Do the pharmacodynamics of the nonsteroidal anti-inflammatory drugs suggest a role in the management of postoperative pain?

Systemic opioids versus other analgesics and sedatives for postoperative pain in neonates

BACKGROUND

Neonates may undergo surgery because of malformations such as diaphragmatic hernia, gastroschisis, congenital heart disease, and hypertrophic pyloric stenosis, or complications of prematurity, such as necrotizing enterocolitis, spontaneous intestinal perforation, and retinopathy of prematurity that require surgical treatment. Options for treatment of postoperative pain include opioids, non-pharmacological interventions, and other drugs. Morphine, fentanyl, and remifentanil are the opioids most often used in neonates. However, negative impact of opioids on the structure and function of the developing brain has been reported. The assessment of the effects of opioids is of utmost importance, especially for neonates in substantial pain during the postoperative period.

OBJECTIVES

To evaluate the benefits and harms of systemic opioid analgesics in neonates who underwent surgery on all-cause mortality, pain, and significant neurodevelopmental disability compared to no intervention, placebo, non-pharmacological interventions, different types of opioids, or other drugs.

SEARCH METHODS

We searched Cochrane CENTRAL, MEDLINE via PubMed and CINAHL in May 2021. We searched the WHO ICTRP, clinicaltrials.gov, and ICTRP trial registries. We searched conference proceedings, and the reference lists of retrieved articles for RCTs and quasi-RCTs.  SELECTION CRITERIA: We included randomized controlled trials (RCTs) conducted in preterm and term infants of a postmenstrual age up to 46 weeks and 0 days with postoperative pain where systemic opioids were compared to 1) placebo or no intervention; 2) non-pharmacological interventions; 3) different types of opioids; or 4) other drugs.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were pain assessed with validated methods, all-cause mortality during initial hospitalization, major neurodevelopmental disability, and cognitive and educational outcomes in children more than five years old. We used the fixed-effect model with risk ratio (RR) and risk difference (RD) for dichotomous data and mean difference (MD) for continuous data. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

We included four RCTs enrolling 331 infants in four countries across different continents. Most studies considered patients undergoing large or medium surgical procedures (including major thoracic or abdominal surgery), who potentially required pain control through opioid administration after surgery. The randomized trials did not consider patients undergoing minor surgery (including inguinal hernia repair) and those individuals exposed to opioids before the beginning of the trial. Two RCTs compared opioids with placebo; one fentanyl with tramadol; and one morphine with paracetamol. No meta-analyses could be performed because the included RCTs reported no more than three outcomes within the prespecified comparisons. Certainty of the evidence was very low for all outcomes due to imprecision of the estimates (downgrade by two levels) and study limitations (downgrade by one level).  Comparison 1: opioids versus no treatment or placebo Two trials were included in this comparison, comparing either tramadol or tapentadol with placebo. No data were reported on the following critical outcomes: pain; major neurodevelopmental disability; or cognitive and educational outcomes in children more than five years old. The evidence is very uncertain about the effect of tramadol compared with placebo on all-cause mortality during initial hospitalization (RR 0.32, 95% Confidence Interval (CI) 0.01 to 7.70; RD -0.03, 95% CI -0.10 to 0.05, 71 participants, 1 study; I² = not applicable). No data were reported on: retinopathy of prematurity; or intraventricular hemorrhage.  Comparison 2: opioids versus non-pharmacological interventions No trials were included in this comparison. Comparison 3: head-to-head comparisons of different opioids One trial comparing fentanyl with tramadol was included in this comparison. No data were reported on the following critical outcomes: pain; major neurodevelopmental disability; or cognitive and educational outcomes in children more than five years old. The evidence is very uncertain about the effect of fentanyl compared with tramadol on all-cause mortality during initial hospitalization (RR 0.99, 95% CI 0.59 to 1.64; RD 0.00, 95% CI -0.13 to 0.13, 171 participants, 1 study; I² = not applicable). No data were reported on: retinopathy of prematurity; or intraventricular hemorrhage.  Comparison 4: opioids versus other analgesics and sedatives One trial comparing morphine with paracetamol was included in this comparison. The evidence is very uncertain about the effect of morphine compared with paracetamol on COMFORT pain scores (MD 0.10, 95% CI -0.85 to 1.05; 71 participants, 1 study; I² = not applicable).  No data were reported on the other critical outcomes, i.e. major neurodevelopmental disability; cognitive and educational outcomes in children more than five years old, all-cause mortality during initial hospitalization; retinopathy of prematurity; or intraventricular hemorrhage.

