperative analgesia in adults. The efficacy of this is not clear.

METHODS

A meta-analysis was performed for two endpoints of efficacy: the time to first postoperative analgesia request and the amount of systemic morphine used during the first 24 h after operation. A Bayesian inference supporting direct statements about the probability of the magnitude of an effect was also used. The frequency of the five adverse events (postoperative nausea or vomiting, sedation, respiratory depression, pruritus, and hypotension) was analysed.

RESULTS

Clonidine increased the duration of analgesia by 1.63 h [95% confidence interval (CI): 0.93-2.33]. There is a 90% probability that clonidine increases the duration of postoperative analgesia by more than 75 min compared with morphine alone. Clonidine reduced the amount of postoperative morphine by a mean of 4.45 mg (95% CI: 1.40-7.49 mg). There is a probability of 90% to obtain a decrease >2.3 mg but only 35% to obtain a decrease >5 mg. The incidence of hypotension was the only adverse event increased by clonidine (odds ratio 1.78; 95% CI: 1.02-3.12).

CONCLUSIONS

The addition of clonidine to intrathecal morphine extends the time to first analgesia and decreases the amount of morphine used. However, as the effects are small, and the results heavily influenced by a study in which intrathecal fentanyl was also given, this must be balanced with the increased frequency of hypotension.

Current concepts in the management of postoperative nausea and vomiting

Postoperative nausea and vomiting (PONV) are still common following surgery. This is not only distressing to the patient, but increases costs. The thorough understanding of the mechanism of nausea and vomiting and a careful assessment of risk factors provide a rationale for appropriate management of PONV. Strategy to reduce baseline risk and the adoption of a multimodal approach will most likely ensure success in the management of PONV.

Nausea and vomiting after surgery under general anesthesia: an evidence-based review concerning risk assessment, prevention, and treatment

BACKGROUND

The German-language recommendations for the management of postoperative nausea and vomiting (PONV) have been revised by an expert committee. Major aspects of this revision are presented here in the form of an evidence-based review article.

METHODS

The literature was systematically reviewed with the goal of revising the existing recommendations. New evidence-based recommendations for the management of PONV were developed, approved by consensus, and graded according to the scheme of the Scottish Intercollegiate Guidelines Network (SIGN).

RESULTS

The relevant risk factors for PONV include female sex, nonsmoker status, prior history of PONV, motion sickness, use of opioids during and after surgery, use of inhalational anesthetics and nitrous oxide, and the duration of anesthesia. PONV scoring systems provide a rough assessment of risk that can serve as the basis for a risk-adapted approach. Risk-adapted prophylaxis, however, has not been shown to provide any greater benefit than fixed (combination) prophylaxis, and PONV risk scores have inherent limitations; thus, fixed prophylaxis may be advantageous. Whichever of these two approaches to manage PONV is chosen, high-risk patients must be given multimodal prophylaxis, involving both the avoidance of known risk factors and the application of multiple validated and effective antiemetic interventions. PONV should be treated as soon as it arises, to minimize patient discomfort, the risk of medical complications, and the costs involved.

CONCLUSION

PONV lowers patient satisfaction but is treatable. The effective, evidence-based measures of preventing and treating it should be implemented in routine practice.

Critical illness, gastrointestinal complications, and medication therapy during enteral feeding in critically ill adult patients

Critically ill patients who are subjected to high stress or with severe injury can rapidly break down their body protein and energy stores. Unless adequate nutrition is provided, malnutrition and protein wasting may occur, which can negatively affect patient outcome. Enteral nutrition (EN) is the mainstay of nutrition support therapy in patients with a functional gastrointestinal (GI) tract who cannot take adequate oral nutrition. EN in critically ill patients provides the benefits of maintaining gut functionality, integrity, and immunity as well as decreasing infectious complications. However, the ability to provide timely and adequate EN to critically ill patients is often hindered by GI motility disorders and complications associated with EN. This paper reviews the GI complications and intolerances associated with EN in critically ill patients and provides recommendations for their prevention and treatment. It also addresses the role of commonly used medications in the intensive care unit and their impact on GI motility and EN delivery.

