The effects of paracetamol, ketorolac, and paracetamol plus morphine on pain control after thyroidectomy

Comparison of Analgesic Effects of Ketorolac Plus Apotel to Meperidine in Patients Undergoing Right Thoracotomy: A Double-Blind Randomized Clinical Trial

Background

Postoperative pain management using nonsteroidal anti-inflammatory drugs with no narcotic-attributed adverse effects, such as respiratory depression, nausea, and vomiting, is still the subject of extensive research. However, concerns about bleeding and nephrotoxicity have limited routine use.

Objectives

The present trial aimed to compare the effects of ketorolac/apotel and meperidine on postoperative pain relief in patients undergoing thoracotomy.

Methods

This randomized controlled trial enrolled 122 patients who were candidates for right thoracotomy. The patients were randomly divided into two groups that received ketorolac (30 mg)/apotel (1 g) or meperidine (0.5 - 1 mg/kg) at the beginning of recovery, respectively. This study assessed the Numeric Rating Scale pain score immediately and 30 and 60 minutes after the surgery in the recovery room, blood pressure, oxygen saturation (SpO2), sweating, and pulse rate.

Results

The average pain score at recovery time was significantly lower in the ketorolac/apotel group (2.06 ± 1.40) than in the meperidine group (2.76 ± 1.61) (P = 0.011). In contrast to the ketorolac/apotel group, an increasing trend was observed in pain scores in the meperidine group throughout the time sequence (P < 0.05). However, a slight non-significant increase was also observed in the ketorolac/apotel group. No statistical differences were observed in blood pressure (P = 0.826), SpO2 (P = 0.826), and pulse rate (P = 0.811) between the two study groups.

Conclusions

This study provides support that the combination of ketorolac/apotel offers a slightly superior analgesic effect for patients undergoing thoracotomy, compared to meperidine. Pain management is crucial during recovery, and the current study's findings suggest that administering ketorolac/apotel provides effective analgesia during recovery after thoracic surgery.

Analgesic Effect of Preoperative Intravenous Administration of Paracetamol on Post-cesarean Pain: A Randomized Clinical Trial

Background

Pain control after every surgery, especially cesarean section, is very important, and physicians strive to discover pain control methods using the least amount of opioids. Paracetamol is a non-opioid analgesic with few complications.

Objectives

The present study aimed to investigate the analgesic effect of preoperative intravenous administration of paracetamol on post-cesarean pain.

Methods

This randomized, double-blind clinical trial was conducted on 240 pregnant women under spinal anesthesia who were candidates for elective cesarean section. The patients' weight, height, age, and body mass index (BMI) were recorded, and patients were randomly divided into 2 equal groups (n = 120). In the first group, 10 mg/kg paracetamol in 100 mL of normal saline (paracetamol group) and, in the second group, 100 mL normal saline (control group) were administered 15 minutes before surgery intravenously. Blood pressure, pulse rate, chills, and nausea were recorded during and 1 hour after surgery; in addition, the visual analogue scale (VAS) and the need for additional analgesics were recorded 1, 2, 4, 6, 12, and 24 hours after surgery.

Results

Mean pain scores were significantly lower in the paracetamol group (4.01 ± 2.22) than in the control group 6 hours (4.83 ± 2.35; P = 0.008) and 24 hours (2.26 ± 1.85 and 2.67 ± 1.80, respectably; P = 0.038) after surgery. Mean meperidine consumption was lower in the paracetamol group than in the control group, but it was not significant. No significant difference was found between the 2 groups in the frequency of chills and nausea (P > 0.05).

Conclusions

Within the limitations of the current study, preoperative intravenous administration of paracetamol significantly reduced post-cesarean pain within 24 hours.

The Effect of Pregabalin Levels on Pain and Substance P Level Post-Cesarean Section

