Effect of piroxicam in addition to continuous thoracic epidural bupivacaine and morphine on postoperative pain and lung function after thoracotomy

NSAID-analgesia, pain control and morbidity in cardiothoracic surgery

OBJECTIVE

While narcotics remain the backbone of perioperative analgesia, the adjunctive role of other analgesics, including non-steroidal anti-inflammatory drugs (NSAIDs), is being recognized increasingly. This meta-analysis sought to determine whether adjunctive NSAIDs improve postoperative analgesia and reduce cumulative narcotic requirements.

METHODS

A comprehensive search was undertaken to identify all randomized trials, in cardiothoracic patients, of NSAIDs plus narcotics vs narcotics without NSAIDs. Medline, Cochrane Library, EMBASE, and abstract databases were searched up to September 2005. The primary outcome was visual analogue scale (VAS) pain score. Secondary outcomes included 24-hr cumulative morphine-equivalents, rescue medications required, mortality, myocardial infarction, atrial fibrillation, stroke, renal failure, hospital readmissions, and in-hospital costs.

RESULTS

Twenty randomized trials involving 1,065 patients were included. A significant reduction in 24-hr VAS pain score was found in patients receiving NSAIDs [weighted mean difference (WMD) -0.91 points, 95% confidence interval (CI) -1.48 to -0.34 points]. In addition, patients required significantly less morphine-equivalents in the first 24 hr (WMD -7.67 mg, 95% CI -8.97 to -6.38 mg). No significant difference was found with respect to mortality [odds ratio (OR) 0.19, 95% CI 0.01 to 4.22], myocardial infarction (OR 0.71, 95% CI 0.09 to 5.71), renal dysfunction (OR 0.95, 95% CI 0.37 to 2.46), or gastrointestinal bleeding (OR 0.96, 95% CI 0.13 to 7.09).

CONCLUSION

In patients less than 70 yr of age undergoing cardiothoracic surgery, the adjunctive use of NSAIDs with narcotic analgesia reduces 24-hr VAS pain score and narcotic requirements.

Chest drain removal pain and its management: a literature review

AIMS AND OBJECTIVES

The purpose of this review was to analyse critically the published research on chest drain removal pain and its management. The findings of descriptive and non-pharmacological intervention studies were summarized and studies of analgesic efficacy were critiqued in depth.

BACKGROUND

The removal of a chest drain is a painful and frightening experience, particularly for children. However, there is limited research regarding the amount of pain experienced or effectiveness of analgesia for this procedure.

RESULTS

Fourteen studies were reviewed, including five descriptive studies; three studies of non-pharmacological interventions; and six randomized controlled trials of morphine, local anaesthetics and Entonox. The search revealed only two paediatric studies. Many of the studies had design limitations or were poorly reported. The majority of studies indicated that patients experienced moderate to severe pain during chest drain removal, even when morphine or local anaesthetics were given.

CONCLUSIONS

Morphine alone does not provide satisfactory analgesia for chest drain removal pain. Non-steroidal anti-inflammatory drugs, local anaesthetics and inhalation agents may have a role to play in providing more effective analgesia for this procedure.

RELEVANCE TO CLINICAL PRACTICE

Analgesic protocols for the management of painful procedures such as chest drain removal are unsatisfactory and practice in this area should be revised. More research is needed to determine the efficacy of drugs other than morphine, particularly Entonox and to investigate multi-modal techniques of management further.