The potential for mu-opioid receptor agonists to be anti-emetic in humans: a review of clinical data

In animal models of vomiting, mu-opioid (MOP, OP(3)) receptors mediate both emesis and anti-emesis. mu-receptors within the blood-brain barrier, mediating anti-emesis, are more rapidly accessible to lipid-soluble mu-opioid receptor agonists such as fentanyl than to morphine, and fentanyl has broad-spectrum anti-emetic effects in a number of species. Whether a similar situation exists in humans is not known. A search was performed for clinical studies comparing the emetic side effects of opioids administered peri-operatively in an attempt to identify differences between morphine and more lipid-soluble mu-receptor-selective agonists such as fentanyl. Overall, the evidence appears to suggest that fentanyl and other phenylpiperidines are associated with less nausea and vomiting than morphine, but not all studies support this, and fentanyl-like drugs are associated with nausea and vomiting per se. Good evidence, however, exists to show that fentanyl and alfentanil do not cause more nausea and vomiting than the ultra fast-acting remifentanil. Because remifentanil is cleared rapidly post-operatively, such trials suggest that the emetic side effects of fentanyl and alfentanil are minimal. The clinical evidence, although limited, is at least consistent with the possibility that central mu-opioid receptors may mediate anti-emesis in humans. It is possible that the role of mu-opioid agonists in anti-emesis may become clearer in the future as a result of the use of peripheral mu-opioid receptor antagonists.

Effectiveness and safety of postoperative pain management: a survey of 18 925 consecutive patients between 1998 and 2006 (2nd revision): a database analysis of prospectively raised data

BACKGROUND

Approximately 30-80% of postoperative patients complain about moderate to severe post-surgical pain, indicating that postoperative pain treatment is still a problem.

METHODS

We analysed prospectively collected data on patients in a university hospital receiving systemic and epidural patient-controlled analgesia and continuous peripheral nerve block (CPNB) documented by the acute pain service team in a computer-based system.

RESULTS

Of 18 925 patients visited in the postoperative period between 1998 and 2006, 14 223 patients received patient-controlled epidural analgesia (PCEA), 1591 i.v. patient-controlled analgesia (IV-PCA), 1737 continuous brachial plexus block, and 1374 continuous femoral/sciatic nerve block. Mean dynamic and resting pain scores (VAS 0-100) were significantly lower for peripheral or neuroaxial regional analgesia compared with patient-controlled systemic opioid analgesia (P<0.05). The risk of a symptomatic spinal mass lesion including epidural haematoma (0.02%; 1:4741) or epidural abscess (0.014%; 1:7142) after PCEA was 1:2857 (0.04%). Neurological complications after CPNB occurred in two patients who received interscalene brachial plexus block.

CONCLUSIONS

We demonstrated that PCEA, IV-PCA, and CPNB are safe and efficient. Although all of these treatment strategies provide effective analgesia, PCEA and CPNB provided superior pain relief compared with IV-PCA. We demonstrated that serious complications of analgesic techniques are rare but possibly disastrous necessitating a close supervision by an acute pain service. We found a low rate of adverse effects including hypotension and motor impairment and a low incidence of epidural haematoma for thoracic PCEA compared with lumbar PCEA.

Prospective evaluation of the pharmacodynamics of piritramide in neonates and infants

Piritramide is a synthetic opioid commonly used in Germany and Austria for the analgesia of pediatric patients. Little pharmacokinetic and pharmacodynamic data for the pediatric population is available. The aim of this investigation was to gain pharmacodynamic data on postsurgical analgesia and the side effects of piritramide. The study was approved by the Ethics Committee of the Medical Faculty. Data were collected in an open, prospective clinical trial. After obtaining the parents' informed written consent, patients received a bolus of piritramide 50 mug/kg for postsurgical analgesia or to prevent pain resulting from invasive procedures. Titration doses of 15 microg/kg were allowed. Vital signs and pain intensity were closely monitored. Data from 39 patients could be included in the analysis. Of the patients, 95% were in the immediate postsurgical course, 5% had piritramide for invasive procedures, and 46% of the patients were ventilated. The mean piritramide dosage was 64 +/- 24 microg/kg. Pharmacodynamic analysis showed adequate analgesia for at least 50% of the spontaneously breathing patients for 120 min after piritramide bolus. More than 50% of the ventilated patients showed inadequate analgesia at any point in time after piritramide bolus. Fifty-nine percent (59%) of the ventilated patients received additive analgesia versus 31% of spontaneously breathing patients. No relevant changes of vital signs could be observed. One patient received naloxone for apnea. We conclude that dosages of more than 50-70 microg/kg are needed for sufficient analgesia in ventilated postsurgical infants. In spontaneously breathing patients, 50-70 microg/kg provides a 120-min period of analgesia for more than 50% of patients. Cardiovascular stability of the patients was good and, with one exception, there was no respiratory depression.

[Systemic analgesia adapted to the children's condition]

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.

