Preoperative oral dextromethorphan does not reduce pain or analgesic consumption in children after adenotonsillectomy

Comparative Evaluation of Preemptive Analgesia of Dextromethorphan and Ibuprofen in Third Molar Surgeries

Introduction:

Postoperative pain following third molar removal is one of the most common and unpleasant complications encountered in routine surgical practice. Various methods have been advocated to minimize the postoperative pain: preemptive analgesia is one of those found to be effective.

Objective:

The aim of this study was to compare the preemptive analgesic efficacy of Dextromethorphan (DM) and Ibuprofen in the third molar surgeries.

Material and Methods:

Thirty-six patients reporting to our institution were included in the study. Patients were randomized into three groups of 12 patients each to receive either DM 30 mg, ibuprofen 100 mg, or placebo in the form of multivitamin syrup, 90 min before the procedure. The difficulty of removal of the teeth was assessed using Campbell difficulty score. The study objectives were to evaluate the time elapsed since surgery after which the patient took their first dose of aceclofenac, to evaluate the postoperative pain using visual analog scale score, and to record the number of aceclofenac tablets consumed postoperatively.

Results:

The results of the study revealed that preemptive DM was significantly better than ibuprofen and placebo in the duration of time that elapsed before the patients consumed their first analgesic postoperatively. Preemptive DM also reduced the total number of aceclofenac tablets consumed on the day of surgery and on the 1^st postoperative day, but the difference was not statistically significant. Between the two drugs, DM is better suited for providing preemptive analgesia. No side effects at a dose of 30 mg of DM were noted in any of the patients.

Conclusion:

DM premedication is a viable preemptive analgesic in reducing postoperative pain.

Endoscopic adenoidectomy: a systematic analysis of outcomes and complications in 1006 patients

Adenoid hypertrophy (AH) is an extremely common condition in the paediatric population, relating to different pathological scenarios. Failure in responding to medical therapy often leads to adenoidectomy. While traditional adenoidectomy is indeed a relatively “blind” procedure, endoscopic procedures allow more radical resections, bleeding monitoring and complete Eustachian tube sparing, making adenoidectomy a safer, more manageable and functional procedure. Though the literature widely describes endoscopic adenoidectomy, only small case series are available and the procedure itself has never really taken hold in routine otolaryngology practice. The aim of this article is to report data on endoscopic adenoidectomy in a large single centre patient population. We retrospectively evaluated the medical records of 1006 children who underwent endoscopic adenoidectomy with or without tonsillectomy (respectively 493 and 513 patients). Data on surgical time, blood loss, hospital stay, short and long-term complications, recurrences and post-operative pain were collected. Our analysis showed that the endoscopic approach requires a longer surgical time, but it is associated with less intraoperative blood loss, a lower complication rate and less treatment failures compared to large contemporary case series of either traditional or power-assisted approaches. The overall better outcomes are more noticeable when comparing our data with classic technique case series than with power-assisted case series. Endoscopic adenoidectomy should therefore be regarded as a valid technique, which, in expert hands, lowers the rates of complications and recurrences at the expense of a slightly increased surgical time.

Immediate rescue designs in pediatric analgesic trials: a systematic review and meta-analysis

BACKGROUND

Designing analgesic clinical trials in pediatrics requires a balance between scientific, ethical, and practical concerns. A previous consensus group recommended immediate rescue designs using opioid sparing as a surrogate measure of analgesic efficacy. The authors summarize the performance of rescue analgesic designs in pediatric trials of four commonly used classes of analgesics: opioids, nonsteroidal antiinflammatory drugs, acetaminophen, and local anesthetics.

METHODS

MEDLINE, Embase, CINAHL, The Cochrane Library, and Web of science were searched in April 2013. The 85 studies selected were randomized or controlled clinical trials using immediate rescue paradigms in postoperative pain settings. A random-effects meta-analysis was used to synthesize predefined outcomes using Hedges' g. Difference between the means of the treatment arms were also expressed as a percentage of the corresponding value in the placebo group (placebo-treatment/placebo). Distributions of pain scores in study and control groups and relationships between opioid sparing and pain scores were examined.