AUTHORS' CONCLUSIONS

Limited evidence is available on opioid administration for postoperative pain in newborn infants compared to either placebo, other opioids, or paracetamol. We are uncertain whether tramadol reduces mortality compared to placebo; none of the studies reported pain scores, major neurodevelopmental disability, cognitive and educational outcomes in children older than five years old, retinopathy of prematurity, or intraventricular hemorrhage. We are uncertain whether fentanyl reduces mortality compared to tramadol; none of the studies reported pain scores, major neurodevelopmental disability, cognitive and educational outcomes in children older than five years old, retinopathy of prematurity, or intraventricular hemorrhage. We are uncertain whether morphine reduces pain compared to paracetamol; none of the studies reported major neurodevelopmental disability, cognitive and educational outcomes in children more than five years old, all-cause mortality during initial hospitalization, retinopathy of prematurity, or intraventricular hemorrhage. We identified no studies comparing opioids versus non-pharmacological interventions.

Ketorolac tromethamine - routes and clinical implications

Opioids have long been used for analgesic purposes for a wide range of procedures. However, the binding of these drugs to opiate receptors has created various challenges to the clinician due to unfavorable side effect profiles and the potential for tolerance and abuse. In 1989, ketorolac became an approved nonsteroidal inflammatory drug (NSAID) for injectable use as an analgesic. Over the last 20 years, numerous studies have been conducted involving ketorolac. These studies have provided additional information about various routes of administration and their effect on the efficacy and the side effect profile of ketorolac. Moreover, ketorolac has been compared with several widely used analgesics. This review evaluates both the potential benefits and potential drawbacks of ketorolac generally, and specifically discusses routes of administration, including their advantages and disadvantages when compared to several traditional analgesics in both inpatient and outpatient settings.

Comparison of benzydamine hydrochloride and Salvia officinalis as an adjuvant local treatment to systemic nonsteroidal anti-inflammatory drug in controlling pain after tonsillectomy, adenoidectomy, or both: an open-label, single-blind, randomized clinical trial

BACKGROUND

Benzydamine hydrochloride (BNZD) is a nonsteroidal anti-inflammatory drug (NSAID) used in an oral rinse formulation as an adjuvant to other NSAIDs in controlling postoperative pain after tonsillectomy, adenoidectomy, or both. Salvia officinalis (SO) is a topically applied herbal preparation frequently used for the same indication. Pain, bleeding, and infection are the most common postoperative complications of tonsillectomy.

OBJECTIVE

The aim of this study was to compare the efficacy and tolerability of BNDZ with those of SO as adjuvant treatments in controlling postoperative pain.

METHODS

This open-label, single-blind, randomized clinical trial was conducted at the Department of Otorhinolaryngology, Clinical Hospital Center "Dr. Dragiša Mišović-Dedinje" (Belgrade, Serbia and Montenegro). Pediatric and adult patients undergoing tonsillectomy, adenoidectomy, or both were enrolled. Patients were randomized to receive BNZD or SO, in addition to ibuprofen 20 mg/kg·d (children) or diclofenac 100 mg/d (adults). The primary end point was the proportion of patients with mild or no pain on postoperative days 1, 2, 4, and 7. Secondary end points were the incidences of infection, hemorrhage, and other adverse events.

RESULTS

A total of 420 patients were enrolled (217 females, 203 males; 278 children, 142 adults; mean [SD] age, 6.2 [2.1] years [children] and 24.1 [9.8] years [adults] [range, 3-45 years]). One hundred thirty-eight children received BNZD; 140 received SO (both in addition to ibuprofen 20 mg/kg·d). Seventy-two adults received BNZD; 70 received SO (both in addition to diclofenac 100 mg/d). A significantly lower proportion of children treated with adjuvant BNZD experienced moderate or severe pain than those treated with SO at each time point (P < 0.01 at days 1 and 4; P < 0.001 at days 2 and 7). In children, the risk for postoperative infection was similar between BNZD and SO (absolute risk reduction [ARR], 6.9%; 95% CI, 6.4%-7.6%); however, the risk was reduced in adults (ARR, 19.0%; 95% CI, 16.5%-21.9%; P = 0.008).

CONCLUSIONS

In this clinical trial of children and adults who underwent tonsillectomy, adenoidectomy, or both, BNZD, as an adjuvant to an NSAID, was more effective than SO in controlling postoperative pain and infection. The pain-reducing effect of BNZD was of quick onset and persisted for 1 week after surgery. The safety profile of BNZD was comparable to that of SO, with the exception of postoperative infection in adults, for which BNZD was more efficacious. In particular, the use of BNZD was not associated with a high risk for early postoperative hemorrhage.