The Thoracic Surgical Patient: Initial Postoperative Care

Thoracic surgery patients require complex perioperative care. Accurate preoperative screening of pulmonary conditions can only partially predict the requirement of postoperative mechanical ventilation. In general, extensive lung resections are associated with significant gas exchange abnormalities. In this group of patients, a mechanical ventilation strategy protective from barotrauma and volutrauma and a conservative use of intraoperative and postoperative fluid limit the inevitable increase of extravascular lung water and gas exchange impairment. A wise use of pulmonary vasodilatatory and bronchodilating drugs and airway manipulation including suctioning and bronchoscopy can also significantly affect postoperative respiratory dysfunction and hospital stay. A number of acute postoperative complications have been described specifically related to the type of surgery or pleural space suctioning devices. The role of the intensivist is to maintain a low index of suspicion for such complications, when acute hemodynamic or pulmonary deterioration occurs and be prepared to immediately correct them or alert the thoracic surgeon. In general, when these roles are observed, thoracic surgery can be safely performed with a low perioperative mortality.

Tenoxicam 20 mg or 40 mg after thoracotomy: a prospective, randomized, double-blind, placebo-controlled study

Forty-five adults undergoing thoracotomy were randomized to receive placebo, tenoxicam 20 mg or tenoxicam 40 mg IV during chest wall closure. All patients received intraoperative fentanyl and intercostal blocks followed by morphine by patient-controlled analgesia. Patient numbers 13 to 45 also received thoracic epidural analgesia by continuous infusion of bupivacaine 0.125%, patient numbers 25 to 45 having fentanyl 2 microg/ml added to the epidural infusion. Efficacy parameters and adverse reactions were assessed over the first 24 hours postoperatively. On a 100 mm visual analogue scale, mean (SD) pain at rest (adjusted area under curve for hours 1 to 24) was 25.8 (12.5), 17.4 (14.8) and 16.5 (13.3) mm for groups receiving placebo, 20 mg and 40 mg tenoxicam, respectively (ANOVA: P<0.05). There were no significant differences between study groups postoperatively in pain on coughing, opioid consumption, blood gas measurements, nausea, vomiting, sedation, blood loss, haemoglobin or serum creatinine. One patient in each tenoxicam group reported epigastric pain, rated moderate. These data support the inclusion of tenoxicam 20 mg IV in the management of pain at rest for patients undergoing thoracotomy, but do not show additional benefit for a higher dose.

Single dose piroxicam for acute postoperative pain

BACKGROUND

Piroxicam is a non-steroidal anti-inflammatory drug (NSAID) with analgesic properties, and is used mainly for treating rheumatic disorders. Some drugs have been directly compared against each other within a trial setting to determine their relative efficacies, whereas other have not. It is possible, however, to compare analgesics indirectly by examining the effectiveness of each drug against placebo when used in similar clinical situations.

OBJECTIVES

To determine the analgesic efficacy and adverse effects of single-dose piroxicam compared with placebo in moderate to severe postoperative pain. To compare the effects of piroxicam with other analgesics.

SEARCH STRATEGY

Published reports were identified from systematic searching of Medline, Biological Abstracts, Embase, The Cochrane Library and the Oxford Pain Relief Database. Additional studies were identified from the reference lists of retrieved reports.

SELECTION CRITERIA

The following inclusion criteria were used: full journal publication, randomised placebo controlled trial, double-blind design, adult patients, postoperative pain of moderate to severe intensity at the baseline assessment, postoperative administration of oral or intramuscular piroxicam.

DATA COLLECTION AND ANALYSIS

Summed pain intensity and pain relief data were extracted and converted into dichotomous information to yield the number of patients obtaining at least 50% pain relief. This was used to calculate estimates of relative benefit and number-needed-to-treat for one patient to obtain at least 50% pain relief. Information was collected on adverse effects and estimates of relative risk and number-needed-to-harm were calculated.

MAIN RESULTS

Three trials (141 patients) compared oral piroxicam 20 mg with placebo and one (15 patients) compared oral piroxicam 40 mg with placebo. For single doses of piroxicam 20 mg and 40 mg the respective numbers-needed-to-treat for at least 50% pain relief were 2.7 (2.1 to 3.8) [95% confidence interval] and 1.9 (1.2 to 4.3) [95% confidence interval] compared with placebo over 4-6 hours in moderate to severe postoperative pain. The reported incidence of adverse effects was no higher with piroxicam (20 mg or 40 mg) than with placebo.