Sedation and analgesia in German intensive care units: how is it done in reality? Results of a patient-based survey of analgesia and sedation

OBJECTIVE

This study carried out the first patient-oriented survey on the practice of analgesia and sedation in German intensive care units, examining whether the goals of early spontaneous breathing and awake, cooperative patients are achieved.

DESIGN

A postal survey was sent to 261 hospitals in Germany. Each hospital received three patient-oriented forms with questions regarding current agents and techniques for analgesia and sedation of a specific patient. Responses were obtained from 220 (84%) hospitals which returned 305 questionnaires.

RESULTS

Patients' Ramsay sedation scale was significantly higher in all phases of analgesia and sedation, indicating that the patients were more deeply sedated than currently intended by the therapist. Propofol was used for most of the patients during short-term sedation (57%) and during weaning (48%). The preferred agent for sedation longer than 72[Symbol: see text]h was midazolam (66%).

CONCLUSION

The choice of agents and techniques for analgesia and sedation in the intensive care unit thus follows the German guidelines. The fact that the patients were more deeply sedated than intended by the therapist in all phases of sedation may be due to the low use of sedation scales and clinical practice guidelines or to the lack of training in using these techniques.

Does perioperative administration of rofecoxib improve analgesia after spine, breast and orthopaedic surgery?

BACKGROUND AND OBJECTIVE

Data on the effectiveness of cyclooxygenase 2 inhibitors in postoperative pain therapy vary widely. We tested in a prospective, placebo-controlled, randomized, double-blind trial the hypotheses that perioperative (i.e. preoperative and postoperative) administration of the cyclooxygenase 2 inhibitor rofecoxib decreases pain scores and morphine consumption after spine, breast and orthopaedic surgery.

METHODS

Five hundred and forty patients scheduled for spine, breast or orthopaedic surgery were randomly assigned to receive in combination with postoperative morphine via patient controlled analgesia pump for 4 days either rofecoxib 50 mg administered perioperatively, rofecoxib 50 mg administered only postoperatively, or placebo. Primary outcome criteria were pain score at rest (numeric rating scale 0-4) and morphine consumption.

RESULTS

Perioperative rofecoxib significantly decreased pain score 0 (0-1) vs. 1 (0-2) (median (interquartile range)), and morphine consumption 18 (6-33) vs. 22.5 (12-38) compared with placebo. In contrast, rofecoxib when administered only postoperatively did not significantly improve analgesic effects or side-effects at time of assessment of the main criteria (24 h after skin closure), but during the follow-up period at 48 h and 72 h after skin closure pain scores and morphine consumption were improved compared to placebo. The analgesic effects of rofecoxib were independent from the type of surgery.

CONCLUSIONS

Perioperative administration of the cyclooxygenase 2 inhibitor rofecoxib decreases pain scores and morphine consumption after orthopaedic, breast and spine surgery. However, the benefit of preoperative administration of the cyclooxygenase 2 inhibitor seems to be only moderate, suggesting that early postoperative administration may be a useful alternative approach. There is no evidence that the type of surgery influences analgesic effects of cyclooxygenase 2 inhibitors.

PONV: a problem of inhalational anaesthesia?

Even nowadays every third or fourth patient suffers from postoperative nausea and vomiting (PONV) after general anaesthesia with volatile anaesthetics. There is now strong evidence that volatile anaesthetics are emetogenic and that there are no meaningful differences between halothane, enflurane, isoflurane, sevoflurane, and desflurane in this respect. However, when propofol is substituted for volatile anaesthetics the risk for PONV is reduced by only about one fifth, indicating that there are other even more important causes for PONV following general anaesthesia. A main causative factor might be the use of perioperative opioids, but their impact--relative to other factors including volatile anaesthetics--has never been quantified. Patient-specific risk factors have also been shown to be clinically relevant; they are therefore included in the calculation of simplified risk scores that allow prediction of a patient's risk independent of the type of surgery. Although controversial, the well-known different incidences following certain types of surgery are most likely caused by patient-specific and anaesthesia-related risk factors. There is a common consensus that prophylaxis with anti-emetic strategies is rarely justified when the risk of PONV is low, while it is warranted in case of imminent medical risk associated with vomiting or in a patient with a high risk for PONV. A recently published large multicentre trial of factorial design, IMPACT, has demonstrated that various anti-emetic strategies are associated with a very similar and constant relative reduction rate of about 25-30% and that the main predictor for the efficacy of prophylaxis is the patient's risk for PONV. Interestingly, all anti-emetics (dexamethasone, droperidol and ondansetron) work independently, so that their combined benefit can be derived directly from the single effects. The effectiveness of the anti-emetics was also independent of a variety of risk factors, including volatile anaesthetics. This means that any anti-emetic prophylaxis for PONV induced by volatile anaesthetics is equally effective. Of course, the most logical approach for prevention would be the omission of volatile anaesthetics and nitrous oxide using a total intravenous anaesthesia with propofol. However, since volatile anaesthetics are probably not the most important risk factors, it might be even better--if appropriate--to avoid general anaesthesia by using a regional, opioid-free anaesthesia if PONV is a serious problem.