Comparison of intravenous ketorolac with or without paracetamol in postoperative pain control following ambulatory surgery

OBJECTIVE

The aim of this randomized, patient-blinded study was to compare efficacy and safety of oral paracetamol plus intra-venous (i.v.) ketorolac with i.v. ketorolac alone after ambulatory uterine evacuation.

RESEARCH DESIGN AND METHODS

Women were randomly assigned to receive either oral paracetamol (1 g), in a melt-in-the mouth, without-water formulation plus ketorolac (30 mg i.v. once daily (o.d.)) or ketorolac (30 mg i.v. o.d.) as monotherapy. The mean duration of uterine evacuation was 11 minutes in the paracetamol + ketorolac group and 13 minutes in the ketorolac-only group. Paracetamol was administered 15 minutes before surgery, on discharge from hospital (mean 6 hours after surgery) and in the morning the day after surgery, while ketorolac was administered at the end of the surgical intervention.

MAIN OUTCOME MEASURES

The numeric rating scale (NRS) was used by patients to rate their pain on an 11 point scale.

RESULTS

Overall, 60 women received paracetamol plus ketorolac (group 1) and 60 ketorolac alone (group 2). There were significant differences in pain levels (NRS 0.92 and 2.08; p < 0.01) at T0 (when patients left the operating room 30 minutes after the end of surgery). At T1 (before discharge from hospital but before the next administration of paracetamol) there were no significant differences between NRS scores in the two groups (3.7 vs. 3.5, respectively, p = 0.3453). At T2 (in the morning after surgery; data collected by phone interview), following administration of the next dose of paracetamol, significant differences in pain scores were recorded (1.58 vs. 1.98; p = 0.01). Only a case of dizziness was reported in the paracetamol + ketorolac group, and no other unexpected adverse events were recorded.

CONCLUSION

Despite the small sample size and the monocentric nature of the study being taken into account, this study suggests, for the first time to our knowledge, that oral paracetamol t.i.d. in combination with i.v. ketorolac o.d. is effective and well tolerated in the control of postoperative pain after ambulatory uterine evacuation.

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.

Efficacy and Safety of Preoperative Etodolac and Butorphanol Administration in Dogs Undergoing Ovariohysterectomy

Eighteen dogs undergoing ovariohysterectomy were premedicated with etodolac, butorphanol, or their combination. Various parameters, such as blood pressure, isoflurane requirements, behavioral pain scores, plasma cortisol concentration, plasma glucose concentration, and mucosal bleeding time, were assessed. The integrated plasma cortisol values were significantly lower in the etodolac and etodolac with butorphanol groups. Dogs receiving etodolac and butorphanol had the lowest behavioral pain scores from extubation until the end of monitoring. Isoflurane concentration over time (area under the curve), buccal mucosal bleeding time, and indices of renal function were not significantly different among the treatment groups.

Sublingual Piroxicam for Postoperative Analgesia: Preoperative Versus Postoperative Administration: A Randomized, Double-Blind Study

Nonsteroidal antiinflammatory drugs have been used to obtain preemptive analgesia. We investigated, in this randomized, double-blind study, whether sublingual (s.l.) piroxicam given before was more effective than that given after surgery. Fifty-two patients scheduled for laparoscopic bilateral inguinal hernia repair under general anesthesia were enrolled. Group PRE (25 patients) received 40 mg of piroxicam s.l. 2 h before surgery and a placebo 10 min after surgery. Group POST (27 patients) were treated with a placebo 2 h before surgery and received 40 mg of piroxicam s.l. 10 min after surgery. After an initial dose of 100 mg tramadol IV, patient-controlled analgesia with tramadol was started and recorded. Visual analog scores were assessed in the recovery and at 6, 20, and 30 h postoperatively. Significantly lower visual analog scores were found in group PRE at 6 and 20 h. Significantly smaller cumulative tramadol consumption was observed after 30 h in group PRE. In summary, our findings suggest that preoperative s.l. piroxicam is more effective than the postoperative administration. Because of the low pain scores in both groups, the clinical relevance of these findings is not clear from this study.

Intraarticular Patient-Controlled Regional Anesthesia After Arthroscopically Assisted Anterior Cruciate Ligament Reconstruction: Ropivacaine/Morphine/Ketorolac Versus Ropivacaine/Morphine