BACKGROUND: Post-operative pain is a very important problem faced by post-operative patients. Antihyperalgesia is caused by the inhibition of the neurotransmitter glutamate and substance P (SP) by pregabalin. This study aimed to compare the effect of preventive administration of 50 mg oral pregabalin and 1 g paracetamol with 75 mg oral pregabalin and 1 g intravenous paracetamol on Numeric Rating Scale (NRS) scores and SP levels after cesarean section with spinal anesthesia. AIM: The objective of the study was to compare the effect of preventive administration of 50 mg oral pregabalin and 1 g paracetamol with 75 mg oral pregabalin and 1 g intravenous paracetamol on NRS scores and SP levels after cesarean section with spinal anesthesia. METHODS: This study used a double-blind randomized trial design. Samples were selected randomly and consecutively from the entire population that met the inclusion criteria. There were a total of 30 samples. SP levels were measured 2 h before cesarean section. The study drug was administered by mouth with a sip of water 1 h before the expected time of the surgical incision. SP levels were checked at the 4th h (SP 1) and 6th h (SP 2) postoperatively. The assessment of the degree of pain using the NRS was carried out at 2 h, 4 h, 6 h, 12 h, and 24 h postoperatively. This study used the Mann–Whitney U-test to compare both the levels of SP and NRS between the two groups. RESULTS: The results of this study showed that there was a significant difference in the NRS scores between the 50 mg and 75 mg pregabalin groups (p < 0.05). In the 75 mg pregabalin group, the NRS scores were lower than in the 50 mg pregabalin group in patients undergoing CS surgery under spinal anesthesia. There was a significant difference in SP levels between the 50 mg and 75 mg pregabalin groups (p < 0.05). SP levels in the 50 mg pregabalin group increased at 4 h and 6 h postoperatively, while in the 75 mg pregabalin group, it tended to decrease at 4 h and 6 h postoperatively. CONCLUSION: The quiescent and mobile NRS scores in the 75 mg pregabalin group were lower than the 50 mg pregabalin group with a combination of 1 g intravenous paracetamol after SC surgery. SP levels in the 75 mg pregabalin group decreased compared to the 50 mg pregabalin group with a 1 g intravenous paracetamol combination which experienced an increase after CS surgery. Pregabalin 75 mg is recommended for preventive use in CS surgery.

Intravenous paracetamol infusion and tramadol as agents for post operative pain relief in urosurgical patient: A randomized control trial

Analgesia is one of the most important consideration in perioperative setting as it determines the recovery and discharge of a patient. Among the drugs used for analgesia, non steroidal anti-inflammatory drugs and opioids are the most commonly used ones in the current scenario. The aim of this study was to compare the efficacy of intravenous (IV) paracetamol and IV tramadol in alienating pain postoperatively. 100 adult patients of ASA grade I & II in the age group of 25-55 years were randomized into two groups of 50 patients , scheduled for elective urosurgical procedures and  were administered IV paracetamol and IV tramadol 30 minutes before the completion of surgery for postoperative analgesia and assessment was done with visual analog scale (VAS)score. In the present study, both the drugs showed effective pain relief. The onset of analgesia is faster in tramadol group. In paracetamol group, the onset of analgesia was slightly delayed but pain scores significantly decreased after 60 min, and this was observed up to 6 h with a statistically significant decrease in post operative nausea vomiting( PONV )with paracetamol group . 

A comparative study of the analgesic effects of intravenous ketorolac, paracetamol, and morphine in patients undergoing video-assisted thoracoscopic surgery: A double-blind, active-controlled, randomized clinical trial

Background:

Opioids are traditionally used as the drug of choice for the management of postoperative pain. However, their use is limited in patients undergoing Video-assisted thoracic surgery (VATS), due to their side effects, such as respiratory depression, nausea, and vomiting.

Aim:

In this double-blind active-controlled randomized study, we have compared the analgesic effects of ketorolac and paracetamol to morphine.

Methods:

Patients were randomly chosen from a pool of candidates who were undergoing VATS and were divided into three groups. During the first 24 h postsurgery, patients in the control group received a cumulative dose of morphine 20 mg, while patients in two treatment groups received ketorolac 120 mg and paracetamol 4 g in total. Doses were administered as bolus immediately after surgery and infusion during the first 24 h. Patients' pain severity was evaluated by visual analogue scale rating (VAS) at rest and during coughing episodes.

Results:

The average pain score at recovery time was 2.29 ± 2.13 and 2.26 ± 2.16 for ketorolac and paracetamol, respectively, and it was significantly lower than the morphine group with an average pain score of 3.87 (P = 0.003). Additionally, the VAS score during cough episodes was significantly higher in the control group throughout the study period compared to study groups. Comparison of mean morphine dose utilized as liberation analgesic (in case of patients had VAS >3) between three groups was not significantly different (P = 0.17).

Conclusion:

Our study demonstrates the non-inferiority of ketorolac and paracetamol to morphine in controlling post-VATS pain without causing any significant side effects. We also show that ketorolac and paracetamol are superior to morphine in controlling pain during 2 h postsurgery.