A procedure-specific systematic review and consensus recommendations for postoperative analgesia following laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy has advantages over the open procedure for postoperative pain. However, a systematic review of postoperative pain management in this procedure has not been conducted.

METHODS

A systematic review was conducted according to the guidelines of the Cochrane Collaboration. Randomized studies examining the effect of medical or surgical interventions on linear pain scores in patients undergoing laparoscopic cholecystectomy were included. Qualitative and quantitative analyses were performed. Recommendations for patient care were derived from review of these data, evidence from other relevant procedures, and clinical practice observations collated by the Delphi method among the authors.

RESULTS

Sixty-nine randomized trials were included and 77 reports were excluded. Recommendations are provided for preoperative analgesia, anesthetic and operative techniques, and intraoperative and postoperative analgesia.

CONCLUSIONS

A step-up approach to the management of postoperative pain following laparoscopic cholecystectomy is recommended. This approach has been designed to provide adequate analgesia while minimizing exposure to adverse events.

Morphine responses and experimental pain: sex differences in side effects and cardiovascular responses but not analgesia

Sex differences in analgesic responses to mu opioid agonists have been reported, although the direction of these differences varies across studies. To further characterize sex differences in responses to mu opioids, the analgesic effects of intravenous morphine (0.08 mg/kg) were determined in healthy women (n = 61) and men (n = 39) by using 3 experimental pain models, heat pain, pressure pain, and ischemic pain. Each pain procedure was conducted before and after double-blind administration of both morphine and saline, which occurred on separate days in counterbalanced order. Although morphine produced significant analgesic effects for all pain stimuli, no significant sex differences in morphine analgesia emerged. However, morphine attenuated cardiovascular reactivity to the ischemic pain task in men but not women, and women reported significantly more drug-related adverse effects than men. These findings are in contrast with some recent clinical and experimental results suggesting more robust analgesic response to mu opioids among women compared to men, although the data indicate that sex differences in non-analgesic effects of morphine were present. These results suggest that sex differences in responses to morphine might depend on the pain model and/or drug dose as well as the specific end point assessed.

PERSPECTIVE

This study examines morphine responses in women and men by using laboratory pain measures. The results indicate no sex differences in analgesia, but women reported greater side effects, and morphine attenuated cardiovascular responses more strongly among men than women. These results add to the literature regarding sex differences in response to opioids.

Day-case sling surgery for stress urinary incontinence: feasibility and safety

OBJECTIVE

To prospectively assess the feasibility for discharge 10 h after a porcine dermal pubovaginal sling procedure (PVS), to examine the surgical factors (postoperative complications) affecting discharge, and to measure the short-term cure rate for stress urinary incontinence (SUI).

PATIENTS AND METHODS

Between June 2003 and December 2003, 40 consecutive patients with SUI and scheduled for treatment using a porcine dermal sling were enrolled in this prospective study. Patients were admitted with a planned overnight stay and returned to the ward with no urinary catheter. Outcome measures were bladder emptying efficiency (EE) at 10 h after surgery, time intervals to the first three spontaneous voids, EE of the first three voids, time required to achieve an EE of > or = 75%, a visual analogue scale pain score, perioperative complications, and short-term cure rate of SUI. Patients were considered suitable for discharge from hospital when the EE was > or = 75% or when they were self-catheterizing confidently with adequate pain control and no significant complication. All patients were followed for 6 months.

RESULTS

The median EE at 10 h was 61%; 16 patients (40%) achieved efficient emptying and were suitable for discharge 10 h after surgery. The median intervals to the first three spontaneous voids were 7, 10 and 17 h, and the median EEs for the first three voids 46%, 61% and 75%. The median visual analogue scale pain score was 3.5. Patients with intrinsic sphincter deficiency (ISD) were significantly less likely to achieve efficient emptying at 10 h (39% vs 70%). Overall SUI was cured or improved in 90% of patients at the 6-month follow-up.