Anterior cruciate ligament reconstruction (ACLR) is associated with moderate to severe postoperative pain. We compared the intraarticular analgesic effects of ropivacaine and morphine with or without ketorolac and the need for rescue IV morphine at rest and during movement in patients undergoing anterior cruciate ligament reconstruction during spinal anesthesia. Thirty-nine patients receiving intraarticular patient-controlled regional analgesia with a 10-mL bolus and a 60-min lockout interval were randomized into 3 groups: the RM group received 0.25% ropivacaine and morphine 0.2 mg/mL; the RMK group received 0.25% ropivacaine, morphine 0.2 mg/mL and ketorolac 1 mg/mL; the P group received saline. Analgesic mixtures were prepared in 100-mL bags and coded. If needed, rescue morphine 2 mg was self-administered IV with 10-min lockout intervals. Pain scores and patient satisfaction were assessed at rest and during movement. There were no significant differences among the groups in pain scores and patient satisfaction. Daily morphine consumption was significantly smaller in the RMK group (8 +/- 8 mg) compared with the RM group (23 +/- 20 mg; P = 0.002) and in both groups compared with control (46 +/- 21 mg; P < 0.001). We conclude that intraarticular patient-controlled regional analgesia provides effective pain relief after anterior cruciate ligament reconstruction. The combination of intraarticular ropivacaine, morphine, and ketorolac was superior to control or to a combination of ropivacaine and morphine.

IMPLICATIONS

This study showed the feasibility and efficacy of intraarticular patient-controlled regional analgesia technique for pain relief after anterior cruciate ligament reconstruction. The combination of intraarticular ropivacaine, morphine, and ketorolac was superior to control or to a combination of ropivacaine and morphine.

Efeitos do Tenoxicam sobre a cicatrização da parede abdominal: estudo experimental em ratos

OBJETIVO: Analisar os efeitos do tenoxicam, um antiinflamatório não hormonal, na cicatrização da parede abdominal de ratos. MÉTODOS: Foram utilizados 40 ratos adultos, submetidos à laparotomia mediana e distribuídos, aleatoriamente, em um grupo controle (C), constituído de 20 animais que receberam solução de NaCl a 0,9 %; e um grupo tratado (T), constituído de 20 animais que receberam o tenoxicam. Os animais de cada grupo foram divididos, conforme a data de sacrifício, em subgrupos de 10 animais, denominados C7, C14, T7 e T14. As inscrições 7 e 14 determinaram o sacrifício dos animais no sétimo e décimo quarto dia pós-operatório, respectivamente. As soluções de tenoxicam (1mg/ml) e de NaCl a 0,9% foram administradas no pós-operatório imediato e nos quatro dias seguintes, por via intramuscular, na dose volume de 0,6 ml/kg/dia. No dia do sacrifício, realizou-se a ressecção de dois fragmentos da parede abdominal (1cm x 3cm), que foram utilizados para determinação da concentração de hidroxiprolina e avaliação da força de ruptura. RESULTADOS: Não foram observadas complicações da ferida operatória, incluindo infecção ou deiscência, nos quatro subgrupos de animais. Na análise comparativa dos quatro subgrupos de animais, não foi evidenciada diferença estatisticamente significante no estudo da força de ruptura (p=0,262) e na concentração de hidroxiprolina (p=0,392). CONCLUSÃO: A administração de tenoxicam, por via intramuscular, não interfere na cicatrização da parede abdominal de ratos.

Postoperative pain control in children: a guide to drug choice

Postoperative pain in children can usually be well controlled with a combination of analgesics, including acetaminophen (paracetamol), NSAIDs, opioids, and local/regional anesthesia. Recent research has shown that the dosage of acetaminophen required to provide analgesia is higher than the traditional dosages used for the regulation of elevated body temperature. Rectal administration of acetaminophen gives a lower and more variable bioavailability compared with oral administration. There is growing experience with the use of NSAIDs in children and several studies have demonstrated the relatively strong analgesic potential of these drugs. Titration of opioids to analgesic effect, and the use of nurse- and patient-controlled continuous opioid infusions in children have gained widespread use and, with proper education and supervision, are considered excellent methods of pain control. Local peripheral and central blocks decrease the need for anesthetics during surgery and provide effective postoperative pain relief.

What is the role of NSAIDs in pre-emptive analgesia?

NSAIDs inhibit the cyclo-oxygenase enzymes, and decrease peripheral and central prostaglandin production. In addition to reducing the inflammation that accompanies tissue injury, decreasing prostaglandin production attenuates the response of the peripheral and central components of the nervous system to noxious stimuli. Such a reduction in the response to pain can reduce the peripheral and central sensitisation induced by noxious stimuli, and reduce the pain experienced in response to subsequent noxious stimuli. These properties would seem to make NSAIDs ideal drugs to use in a pre-emptive fashion, where analgesics are administered prior to a noxious stimulus, such as surgery, with the expectation that reduction in peripheral and central sensitisation will lead to a decrease of pain.However, the available perioperative trials of pre-emptive NSAID use have yielded modest or equivocal results, and these may be due, in part, to controversy associated with the definition of pre-emptive analgesia and how to conduct the corresponding clinical trials. Although NSAIDs may have a limited ability by themselves to induce a pre-emptive analgesic effect, the available trials suggest how the perioperative use of these drugs may be made more effective. It is expected that NSAIDs will play an increasing role in multimodal analgesia and pain relief in general.