REVIEWER'S CONCLUSIONS

Piroxicam appears to be of similar efficacy to other non-steroidal anti-inflammatory drugs (NSAIDs) and intramuscular morphine 10 mg when used as a single oral dose in the treatment of moderate to severe postoperative pain.

The Pharmacology of New Drugs and New Uses for Older Drugs Used for Thoracic Pain Relief

Thoracotomy results in severe pain and deleterious changes in pulmonary physiology. These alterations are inevitable and can be minimized by effective analgesia. There are many options available for the treatment of postthoracotomy pain. Systemic opioids have been extensively used in this context but their side effects have led to the development of various routes of administration; the epidural route in combination with local anesthetics is the most effective. Other techniques include intercostal nerve block and intrapleural analge sia. Drugs such as clonidine, nonsteroidal anti-inflamma tory drugs, and ketamine are promising for the relief of pain after thoracotomy but further investigations are still warranted.

The effect of preoperative methylprednisolone on pulmonary function and pain after lung operations

Thirty-six patients undergoing elective thoracotomy with pulmonary resection with the use of combined epidural and general anesthesia were randomized into a double-blind study to receive a single intravenous preoperative dose of methylprednisolone 25 mg/kg body weight or a placebo (saline solution). Postoperative pain relief consisted of epidural morphine 4 mg and paracetamol 1 gm three times a day for 4 days. Postoperative pulmonary function (peak expiratory flow rate, forced expiratory volume in first second, forced vital capacity) was evaluated on days 1, 2, 3, 4, and 7 and after 1 month. The value obtained after 1 month served as the control value. Pain score at rest and during cough was evaluated after 4 and 8 hours and on days 1, 2, 3, and 4. Pulmonary function was reduced after operation to the same degree in the steroid and placebo group: 42% versus 41% for forced expiratory volume in first second and 38% versus 39% for forced vital capacity, compared with control values after 1 month. Pain score was reduced in the steroid group after 4 hours and on day 1 during rest and after 4 and 8 hours and on day 2 during cough, compared with results in the placebo group (p < 0.05). In the steroid group three patients underwent reoperation because of leakage through the chest wall incision. In conclusion, administration of a single preoperative dose of methylprednisolone did not affect the postoperative reduction in pulmonary function after thoracotomy despite attenuated pain response, and the results do not warrant steroid administration before lung operation.

Is preoperative ketorolac a useful adjunct to regional anesthesia for inguinal herniorrhaphy?

BACKGROUND

Nonsteroidal antiinflammatory drugs (NSAIDs) have become a popular component of analgesia regimens, particularly in combination with narcotics. We questioned whether there might also be a place for their use in conjunction with regional anesthesia and whether there was a preferable route for NSAID administration.

METHODS

Ilioinguinal and field blocks were performed preoperatively on seventy patients undergoing outpatient inguinal hernia repair. Patients were divided into a control group who received no ketorolac and four study groups who received a preoperative dose of 30 mg ketorolac by one of the following routes: i.v., i.m., p.o., or intrawound (i.w.). The ketorolac in the i.w group was mixed in the syringe with the local anesthetic used for the field block. i.v. and i.m. groups also received ketorolac at the time of the preoperative regional anesthesia and the PO group received the dose at least one hour preoperatively. All patients received a similar general anesthetic intraoperatively.

RESULTS

Postoperative pain scores and analgesic requirements were lowest for the i.m., i.v., and i.w. groups. Pain scores and analgesic requirements for the PO group were less than for the control group but more than for the other three groups. Analgesic efficacy therefore ranked: i.m. = i.v. = i.w. > p.o. > control. Though no differences were found between groups in the time to discharge from the recovery room, the ease of nursing care paralleled the findings for pain scores and analgesia requirements.