CONCLUSIONS

In the present study only 40% of patients were suitable for day-case sling surgery. Early bladder emptying inefficiency was the main limiting factor. Exclusion of patients with ISD and possibly decreasing the EE threshold to 50% would improve the discharge rate. The short-term results of this PVS are similar to those obtained with the autologous fascial sling.

Practice of sedation and analgesia in German intensive care units: results of a national survey

Introduction

Sedation and analgesia are provided by using different agents and techniques in different countries. The goal is to achieve early spontaneous breathing and to obtain an awake and cooperative pain-free patient. It was the aim of this study to conduct a survey of the agents and techniques used for analgesia and sedation in intensive care units in Germany.

Methods

A survey was sent by mail to 261 hospitals in Germany. The anesthesiologists running the intensive care unit were asked to fill in the structured questionnaire about their use of sedation and analgesia.

Results

A total of 220 (84%) questionnaires were completed and returned. The RAMSAY sedation scale was used in 8% of the hospitals. A written policy was available in 21% of hospitals. For short-term sedation in most hospitals, propofol was used in combination with sufentanil or fentanyl. For long-term sedation, midazolam/fentanyl was preferred. Clonidine was a common part of up to two-thirds of the regimens. Epidural analgesia was used in up to 68%. Neuromuscular blocking agents were no longer used.

Conclusion

In contrast to the US 'Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult', our survey showed that in Germany different agents, and frequently neuroaxial techniques, were used.

Endogenous opiates and behavior: 2003

This paper is the 26th consecutive installment of the annual review of research concerning the endogenous opioid system, now spanning over a quarter-century of research. It summarizes papers published during 2003 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (Section 2), and the roles of these opioid peptides and receptors in pain and analgesia (Section 3); stress and social status (Section 4); tolerance and dependence (Section 5); learning and memory (Section 6); eating and drinking (Section 7); alcohol and drugs of abuse (Section 8); sexual activity and hormones, pregnancy, development and endocrinology (Section 9); mental illness and mood (Section 10); seizures and neurologic disorders (Section 11); electrical-related activity and neurophysiology (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration and thermoregulation (Section 16); and immunological responses (Section 17).

[Postoperative nausea and vomiting]

Numerous pathophysiological mechanisms are known to cause nausea or vomiting but their role for postoperative nausea and vomiting (PONV) is not quite clear. Volatile anesthetics, nitrous oxide and opioids appear to be the most important causes for PONV. Female gender, non-smoking and a history of motion sickness and PONV are the most important patient specific risk factors. With these risk factors an objective risks assessment is achievable as a good rational basis for a risk dependent antiemetic approach: When the risk is low, moderate, or high, the use of none, a single or a combination of prophylactic antiemetic interventions seems to be justified. Performing a total intravenous anesthesia (Ti.v.A) with propofol is a reasonable prophylactic approach, but does not solve the problem satisfactorily alone if the risk is very high, reducing the risk of PONV only by 30%. This is comparable to the reduction rate of antiemetics, such as serotonin antagonist, dexamethasone and droperidol. It must be stressed that metoclopramide is ineffective. Data from IMPACT indicate that prophylaxis is not very effective if the patients risk is low. At a moderate risk the use of Ti.v.A or an antiemetic is reasonable and only a (very) high risk justifies the combination of several prophylactic antiemetic interventions. For the treatment of PONV an antiemetic should be chosen which has not been used prophylactically. The necessary doses are usually a quarter of those needed for prophylaxis.

Applicability of risk scores for postoperative nausea and vomiting in adults to paediatric patients

BACKGROUND

Scores to predict the occurrence of postoperative vomiting (PV) or nausea and vomiting (PONV) are well established in adult patients. The aim of this survey was to evaluate the applicability of risk scores developed and tested in adult patients in 983 paediatric patients (0-12 yr) undergoing various surgical procedures.

METHOD

The predictive properties of five models were compared with respect to discriminating power (measured by the area under a receiver operating characteristic curve) and calibration (comparison of the predicted and the actual incidences of the disease by weighed linear regression analysis).

RESULTS

The cumulative incidence of PV was 33.2% within 24 h. The discriminating power was low and insufficient in all models tested (0.56-0.65). Furthermore, the predicted incidences of the scores correlated only vaguely with the actual incidences observed.

CONCLUSION

Specialized scores for children are required. These might use the history of PV, strabismus surgery, duration of anaesthesia > or =45 min, age > or =5 yr and administration of postoperative opioids as independent risk factors.