Patients' perceptions of pain management after cardiac surgery in an australian critical care unit

OBJECTIVE

The purpose of this study was to investigate patients' perceptions of the effectiveness of a pain management regimen, which consisted of intermittent prn bolus doses of morphine, in a critical care unit after cardiac surgery.

DESIGN

This was a escriptive and correlational study.

SETTING

This study took place at the cardiothoracic intensive care unit of a major teaching hospital in Sydney, Australia.

PATIENTS

The subjects were 102 patients who underwent cardiac surgical procedures. The mean age of the group was 61 years, and 24.5% were females and 75.5% were males.

RESULTS

Analysis revealed that patients received limited total amounts of morphine during their critical care stay (mean = 26.7 mg; SD = 13.3; range: 0-68). All activities were associated with increased pain sensation. Patients requiring an internal mammary artery graft experienced increased pain despite receiving greater amounts of morphine. Elderly patients received less morphine and were refused pain killers more often than younger patients. Females found their overall pain experience to be less acceptable than did males. Less than half the participants always communicated their experience of pain to nurses.

CONCLUSION

Overall, the majority of participants were reasonably satisfied with their pain experience. However, the following areas need improvement: the assessment and management of pain in relation to gender and age differences and the type of graft/s used; the administration of morphine before activity; and the communication of pain experience by patients.

Ketoprofen 75 mg qid versus acetaminophen 1000 mg qid for 3 days on swelling, pain, and other postoperative events after third-molar surgery

A randomized, double-blind, within-patient, crossover study was carried out after bilateral "identical" surgical procedures using local anesthesia only. A 3-day tablet regime of racemic ketoprofen 75 mg or acetaminophen 1000 mg qid (x 4) was given starting 3 hours after surgery. Ketoprofen reduced objectively measured swelling 27.8% (p < 0.04) better than acetaminophen 3 days after surgery and 70.8% (p < 0.02) better than acetaminophen 6 days after surgery. The pain intensity (PI) was lower after ketoprofen than after acetaminophen from 2 to 6 hours after the first drug intake (all p-values < or = 0.03). Sum PI during the first (SUMPI3.5-6, p = 0.003) and second dose intervals (SUMPI6.5-9, p = 0.007) was lower for ketoprofen than for acetaminophen but not different for the third dose interval (SUMPI9.5-11, p = 0.53). Ketoprofen was a more effective analgesic than acetaminophen on the day of surgery (SUMPI3.5-11, p = 0.005). There was no difference (p > 0.05) between the treatments with respect to mouth opening, drug preference, global evaluation, or adverse reports. Adverse reports included stomach pain and diarrhea in both treatment groups. Ketoprofen 75 mg x 4 for 3 days reduces subjectively assessed pain and objectively measured swelling (i.e., anti-inflammatory effect) following third-molar surgery.

Day-case laparoscopy: a comparison of prophylactic opioid, NSAID or local anesthesia for postoperative analgesia

BACKGROUND

The study was aimed to evaluate the analgesic efficacy, postoperative comfort, recovery characteristics and side effects of three different analgesic agents administered prophylactically.

METHODS

Eighty patients undergoing day-case minor operative laparoscopy were randomly allocated into four groups to receive tenoxicam 20 mg i.v. (Group T), fentanyl 100 microg i.v. (Group F), 5 ml of bupivacaine 2.5 mg/ml for infiltration of trocar sites (Group B), 30, 10 and 5 min before incision respectively. Bupivacaine, 35 ml, 2.5 mg/ml was also administered into the pelvic cavity in Group B. Group P received only placebo. Postoperative pain, analgesic requirements, first response to verbal stimulus, first analgesic requirement, ability to walk without help, to drink and to void, blood pressures, SpO2 and respiration rates were recorded in the PACU. Postoperative pain was evaluated by verbal rating scale. Pain scores, analgesic requirements and side effects were evaluated by telephone calls until the 48th postoperative hour.

RESULTS

Postoperative pain scores were lower and time to requirement of rescue analgesics was longer in groups F and B compared to Group P. In the PACU, analgesic requirements were lower in Group B, compared to Group P. Nausea and vomiting were increased in Group F.

CONCLUSION

Tenoxicam 20 mg i.v. was found to be ineffective whereas bupivacaine was superior to other groups in reducing pain and analgesic requirements. Bupivacaine also increased time to first analgesics and obtained better recovery characteristics, underlining its value in prophylactic pain management compared to the other two agents.