Perioperative Analgesia for Patients Undergoing Thyroidectomy and Parathyroidectomy: An Evidence-Based Review

Objective:

To perform an evidence-based systematic review evaluating perioperative analgesia, including opioid alternatives, used for patients undergoing thyroidectomy and parathyroidectomy.

Methods:

A comprehensive literature search from 1997 to January 2018 of Pubmed, Cochrane, and EmBase libraries was performed for studies reporting analgesic administration following thyroid or parathyroid surgery. This systematic review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Studies were evaluated for level of evidence and given a Jadad score to assess for risk of bias. Outcomes gathered included postoperative pain scores, time to rescue analgesia, rescue analgesic consumption, and adverse events.

Results:

Thirty-eight randomized controlled trials met inclusion criteria. The GRADE criteria determined the overall evidence to be moderate-high. Studies utilizing NSAIDs reported reduced requirements for rescue analgesics. Acetaminophen studies presented with conflicting data on effectiveness. Gabapentinoid studies demonstrated lower pain scores and an increased time to rescue analgesic. Local anesthetics were effective at decreasing Visual Analogue Scale (VAS) and Numeric Rating Scale (NRS) pain scores while also reducing rescue analgesic consumption. Ketamine was shown to increased postoperative nausea and vomiting. NSAIDs and local anesthetic studies had an aggregate grade of evidence A, while all others had grade B evidence.

Conclusion:

There is significant evidence supporting the use of NSAIDs and local anesthetics in the perioperative period for pain management for thyroid and parathyroid surgeries. Acetaminophen, gabapentinoid and ketamine have some supporting evidence and may serve as adequate alternatives. Further multi-institutional RCTs are warranted to delineate optimal analgesic regimens.

Level of Evidence:

NA

Paracetamol as a basic component of a modern approach to adequate perioperative analgesia

The problem of adequate perioperative anesthesia is one of the most pressing in the current health care system, given its medical, humanistic and socio-economic aspects. Currently, the standard of postoperative analgesia is multimodal analgesia (MMA). One of the major and required components of MMA is paracetamol, which has antipyretic and analgesic effects with limited peripheral anti-inflammatory activity. Most authors consider intravenous paracetamol as a base drug in a multimodal analgesia strategy for a variety of surgical interventions, which reduces the need for opioids and reduces the side effects of the latter, which in turn significantly affects the results of treatment and the length of hospital stay.Numerous studies in many countries have created a broad evidence base for the clinical use of this drug. Due to its pharmacokinetic and pharmacodynamic properties, it has been shown that intravenous paracetamol has several advantages over oral and rectal forms: early and more effective onset of analgesia and stable maintenance of the therapeutic dose of paracetamol are explained by the formation of a faster and higher peak in the concentration of the drug. The side effects of using paracetamol can be compared with placebo. The mechanism of action of the drug is different from the mechanism of action of NSAIDs, however, is still not fully understood. It may possibly involve inhibition of cyclooxygenase, cannabinoid, or nitric oxide pathways in the central nervous system. Intravenous paracetamol is a safe and effective first-line drug for the treatment of moderate pain in the perioperative period.

Prescription and Usage Pattern of Opioids after Thyroid and Parathyroid Surgery

OBJECTIVE

We seek to characterize the prescribing patterns of opioids, opioid consumption, and pain severity after thyroid and parathyroid surgery. We also aim to determine if a relationship exists between preoperative medication use and postoperative pain or opioid consumption.

STUDY DESIGN

Case series with chart review.

SETTING

Academic university hospital.

SUBJECTS AND METHODS

Medical records of 237 adult patients undergoing thyroid and parathyroid surgery were included. Clinicopathologic data were collected, including pain scores, preoperative medications, and inpatient pain medications.

RESULTS

The mean maximum pain score was 5.74 and varied by surgery type (range, 0-10). Mean pain score decreased to 2.61 upon discharge (0-8) and to 0.51 at the first postoperative visit. Patients with a length of stay exceeding 1 day had significantly higher maximum pain scores than those with a length of stay of 0 or 1 day (8 vs 5.58, P < .001). Morphine milligram equivalents while in the hospital averaged 25.4 per day and were significantly influenced by preoperative opioid use (0-202). Acetaminophen/oxycodone was the most commonly prescribed opioid. The mean number of pills prescribed postoperatively was 43.1 (0-120).