CONCLUSION

Beyond the analgesia provided by the regional anesthesia of the ilioinguinal and field blocks, the preoperative use of ketorolac further reduced postoperative pain scores and the need for additional postoperative analgesic medication. Comparable outcomes for the i.v., i.m. and i.w. groups indicate the lack of any benefit to concentrating the non-steroidal anti-inflammatory drug at the wound (i.w.) or to achieving high blood levels rapidly (i.v.). In conclusion, ketorolac is a useful supplement to ilioinguinal plus field block regional anesthesia for hernia surgery and is most effective administered parenterally.

Analgesia following day-case knee arthroscopy--the effect of piroxicam with or without bupivacaine infiltration

Sixty patients presenting for day-case arthroscopy of the knee under general anaesthesia were studied. Patients were randomly allocated to receive, in addition to intramuscular piroxicam 20 mg, either bupivacaine 0.25% 20 ml applied locally to the knee at the end of the procedure (n = 30) or no further intra-operative analgesia (n = 30). Visual analogue pain scores were significantly lower at 1, 2 and 4 h postoperatively in the bupivacaine group (p < 0.05). A higher proportion of patients in the piroxicam-only group required supplemental analgesia before discharge from hospital. The combination of piroxicam and bupivacaine provided superior analgesia to piroxicam alone.

Synergism between analgesics

The concept and value of 'multimodal' or 'balanced' analgesia in the treatment of postoperative pain is reviewed. Based upon the relatively few multimodal studies compared to unimodal studies, it is concluded that a combination of analgesics will improve pain relief including movement-associated pain. Since analgesic combination therapy is rational, further studies are needed to evaluate the optimal combination for each surgical procedure, as well as to assess the risk of side effects and need for surveillance in large-scale studies.

The effect of parenteral diclofenac and morphine on duration and height of blockade of continuous epidural infusion of bupivacaine 0.5%

Twenty-six patients undergoing abdominal hysterectomy (ASA 1-2) were entered into a double-blind randomised trial to determine: (a) whether diclofenac given intravenously could influence the effective duration of a continuous epidural infusion of bupivacaine 0.5%, and (b) whether morphine given intravenously altered the height of the regressing block. A block to T4 was established pre-operatively and a continuous infusion of 0.5% bupivacaine 8 ml.h-1 ran for 14 h. Thirteen patients received 50 mg diclofenac intramuscularly before surgery repeated at 4 and 10 h later and 13 patients received saline intramuscularly. The height of blockade and pain scores were measured hourly. Effective block duration was defined as regression to T10 or lower and/or a pain score of 2 or more. At this point 10 mg of morphine was given intravenously and the height of the block reassessed. Duration of blockade was not significantly prolonged (p > 0.05), but pain scores were significantly reduced with diclofenac (p < 0.01). Morphine did not alter blockade height. It is concluded that epidural bupivacaine and diclofenac act additively on postoperative pain.

The effect of balanced analgesia on early convalescence after major orthopaedic surgery

Forty-two patients scheduled for total knee arthroplasty (n = 20) or hip arthroplasty (n = 22) were randomly allocated to receive either continuous epidural bupivacaine/morphine for 48 h postoperatively plus oral piroxicam, or general anaesthesia followed by a conventional intramuscular opioid and acetaminophen regimen. Patients undergoing knee- or hip arthroplasty treated with epidural analgesia had significantly lower pain scores during mobilization under the 48 h epidural infusion compared with patients receiving conventional treatment, while no important differences were observed after cessation of the epidural regimen. However, the achieved pain relief had no impact on postoperative convalescence parameters, such as ambulation, patient activity including need for nursing care, fatigue or hospital stay. Late postoperative pain, fatigue and conservative attitudes and routines in the postoperative care, were the most important reasons limiting mobilization and activity. We conclude that effective early (48 h) postoperative pain relief with balanced analgesia does not per se lead to important improvements in convalescence and hospital stay.