A double-blind study of the effect on hemostasis of nabumetone (Relafen) compared to placebo

A double-blind, placebo-controlled clinical trial comparing the effect on hemostasis of nabumetone (Relafen) to placebo in patients who were about to undergo forefoot surgery was performed. Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) are reported to inhibit platelet cyclooxygenase activity, resulting in altered platelet function and thus potentially enhanced bleeding. Nabumetone has been reported to have no effect on platelet aggregation and bleeding time in normal volunteers and in patients who have undergone knee arthroscopy. After fulfilling the inclusion criteria and after a 1-week washout period (acetaminophen controlled), 15 patients were enrolled in the nabumetone group and 15 patients were randomized in the placebo group. Hemostatic parameters [prothrombin time (PT), partial thromboplastin time (PTT), and Ivy bleeding time (IBT)] were assessed at baseline, visit 2, visit 3, and final visit. No meaningful differences were observed between treatment groups in any of the measured hemostatic parameters. No significant adverse events were reported. There was no significant change from baseline for PT, PTT, and IBT in the nabumetone group (PT, p < .06; PTT, p < .64; IBT, p < .17) versus the placebo group (PT, p < .61; PTT, p < .63; IBT, p < .25). The lack of bleeding diathesis and significant prolongation of PT, PTT, or IBT in this study suggests that nabumetone in dosages up to 1000 mg/day can be administered safely in the immediate preoperative period to patients undergoing forefoot surgery.

The analgesic efficacy of intravenous tenoxicam as an adjunct to patient-controlled analgesia in total abdominal hysterectomy

Nonsteroidal antiinflammatory drugs may reduce postoperative opioid consumption. We evaluated the analgesic efficacy of preoperatively administered tenoxicam in patients undergoing total abdominal hysterectomy. Patients were randomly assigned to receive IV either normal saline 4 mL (Group NS), tenoxicam 20 mg (Group T20), or tenoxicam 40 mg (Group T40) before the induction of anesthesia in a double-blinded fashion. Patient-controlled analgesia with fentanyl was used to assess postoperative opioid requirements. Pain was evaluated by visual analog scale at 2, 4, 6, 8, and 24 h postoperatively. Intraoperative bleeding as assessed by the surgeon, incidence of nausea, and gastrointestinal symptoms were recorded. No statistically significant difference was identified between groups in fentanyl consumption or pain scores. The incidence of nausea was similar in all groups. Two patients in Group T20 and two in Group T40 exhibited mild gastrointestinal symptoms. Intraoperative oozing was noted in two patients in Group T40. We conclude that patients undergoing total abdominal hysterectomy and receiving fentanyl via patient-controlled analgesia postoperatively do not benefit from tenoxicam pretreatment. On the contrary, the drug may be associated with an increased incidence of side effects.

IMPLICATIONS

The preoperative administration of 20 or 40 mg IV tenoxicam does not reduce fentanyl consumption via Patient-Controlled Analgesia, compared with placebo, after total abdominal hysterectomy. Additionally, tenoxicam may increase intraoperative bleeding and gastrointestinal side effects.

Renal dysfunction associated with the perioperative use of diclofenac

Postoperative renal dysfunction in rats is induced by ketorolac dosed concurrently with gentamicin. Herein, we report the renal effects of diclofenac in four groups of rats: control (C = anesthesia, surgery); diclofenac (D = anesthesia, surgery, diclofenac 18 mg x kg(-1) x d(-1)); gentamicin (G = anesthesia, surgery, gentamicin 20 mg x kg(-1) x d(-1)); and diclofenac and gentamicin (DG = anesthesia, surgery, diclofenac, gentamicin). Renal function, after three treatment days, was assessed using histology, p-aminohippurate (PAH), and iothalamate (IOT) clearances, serum and urine electrolytes, osmolality, urea, and creatinine. Urine output was increased (from 5.2 to 12.5 mL/24 h), and urine osmolality was decreased (from 2121 to 883 mOsm/kg) in the DG group. PAH and IOT clearances were decreased in the G and DG groups (PAH by 18%, IOT by 22%; PAH by 38%, IOT by 43%, respectively); there were no changes in the C and D groups. Urea and creatinine clearances were decreased by 61% and 43%, respectively, in the DG group. Kidney sections showed the most severe pathologic changes in the DG group. Our data indicate that the perioperative combination of diclofenac and gentamicin was deleterious to renal function.

IMPLICATIONS

Diclofenac alone does not result in significant perioperative renal dysfunction, but the combination of gentamicin and diclofenac is deleterious to renal function. Considering this and previous findings, the evidence suggests that treatment with aminoglycosides may be a significant risk factor for inducing perioperative renal failure during treatment with nonsteroidal antiinflammatory drugs.