CONCLUSION

In our population, patients are discharged with opioid prescriptions that may be in excess of their requirements following thyroid and parathyroid surgery. Preoperative opioid use was associated with higher postoperative pain score and, on multivariate analysis, greater inpatient opioid consumption. Further investigation is warranted to ensure that we are prescribing opioids appropriately following thyroid and parathyroid surgery.

Paracetamol Instead of Ketorolac in Post-Video-Assisted Thoracic Surgery Pain Management: A Randomized Trial

BACKGROUND

Video-assisted thoracic surgery (VATS) is a minimally invasive procedure that is growing more common around the world. Despite causing less pain compared open thoracic surgery, postoperative pain management is still important.

OBJECTIVES

The aim of the present study was to compare the analgesic effects of paracetamol and ketorolac in VATS patients.

METHODS

This was a double-blinded randomized clinical trial conducted on 70 patients undergoing lobectomy or segmentectomy due to lung masses, using video-assisted methods. The patients were randomly divided into two groups (each n = 35): the ketorolac (K) group and the paracetamol (P) group. The K group received ketorolac 30 mg IV stat at the end of surgery and then a 90 mg/24 h infusion. The P group received paracetamol 1 g IV stat at the end of surgery and then a 3 g/24 h infusion. Pain scores were recorded during recovery and 2, 4, 8, 12, and 24 hours after drug administration. Pain scores, total doses of rescue analgesics, and patient satisfaction levels were compared between the groups.

RESULTS

There was no significant difference between the K and P groups in pain scores in any of the evaluations. Seventeen (48.6 %) and 9 (25.7 %) patients in the K and P groups, respectively, did not require any rescue analgesia (P = 0.047). The mean doses of rescue analgesia in the K and P groups were 3.129 ± 4.27 mg and 4.38 ± 3.69 mg, respectively, which were similar (P = 0.144). There was no significant difference between the groups in satisfaction scores (P = 0.175).

CONCLUSIONS

Paracetamol 1 g stat + 3 g/24 h infusion is as effective as ketorolac 30 mg stat + 90 mg/24 h infusion in post-VATS pain management, with good tolerability and a low incidence of adverse effects.

Comparison of Efficacy and Safety of Intramuscular Piroxicam and Tramadol for Post-operative Pain in Patients Undergoing Caesarean Delivery

INTRODUCTION

Post-caesarean section pain can be both stressful and unfavourable. Effective and rapid reduction of pain facilitates early ambulation and care of the new born. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and opioids are used for pain relief but they are associated with adverse effects both in the mother and the child.

AIM

To evaluate efficacy and safety of piroxicam and tramadol in post-caesarean section pain.

MATERIALS AND METHODS

Primigravidae who underwent elective caesarean section received either piroxicam 20mg or tramadol 100mg intra-muscularly, following recovery from anaesthesia. Severity of pain was assessed using Visual Analogue Scale (VAS) and side-effects to study drugs were noted. Rescue analgesic butorphanol 2mg was administered if VAS score was more than four. Patient's satisfaction score was assessed at 12 hours post-operatively.

RESULTS

Mean age in piroxicam and tramadol groups were 23.32±3.43 and 22.03±2.0 years respectively. Significant reduction in pain was observed at 2, 4, 8, 12 and 24 hours in both groups (p<0.001). Pain relief was significant at 2, 4 and 8 hours in piroxicam group compared to tramadol. Twenty-one and 12 patients in tramadol and piroxicam groups received rescue analgesic respectively. Sedation and nausea was significantly higher in tramadol group (p<0.001), 46.66% of patients graded their satisfaction score as good and 15% as excellent in piroxicam group.

CONCLUSION

Intra-muscular piroxicam was effective in reducing post-caesarean section pain for 24 hours with minimal side-effects compared to tramadol.

Comparison of the analgesic efficacy of oral ketorolac versus intramuscular tramadol after third molar surgery: A parallel, double-blind, randomized, placebo-controlled clinical trial

BACKGROUND

Preemptive analgesia is considered an alternative for treating the postsurgical pain of third molar removal. The aim of this study was to evaluate the preemptive analgesic efficacy of oral ketorolac versus intramuscular tramadol after a mandibular third molar surgery.