RESULTS

For each of the four study drug classes, significant opioid sparing was demonstrated in a majority of studies by one or more of the following endpoints: (1) total dose (milligram per kilogram per hour), (2) percentage of children requiring rescue medication, and (3) time to first rescue medication (minutes). Pain scores averaged 2.4/10 in study groups, 3.4/10 in control groups.

CONCLUSIONS

Opioid sparing is a feasible pragmatic endpoint for pediatric pain analgesic trials. This review serves to guide future research in pediatric analgesia trials, which could test whether some specific design features may improve assay sensitivity while minimizing the risk of unrelieved pain.

Acute pain management in children

The greatest advance in pediatric pain medicine is the recognition that untreated pain is a significant cause of morbidity and even mortality after surgical trauma. Accurate assessment of pain in different age groups and the effective treatment of postoperative pain is constantly being refined; with newer drugs being used alone or in combination with other drugs continues to be explored. Several advances in developmental neurobiology and pharmacology, knowledge of new analgesics and newer applications of old analgesics in the last two decades have helped the pediatric anesthesiologist in managing pain in children more efficiently. The latter include administering opioids via the skin and nasal mucosa and their addition into the neuraxial local anesthetics. Systemic opioids, nonsteroidal anti-inflammatory agents and regional analgesics alone or combined with additives are currently used to provide effective postoperative analgesia. These modalities are best utilized when combined as a multimodal approach to treat acute pain in the perioperative setting. The development of receptor specific drugs that can produce pain relief without the untoward side effects of respiratory depression will hasten the recovery and discharge of children after surgery. This review focuses on the overview of acute pain management in children, with an emphasis on pharmacological and regional anesthesia in achieving this goal.

Preoperative oral dextromethorphan does not reduce pain or morphine consumption after open cholecystectomy

BACKGROUND

Dextromethorphan, the D-isomer of the codeine analog levorphanol, is a weak, noncompetitive N-Methyl-D-Aspartate (NMDA) receptor antagonist. It has been suggested that NMDA receptor antagonists induce preemptive analgesia when administered before tissue injury occurs, thus decreasing the subsequent sensation of pain.

MATERIALS AND METHODS

The study was conducted in the Dr. Ali Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran, between February 2005 and December 2006. In this study, 72 patients scheduled for elective cholesyctectomy were randomized into three groups to receive either oral dextromethorphan 45 mg (Group D45 = 24), dextromethorphan 90 mg (Group D90 = 24), or placebo (Group C, n = 24), as premedication, 120 minutes before surgery. A visual analog scale (VAS) for pain of each patient was measured at arrival in the ward and six and 24 hours after surgery.

RESULTS

The demographic characteristics of patients, ASA physical status class, duration of surgery, and the basal VAS pain score were similar in the two groups. There was no significant difference in the mean of the VAS pain scores measured over time or morphine consumption among the three groups.

CONCLUSION

Dextromethorphan 45 mg and 90 mg, administrated orally, two hours before surgery, had no effect on postoperative morphine requirement and pain intensity.

Efficacy of pre- and postoperative oral dextromethorphan for reduction of intra- and 24-hour postoperative morphine consumption for transabdominal hysterectomy

OBJECTIVE

We studied the effect of dextromethorphan (DEX), an N-methyl-D-aspartate receptor antagonist, on analgesic consumption and pain scores after abdominal hysterectomy. We aimed to compare the analgesic effectiveness and incidence of adverse side effects of oral DEX with placebo (P).

DESIGN

This was a double-blinded, randomized, placebo-controlled study.

SETTING AND PATIENTS

One hundred patients were randomized to two groups. Group DEX was given 30-mg tablets of oral DEX with their premedication and three more times in the first 24 hours after surgery. Group P received the placebo following the same schedule. Postoperative analgesic requirements were assessed using a patient-controlled analgesia system. Pain was assessed at rest using a visual analogue scale in the post-anesthetic care unit (PACU), 6 and 24 hours after surgery.