[Role of non-steroidal anti-inflammatory agents in the perioperative period. Usefulness and limitations]

Nonsteroidal antiinflammatory drugs (NSAIDs), including various chemical families of drugs, inhibit prostaglandin synthesis and act on the central nervous system. Prostaglandins are involved in regulation of regional circulations, cell turn-over in the gastrointestinal tract, and in primary haemostasis. The patterns of action of NSAIDs result in analgesic properties, but also in adverse effects. NSAIDs are increasingly used perioperatively, alone or associated with opioids or local anaesthetics, because of their analgesic and opioid sparing properties. Some of their adverse effects, especially ischaemic acute renal failure and gastrointestinal complications, can be life-threatening, and increased haemorrhagic risk is an issue for spinal or epidural anaesthesia in patients taking aspirin. Safe use of NSAIDs is possible in consideration of contraindications (elderly patient, hypovolaemia, cirrhosis, congestive heart failure, renal failure, active gastrointestinal ulcer, bleeding diathesis, pregnancy), and requires close monitoring of renal function if they must be used in patients at risk for renal failure. NSAIDs are not ulcerogenic in the short-term in healthy subjects. They must be used with caution in patients with a preexisting haemostatic defect or undergoing haemorrhagic surgical procedures.

Acetaminophen as an adjunct to morphine by patient-controlled analgesia in the management of acute postoperative pain

Opioids play a fundamental role in the management of postoperative pain, but their use is associated with a number of side effects, including nausea and vomiting, sedation, and respiratory depression. Co-administration of a nonopioid has been proposed as a method of reducing opioid intake and minimizing side effects. Sixty-one ASA physical status I and II patients were enrolled in a double-blind, randomized, placebo-controlled, parallel study to investigate the effect of a combination of acetaminophen and morphine after open reduction and internal fixation of acute limb fractures. Patients were randomized to receive either oral acetaminophen (1 g every 4 h) or placebo as an adjuvant to morphine by patient-controlled analgesia (PCA) postoperatively. They were assessed daily for 72 h or until the PCA was discontinued according to standardized guidelines. The outcome variables collected were pain scores (11-point scale), amount of morphine self-administered, duration of PCA use, compliance with study design, incidence of nausea and sedation, and overall patient satisfaction. The acetaminophen group had lower pain scores on Day 1 (2.1 vs 3.3; P = 0.03) and a shorter average duration of PCA use (35.8 vs 45.5 h; P = 0.03). Overall patient satisfaction was also significantly greater in the acetaminophen group (8.7 vs 7.9; P = 0.04). These data suggest that acetaminophen is a useful adjunct to morphine PCA.

IMPLICATIONS

This study assesses the benefit of combining two analgesics for the treatment of postoperative pain. Such a combination improves the quality of pain relief and patient satisfaction.

Effect of nabumetone on hemostasis during arthroscopic knee surgery

The known effects of commonly used nonsteroidal anti-inflammatory drugs (NSAIDs) on hemostatic parameters have led to concern over their use in the perioperative period. Nabumetone, unlike other NSAIDs, has little effect on collagen-induced platelet aggregation. To evaluate the effect of nabumetone 2000 mg daily on other hemostatic parameters (e.g., bleeding time, prothrombin time, and partial thromboplastin time) in the clinical setting, this double-masked study was conducted in patients with osteoarthritis undergoing arthroscopic knee surgery. After a 1-week placebo washout period, 58 patients were randomized to receive nabumetone and 53 were randomized to receive placebo. They were assessed before surgery (after 1 to 2 weeks of treatment) and again after surgery (after an additional 3 weeks of treatment). The study was designed to have 90% power to show equivalence in bleeding time to within 1.5 minutes, a difference assumed to be of no clinical importance. No meaningful differences were observed between the groups in any of the measured hemostatic parameters. Before surgery, the bleeding time increased by only 0.3 minutes with nabumetone and decreased by 0.2 minutes with placebo. The mean (+/- SD) difference between the groups in change from baseline was 0.5 +/- 0.3 minutes. After surgery, the changes were 0.1 minutes and 0.0 minutes, respectively, and the difference between groups was 0.2 +/- 0.3 minutes. These differences were neither statistically nor clinically significant, and maximum individual increases were similar in each group. Furthermore, there were no reports of abnormal bleeding in the operative knees. The results of this study show that nabumetone had little or no effect on hemostasis and suggest that this drug can be used safely in the perioperative period.