MATERIAL AND METHODS

A parallel, double-blind, randomized, placebo-controlled clinical trial was carried out. Thirty patients were randomized into two treatment groups using a series of random numbers: Group A, oral ketorolac 10 mg plus intramuscular placebo (1 mL saline solution); or Group B, oral placebo (similar tablet to oral ketorolac) plus intramuscular tramadol 50 mg diluted in 1 mL saline solution. These treatments were given 30 min before the surgery. We evaluated the time of first analgesic rescue medication, pain intensity, total analgesic consumption and adverse effects.

RESULTS

Patients taking oral ketorolac had longer time of analgesic covering and less postoperative pain when compared with patients receiving intramuscular tramadol.

CONCLUSIONS

According to the VAS and UAC results, this study suggests that 10 mg of oral ketorolac had superior analgesic effect than 50 mg of tramadol when administered before a mandibular third molar surgery.

The Effects of Diclofenac Suppository and Intravenous Acetaminophen and their Combination on the Severity of Postoperative Pain in Patients Undergoing Spinal Anaesthesia During Cesarean Section

INTRODUCTION

The main tasks of postoperative care are postoperative pain and complications control which play an important role in accelerating the recovery of patient's general condition.

AIM

This study was performed in order to compare the effects of diclofenac suppository, intravenous acetaminophen and their combination on the severity of postoperative pain in patients undergoing spinal anaesthesia for cesarean section in Sayyad Shirazi teaching Hospital, Gorgon, Iran.

MATERIALS AND METHODS

This was a double-blind clinical trial on 90 patients undergoing cesarean section. The patients were randomly divided into three groups, group A: 100 mg diclofenac suppository, group B: 1000 mg intravenous acetaminophen, group C: 100 mg diclofenac suppository and 500 mg intravenous acetaminophen. The same spinal anaesthesia circumstances were applied for all the participants. At the end of surgery, pain severity was assessed according to VAS scale at different times. Data were then analysed by SPSS 18 statistical software.

RESULTS

The mean age of participants was (28.27±6.07). There was significant difference between the mean pain scores of the three groups before the intervention (p=0.018), which was considered as co-variate. This difference was more notable between the combination of acetaminophen - diclofenac group and diclofenac alone. After the intervention, significant difference was observed in mean pain severity between acetaminophen group and the combination group and also between diclofenac and the combination group. During the study, the least mean pain severity was found in the combination group and the highest was observed in the diclofenac group.

CONCLUSION

Results of this study indicates a significant effect of concomitant use of intravenous acetaminophen and diclofenac suppository on pain severity reduction and reducing the need for repeated doses of narcotics and prolonging the postoperative analgesia.

Single dose intravenous paracetamol or intravenous propacetamol for postoperative pain

BACKGROUND

This is an updated version of the original Cochrane review published in Issue 10, 2011. Paracetamol (acetaminophen) is the most commonly prescribed analgesic for the treatment of acute pain. It may be administered orally, rectally, or intravenously. The efficacy and safety of intravenous (IV) formulations of paracetamol, IV paracetamol, and IV propacetamol (a prodrug that is metabolized to paracetamol), compared with placebo and other analgesics, is unclear.

OBJECTIVES

To assess the efficacy and safety of IV formulations of paracetamol for the treatment of postoperative pain in both adults and children.

SEARCH METHODS

We ran the search for the previous review in May 2010. For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 1), MEDLINE (May 2010 to 16 February 2016), EMBASE (May 2010 to 16 February 2016), LILACS (2010 to 2016), a clinical trials registry, and reference lists of reviews for randomized controlled trials (RCTs) in any language and we retrieved articles.

SELECTION CRITERIA

Randomized, double-blind, placebo- or active-controlled single dose clinical trials of IV paracetamol or IV propacetamol for acute postoperative pain in adults or children.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, which included demographic variables, type of surgery, interventions, efficacy, and adverse events. We contacted study authors for additional information. We graded each included study for methodological quality by assessing risk of bias and employed the GRADE approach to assess the overall quality of the evidence.