RESULTS

Mean pain scores were significantly lower at the PACU (62.6 vs 75.7) as was the mean sum of all resting pain scores (144.5 vs 173.1). Mean morphine consumption was greatest in the DEX group (35.1 vs 33.0 mg; P < 0.05). The sedation scores, postoperative analgesic requirements, and incidence of side effects were similar between the P and DEX groups as were the mean pain scores.

CONCLUSIONS

During PACU, however, there were two differences between the DEX and placebo groups: 1) a lower pain score at PACU; and 2) a prolonged time to the first use of morphine at PACU in the DEX group as compared with the placebo group. A low-dose DEX had a weaker though still measurable effect in this clinical trial compared with trials using higher doses.

Pain management for pediatric ambulatory anesthesia

PURPOSE OF REVIEW

New developments in analgesic drugs and techniques are being applied to the pediatric population. Appropriate pain management for ambulatory surgery patients helps to facilitate early discharge and minimize postoperative morbidity.

RECENT FINDINGS

A variety of opioid-related drugs, as well as novel delivery routes for opioids, have been reported in the pediatric population. New pharmacokinetic information for acetaminophen has resulted in revised dosage recommendations; applications of the nonsteroidal antiinflammatory agents are also discussed. Furthermore, regional anesthesia and adjuncts are useful in the pediatric ambulatory surgery patient.

SUMMARY

Recent data on techniques for pain management after pediatric ambulatory surgery will help the anesthetist develop a comprehensive plan for the postoperative period.

The pharmacological basis of contemporary pain management

Pain management has become an increasingly well researched area in medicine over recent years, and there have been advances in a number of areas. While opioids remain an integral part of pain-management strategies, there is now an emphasis on the use of adjuvant drugs, such as paracetamol and anti-inflammatory agents, which through physiological or pharmacological synergism, both enhance pain control and reduce opioid use. The management of neuropathic pain continues to be a challenge. Anti-epileptics and antidepressants, together with clonidine and ketamine, provide the foundations for treatment. Another area of interest has been the widespread use of patient-controlled analgesia and the administration of some drugs, especially opioids, by means other than traditional oral and parenteral routes. The number of new drugs that have reached the stage of clinical trials has been small, yet they offer exciting possibilities. The epibatidine analogue ABT-594 and zinconitide both offer novel approaches to the management of neuropathic pain states, while selective cyclo-oxygenase-2 inhibitors and nitroaspirins may see advances in the management of nociceptive pain states.

The effect of dextromethorphan, alone or in combination with ibuprofen, on postoperative pain after minor gynaecological surgery

BACKGROUND

Experimental studies have demonstrated that peripheral tissue injury may lead to hyperexcitability of nociceptive neurones in the dorsal horn, in part mediated by N-methyl-D-aspartate (NMDA)-receptor mechanisms. Sensitisation of dorsal horn neurones may be an important contributor to postoperative pain. The aim of the present study was to investigate the effect of the NMDA-receptor antagonist dextromethorphan on pain after minor gynaecological surgery, and to evaluate a potential additive effect with ibuprofen.

METHODS

In a double-blind, placebo-controlled study, 100 patients scheduled for elective termination of pregnancy were randomised to receive placebo, oral ibuprofen 400 mg, oral dextromethorphan 120 mg, or a combination of ibuprofen 400 mg and dextromethorphan 120 mg, 1 h before surgery. Pain and analgesic requirements were assessed 0.5, 1 and 2 h after operation.

RESULTS

We observed no effect of dextromethorphan on visual analogue scale (VAS) pain scores or analgesic consumption, and no additive or synergistic analgesic effects between ibuprofen and dextromethorphan. Ibuprofen reduced pain scores compared with placebo, and analgesic consumption compared with both placebo and dextromethorphan. The combination of ibuprofen and dextromethorphan increased preoperative nausea compared with both placebo and ibuprofen, whereas no statistically significant side effects were observed with dextromethorphan alone.

CONCLUSION

No analgesic effects of oral dextromethorphan 120 mg on pain after surgical termination of labour, and no additive analgesic effects when combined with ibuprofen 400 mg, were observed. Ibuprofen reduced both VAS pain scores and analgesic consumption compared with placebo.