A comparison of the efficacy of ketorolac and indomethacin for postoperative analgesia following laparoscopic surgery in day patients

The analgesia provided in the postoperative period by three regimens commonly used in our private anaesthetic practice were compared in a double-blind study of one hundred and thirty-seven women presenting for day-case laparoscopic procedures. After random allocation into three groups, all patients were similarly anaesthetized and then received both a rectal suppository and an IM injection. Group P received two placebos, Group I had an indomethacin suppository 100 mg and Group K an IM injection of ketorolac 30 mg. The trial showed a statistically significant reduction in pain at 180 minutes postoperatively in the group receiving ketorolac (visual analog pain score of 13.8 v 21.7). The parenterally administered ketorolac may be a useful analgesic supplement in these patients. However the trial was aborted following the appearance in the literature of case reports of postoperative renal failure. Further investigation of the efficacy and side-effect profile of reduced doses may be warranted.

Intravenous ketorolac vs diclofenac for analgesia after maxillofacial surgery

PURPOSE

To compare the efficacy of the non-steroidal antiinflammatory drugs (NSAID), ketorolac and diclofenac in prevention of pain after maxillofacial surgery.

METHODS

Sixty ASA I-II patients (30 in each group) received randomly, and double blindly either ketorolac 0.4 mg.kg-1 or diclofenac 1.0 mg.kg-1 iv after general anaesthesia induction, before surgical incision. In the ketorolac group, the same dose was repeated iv three times at six hour intervals. The diclofenac group patients received diclofenac 1.0 mg.kg-1 after 12 hr iv. Rescue analgesic medication consisting of oxycodone 0.03 mg.kg-1 iv, was administered by a patient controlled analgesia apparatus.

RESULTS

Two patients in the ketorolac and three patients in the diclofenac group did not need oxycodone during the study period. On average, 12 and 11 doses of oxycodone were needed in the ketorolac and the diclofenac groups, respectively (NS). Side-effects were similar in both groups. All patients except one were satisfied with the pain therapy.

CONCLUSION

Parenteral ketorolac (0.4 mg.kg-1 four times in 24 hr) and diclofenac (1 mg.kg-1 twice in 24 hr) were similar, but insufficient alone, for analgesia after maxillofacial surgery.

Postsurgical complications in older patients. The role of pharmacological intervention

The number of elderly patients undergoing surgery has been rapidly increasing during the last few years. Following surgical interventions, high rates of mortality and morbidity have been reported in the most advanced age groups. Nevertheless, perioperative evaluation and postoperative care are the major determinants of the overall outcome. Postsurgical complications are common in advanced age, since multiple pathology is often present in geriatric patients. Furthermore, the decreased efficiency of homeostatic mechanisms may facilitate the development of multiple organ failure (MOF), even as a consequence of apparently slight alterations in immune, cardiac or respiratory systems. Thus, prompt recognition and treatment of any complication often prevents the development of irreversible conditions. While cardiac and pulmonary complications account for 50% of early postoperative adverse events, infections, thromboembolism, renal failure, stress ulcers and coagulation disorders may occur well after surgical procedures. An important part of postoperative geriatric care is the diagnosis and correction of fluid, electrolyte and acid-base disturbances. These disturbances may manifest as mild, atypical signs, such as slight neuromuscular depression or delirium. Yet, they often constitute life-threatening conditions that should be rapidly and properly corrected. Finally, it should be remembered that, due to the frequent use of multiple drugs, elderly patients are at high risk of developing adverse drug reactions. Thus, the treatment of postoperative complications requires a strong rational effort to disentangle the combined effects of aging, drugs and pathology.

Techniques for post-op pain management in the adult

Nurse-administered analgesia is simple, universally accessible, and cost-effective. This route of administration must be fully explored and exploited to gain maximal analgesia at minimal cost. Combined, balanced multimodal analgesia with NSAIDs and opioids used preoperatively to prevent pain should be encouraged. Intraoperative analgesia should not consist solely of opioids, but also local anaesthetics and NSAIDs. Postoperatively, balanced analgesia should continue and when the patient is able to tolerate fluids the oral route of administration should be used. The solution to improved postoperative analgesia lies in exploitation and liberalization of traditional analgesic drugs and techniques. We do not need new pharmacology or new technology. We need to use the drugs and techniques we already have in a much more effective and efficient fashion. Anaesthetists have been at the forefront of delivering superb analgesia to patients after extensive major surgical procedures using epidural analgesia and patient-controlled analgesia. We must focus on postoperative pain management of all patients to ensure that optimal analgesia is provided throughout the institution. This requires a multi-disciplinary team of health care professionals and a multi-modal array of analgesics. This approach represents a change from current practice. Considerable time and energy has been invested in the development of the clinical practice guidelines and they deserve our consideration as we manage patients now and in the future.