MAIN RESULTS

We included 75 studies (36 from the original review and 39 from our updated review) enrolling a total of 7200 participants.Among primary outcomes, 36% of participants receiving IV paracetamol/propacetamol experienced at least 50% pain relief over four hours compared with 16% of those receiving placebo (number needed to treat to benefit (NNT) = 5; 95% confidence interval (CI) 3.7 to 5.6, high quality evidence). The proportion of participants in IV paracetamol/propacetamol groups experiencing at least 50% pain relief diminished over six hours, as reflected in a higher NNT of 6 (4.6 to 7.1, moderate quality evidence). Mean pain intensity at four hours was similar when comparing IV paracetamol and placebo, but was seven points lower on a 0 to 100 visual analog scale (0 = no pain, 100 = worst pain imaginable, 95% CI -9 to -6, low quality evidence) in those receiving paracetamol at six hours.For secondary outcomes, participants receiving IV paracetamol/propacetamol required 26% less opioid over four hours and 16% less over six hours (moderate quality evidence) than those receiving placebo. However, this did not translate to a clinically meaningful reduction in opioid-induced adverse events.Meta-analysis of efficacy comparisons between IV paracetamol/propacetamol and active comparators (e.g., opioids or nonsteroidal anti-inflammatory drugs) were either not statistically significant, not clinically significant, or both.Adverse events occurred at similar rates with IV paracetamol or IV propacetamol and placebo. However, pain on infusion occurred more frequently in those receiving IV propacetamol versus placebo (23% versus 1%). Meta-analysis did not demonstrate clinically meaningful differences between IV paracetamol/propacetamol and active comparators for any adverse event.

AUTHORS' CONCLUSIONS

Since the last version of this review, we have found 39 new studies providing additional information. Most included studies evaluated adults only. We reanalyzed the data but the results did not substantially alter any of our previously published conclusions. This review provides high quality evidence that a single dose of either IV paracetamol or IV propacetamol provides around four hours of effective analgesia for about 36% of patients with acute postoperative pain. Low to very low quality evidence demonstrates that both formulations are associated with few adverse events, although patients receiving IV propacetamol have a higher incidence of pain on infusion than both placebo and IV paracetamol.

A comparative study of intravenous paracetamol and intravenous tramadol for postoperative analgesia in laparotomies

Background:

Pain in the perioperative setting or thereafter plays a significant role in delaying an otherwise successful recovery. Hence, mitigation of such postoperative pain assumes importance. Among the various agents employed for such mitigation, opioids and non-steroidal anti-inflammatory drugs have for some time taken center stage. However, alas they are not without their share of adverse effects. This study was undertaken with the purpose of elucidating the efficacy of intravenous (IV) paracetamol as compared to IV tramadol in mitigating postoperative pain while observing its effect on hemodynamic stability and the presence of adverse drug reactions, if any.

Materials and Methods:

A total of 60 randomized cases aged ranges from 20 to 60 years of both sexes divided into two groups (each for paracetamol and tramadol) scheduled for laparotomies were administered IV paracetamol and tramadol for postoperative pain relief and assessed with visual analog scale (VAS) score and variations in vital parameters to ascertain extent of pain relief and post-operative nausea vomiting (PONV).

Results:

Data so collected was statistically interpreted, and observations extrapolated. Save for a perceptible decline in PONV with paracetamol group compared with tramadol group with a statistically significant P < 0.001, nothing statistically significant was observed in any other parameter, including VAS scores between either group.

Conclusion:

IV paracetamol is a safer alternative to tramadol with lesser PONV in the postoperative period translates into the lesser duration of hospitalization and hence earlier discharge.

Therapeutic approaches for renal colic in the emergency department: a review article

Context:

Renal colic is frequently described as the worst pain ever experienced, and management of this intense pain is necessary. The object of our review was to discuss different approaches of pain control for patients with acute renal colic in the emergency department.

Evidence Acquisition:

Studies that discussed the treatment of renal colic pain were included in this review. We collected articles from reputable internet databases.

Results:

Our study showed that some new treatment approaches, such as the use of lidocaine or nerve blocks, can be used to control the severe and persistent pain of renal colic.

Conclusions:

Some new approaches are discussed and their impact on renal colic pain control was compared with traditional therapies. The effectiveness of the new approaches in this review is similar or even better than in traditional treatments.

Oral oxycodone plus intravenous acetaminophen versus intravenous morphine sulfate in acute bone fracture pain control: a double-blind placebo-controlled randomized clinical trial

OBJECTIVES

Bone fracture is a common cause of acute pain in emergency and orthopedics departments. Targeting the multifaceted mechanisms of pain with combinations of multiple analgesics (multimodal analgesia) can increase the pain control efforts efficacy and decrease the adverse effects of each medication.

METHODS

One hundred and fifty-three patients with acute bone fracture were randomly allocated to two groups receiving intravenous morphine sulfate (74 patients) or oral oxycodone plus intravenous acetaminophen (79 patients). Pain scores and drugs' adverse effects were assessed 10, 30 and 60 min after treatment.

RESULTS

Pain scores were similar between groups before, 30 and 60 min after medication but patients in morphine sulfate group experienced less pain 10 min after medication. Eight (10.8%) patients in morphine sulfate group and 26 (32.9%) patients in acetaminophen/oxycodone group experienced nausea that was statistically significant higher (P value = 0.001). Itching was seen in 12 (15.1%) patients of acetaminophen/oxycodone group and three (4.0%) patients of patients in morphine sulfate group (P value = 0.02).

CONCLUSION

Intravenous acetaminophen plus oral oxycodone is as effective as intravenous morphine sulfate in acute pain control in emergency department but with a less desirable safety profile.

Intravenous acetaminophen vs. ketorolac for postoperative analgesia after ambulatory parathyroidectomy

Background and methods Minimally invasive parathyroidectomy requires limited analgesia and short recovery times. The preferred post-operative analgesic regimen for this patient population has not been established but non-narcotic components would be quite appropriate. The aim of the study was to determine whether intravenous (IV) acetaminophen (1 g) or ketorolac (30 mg) provide better pain control after parathyroidectomy. A parallel, randomized, double blind, comparative study was completed on 180 patients scheduled for outpatient parathyroidectomy utilizing general anesthesia. Patients were randomized to a blinded administration of either intravenous acetaminophen 1 g or ketorolac 30 mg intra-operatively. Upon arrival but before premedication, baseline pain scores were assessed in all patients. A consecutive series of postoperative pain scores were collected every 15 min using a 10 cm visual analog pain scale (VAS) upon arrival to the post anesthesia care unit (PACU) until discharge by blinded study personnel. Other data collected included: anesthesia time, surgical time, time to discharge, supplemental morphine and postoperative side effects. Results Overall mean postoperative VAS scores were not significantly different between the two treatment groups (p = 0.07). However, ketorolac produced significantly lower pain scores compared with acetaminophen in the later postoperative periods (3.9 ± 1.9 vs. 4.8 ± 2.4 at 45 min, p = 0.009; 3.4 ± 1.7 vs. 4.5 ± 2.1 at 60min, p = 0.04; and 3.2 ± 2.1 vs. 4.4 ± 2.1 at 75 min, p = 0.03). Supplemental morphine was administered to 3 patients in the ketorolac group and 9 patients in the acetaminophen group but total consumption was not significantly different between groups (p = 0.13). The occurrence of nausea was significantly lower in the ketorolac group compared with the IV acetaminophen group (3.4% vs. 14.6%, respectively; p = 0.02). The overall incidence of morphine supplementation, vomiting, headache, muscular pain, dizziness, and drowsiness were not significantly different when compared between the treatment groups. Conclusions Both postoperative regimens provided adequate analgesia but patients receiving ketorolac intraoperatively had significantly lower pain scores at later recovery time points and significantly lower occurrences of nausea. Implications The large volume of patients undergoing parathyroidectomies at our facility warranted a study to develop a standardized postoperative analgesic regimen. We conclude both medications can be utilized safely in this patient population, but there is a slight advantage in pain control with the usage of ketorolac for minimally invasive parathyroidectomies.

Intravenous acetaminophen: a review of pharmacoeconomic science for perioperative use

Hospitals are subject to more economic pressures than ever before. On the one hand, cost containment or cost reduction is paramount, particularly in relation to costly branded pharmaceuticals. On the other hand, quality measures and value-based reimbursement penalizes poor patient care. Multimodal analgesia sits squarely in this quandary, since its very nature requires use of multiple drugs with their associated costs, though this approach has the potential to improve quality of care. We undertook a comprehensive review of the pharmacoeconomics of IV acetaminophen, a new drug useful as part of a multimodal analgesic approach. While this new branded drug adds to direct drug costs, there is clear potential for IV acetaminophen to reduce the incidence of opioid-related adverse events and, in so doing, result in net hospital savings. This review describes many clinical studies showing significant improvements in postoperative nausea and vomiting, excessive sedation and pruritus. In addition, we describe studies demonstrating faster recovery times in the post-anesthesia care unit, intensive care unit and total hospital length of stay. Lastly, we summarize many studies demonstrating the robust effect of IV acetaminophen on patient satisfaction. A holistic view of total hospital performance should be adopted when reviewing drugs rather than a silo mentality within the pharmacy. While IV acetaminophen adds to drug costs, the body of evidence indicates this drug has the potential to improve outcomes and hospital efficiency.

Medical management of acute pain in patients with chronic pain

The number of patients with chronic pain has increased over the years, as well as the number of patients who manage chronic pain with opioids. As prescribed opioid use has increased, so has its abuse and misuse. It has also been estimated that the number of people using opioids illicitly has doubled worldwide over the last 20 years. Management of chronic pain with opioids is associated with pathophysiological phenomena such as tolerance, dependence and hyperalgesia. They can become a problem when chronic pain patients present for a surgical procedure. Furthermore, patients who are on opioids on a regular basis require higher amounts during the perioperative period. The perioperative management of the chronic pain patient is difficult and complex. Developing an appropriate plan that can fulfill patients' and surgical team's needs requires skills and experience. The aim of this review is to describe the options available for the optimal perioperative management of acute pain in patients with a history of chronic pain.

Comparing the efficacy of preemptive intravenous paracetamol on the reducing effect of opioid usage in cholecystectomy

BACKGROUND

The purpose of the present study was to determine the post-operative analgesic effects of preemptive intravenous (iv) paracetamol and the amount of reduction in tramadol (Contramal(®)) consumption.

MATERIALS AND METHODS

Following local research ethics committee approval, ASAI-II, 300 patients were assigned in a randomized manner into three groups: Group I (preemptive) received iv paracetamol 1 g/100 mL 10 min before skin inscision and 100 mL of saline solution at the end of the operation, Group II (post-operative) received 100 mL of saline solution 10 min before skin inscision and iv paracetamol 1 g/100 mL at the end of the operation and Group III (placebo) received 100 mL of saline solution 10 min before skin insicision and 100 mL of saline solution at the end of the operation as well. The time to first analgesic requirement use and 24 h total analgesic consumption were recorded. Visual analog scale (VAS) pain scores were obtained from all patients at 15, 30, min 1, 2, 4, 6, 8, 12 and 24 h after the end of the operation.

RESULTS

Time to first analgesic requirement was significantly longer in Group I and Group II, compared to Group III (P < 0.05). Time to first analgesic requirement was significantly longer in Group I compared to Group II (P < 0.05). Total analgesic consumption and postoperative VAS pain scores recorded were significantly lower in Group I and II, compared to Group III. Total analgesic consumption and postoperative VAS pain scores recorded were significantly lower in Group I compared to Group II (P < 0.05).

CONCLUSION

In conclusion, preemptive iv paracetamol provided effective and reliable pain control after cholecystectomy surgeries and reduced post-operative pain scores, the need for and use of supplementary opioids and the time to first request of analgesics.

Intravenous acetaminophen reduces postoperative nausea and vomiting: a systematic review and meta-analysis

Opioids are a key risk factor for postoperative nausea and vomiting (PONV). As intravenous (i.v.) acetaminophen reduces postoperative pain and opioid requirements, one would expect i.v. acetaminophen to be associated with a lower incidence of opioid-induced side effects, including PONV. We conducted a systematic search using Medline and Cochrane databases supplemented with hand search of abstract proceedings to identify randomized-controlled trials of i.v. acetaminophen. Inclusion criteria were (a) randomized for i.v. acetaminophen vs a placebo control, (b) general anesthesia, and (c) reported or obtainable PONV outcomes. Primary outcome was postoperative nausea and secondary outcome was postoperative vomiting. We included 30 studies with 2364 patients (1223 in the acetaminophen group, 1141 in the placebo group). The relative risk (95% confidence interval) was 0.73 (0.60-0.88) for nausea and 0.63 (0.45-0.88) for vomiting. Data showed significant heterogeneity for both nausea (P=0.02, I(2)=38%) and vomiting (P=0.006, I(2)=47%), but were homogeneous when studies were grouped according to timing of first administration: i.v. acetaminophen reduced nausea when given prophylactically either before surgery, 0.54 (0.40-0.74), or before arrival in the postanesthesia care unit, 0.67 (0.55-0.83); but not when given after the onset of pain, 1.12 (0.85-1.48). When i.v. acetaminophen was given prophylactically, the reduction of nausea correlated with the reduction of pain (odds ratio 0.66, 0.47-0.93), but not with reduction in postoperative opioids (odds ratio 0.89, 0.64-1.22). Prophylactically administered i.v. acetaminophen reduced PONV, mainly mediated through superior pain control.

Endogenous opiates and behavior: 2011

This paper is the thirty-fourth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2011 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 (Section 16); and immunological responses (Section 17).