A single dose of celecoxib 200 mg improves postoperative analgesia provided via patient-controlled epidural technique after caesarean section

The Current Consideration, Approach, and Management in Postcesarean Delivery Pain Control: A Narrative Review

Optimal postoperative analgesia has a significant impact on patient recovery and outcomes after cesarean delivery. Multimodal analgesia is the core principle for cesarean delivery and pain management. For a standard analgesic regimen, the use of long-acting neuraxial opioids (e.g., morphine) and adjunct drugs, such as scheduled acetaminophen and nonsteroidal anti-inflammatory drugs, is recommended unless contraindicated. Oral or intravenous opioids should be reserved for breakthrough pain. In addition to the aforementioned use of multimodal analgesia, preoperative evaluation is critical to individualize the analgesic regimen according to the patient requirements. Risk factors for severe postoperative pain or analgesia-related adverse effects will require modifications to the standard analgesic regimen (e.g., the use of ketamine, gabapentinoids, or regional anesthetic techniques). Further investigation is required to determine analgesic drugs or dose alterations based on preoperative predictions for patients at risk of severe pain. Outcomes beyond pain and analgesic use, such as functional recovery, should be determined to evaluate analgesic treatment protocols.

Lessons learned from first case of Cesarean delivery in a COVID-19 positive parturient in Greek region

We report the successful anesthetic management of a 24-year-old patient, with an active COVID-19 viral infection, scheduled for elective Cesarean section at 40^th week of pregnancy. This was the first case in Greek region, and we report and discuss the difficulties and safety issues regarding a COVID-19 positive patient during an elective cesarean delivery. Regional anesthesia with full protective equipment for health personnel involved, along with careful planning and adherence to guidelines achieved safe completion of the operation.

Systemic adjunct analgesics for cesarean delivery: a narrative review

It is critical to adequately treat postoperative cesarean delivery pain. The use of parenteral or neuraxial opioids has been a mainstay, but opioids have side effects that can be troubling and the opioid crisis in the United States has highlighted the necessity to utilize analgesics other than opioids. Other analgesic options include neuraxial analgesics, nerve blocks such as the transversus abdominis plane block, and non-opioid parenteral and oral medications. The goal of this article is to review non-opioid systemic analgesic adjuncts following cesarean delivery, focusing on their efficacy and side effects as well as their impact on reduction of opioid requirements after surgery.

The Analgesic Efficacy of Nonsteroidal Anti-inflammatory Agents (NSAIDs) in Patients Undergoing Cesarean Deliveries: A Meta-Analysis

BACKGROUND AND OBJECTIVES

Postoperative pain after cesarean delivery, which accounts for approximately 1 in 3 live births in the United States, can be severe in many patients. Nonsteroidal anti-inflammatory agents (NSAIDs) are potent analgesics that are effective in the treatment of postoperative pain. In this meta-analysis, we assessed the analgesic efficacy of NSAIDs in postoperative cesarean delivery patients.

METHODS

An electronic literature search of the Library of Medicine's PubMed, Cochrane CENTRAL, Scopus, and EMBASE databases was conducted in May 2013 and updated in January 2015 (Appendix, Supplemental Digital Content 1, http://links.lww.com/AAP/A174). Searches were limited to randomized controlled trials. The primary outcome variable was visual analog scale or numerical rating scale pain scores. Secondary outcomes included cumulative postoperative opioid consumption and opioid-related adverse effects (drowsiness/sedation, nausea, and vomiting). Data extraction was performed independently by 2 reviewers. Extracted data were input into Review Manager.

RESULTS

Twenty-two randomized controlled trials compared a NSAID (n = 639) to a control (n = 674). Patients in the NSAID group versus control reported lower pain scores at 12 hours (P = 0.003) and at 24 hours (P < 0.001). Subgroup analysis showed a significant difference in pain scores at 24 hours, with patients receiving NSAIDs via intravenous/intramuscular (P < 0.001) route, but not the oral (P = 0.39) or rectal routes (P = 0.99). Significantly lower average pain scores were reported for pain with movement at 24 hours in the NSAID group (P = 0.001). Patients in the NSAID group versus controls consumed significantly less opioids (P < 0.001) and had significantly less drowsiness/sedation (P = 0.03), but there was no significant difference between the groups with regard to nausea or vomiting (P = 0.48 and P = 0.17, respectively).

CONCLUSIONS

The perioperative use of NSAIDs in cesarean delivery patients will result in a significantly lower pain scores, less opioid consumption, and less drowsiness/sedation but no difference in nausea or vomiting compared to those who did not receive NSAIDs. Further research should address the optimal NSAID regimen and examine the effect of improved analgesia on patient-centered outcomes such as patient satisfaction and quality of breastfeeding.

The effects of treadmill exercise on penicillin-induced epileptiform activity

INTRODUCTION

The aim of this study was to evaluate the effects of short-, moderate- and long-duration treadmill exercise (15, 30 and 60 min) on the mean frequency and amplitude of penicillin-induced epileptiform activity in rats.

MATERIAL AND METHODS

In this study, 32 rats were assigned to 15, 30, and 60 min running exercise groups and the control group, each consisting of 8 rats. According to the specified protocol, the rats were submitted to running exercises at the same hour of each day for 90 days. After the exercise program, the rats were administered (500 IU/2.5 µl) of penicillin into the left cortex by the microinjection method. An electrocorticogram (ECoG) recording was performed for 3 h using a data acquisition system. The frequency and the amplitude of the recordings were analyzed.

RESULTS

Short-duration treadmill exercise (15 min) caused a decrease in the frequency of penicillin-induced epileptiform activity at 70 min after penicillin injection (p < 0.001). The mean frequency of epileptiform activity decreased at 90 min after penicillin injection in the 30 and 60 min treadmill exercise groups (p < 0.01). The mean amplitude of epileptiform activity was not changed in any of the exercise groups compared to the control (p > 0.05).

CONCLUSIONS

The results of the present study demonstrate for the first time that short-, moderate- and long-duration treadmill exercises decreased the frequency of penicillin-induced epileptiform activity. These findings may contribute to improving the quality of life in epileptic patients.

Postoperative analgesia using fentanyl plus celecoxib versus epidural anesthesia after laparoscopic colon resection

PURPOSE

Effective postoperative analgesia is essential to a patient's recovery after laparoscopic colon resection (LCR). We introduce a new analgesic protocol using fentanyl plus celecoxib following LCR.

METHODS

The subjects of this retrospective comparative study were 137 patients who underwent LCR, 63 of whom were treated with 72 h of epidural anesthesia (group E), and 74 of whom were treated with 24 h of fentanyl intravenous injection followed by 7 days of oral celecoxib (group FC). We evaluated the safety and efficacy of this new protocol.

RESULTS

The combination of fentanyl and celecoxib maintained a low postoperative pain score (<1.5, evaluated by the FACES Pain Scale) and reduced the need for rescue analgesic drugs for 7 days (groups E vs. FC: 5.39 ± 3.77 vs. 2.79 ± 2.92, p < 0.001). The postoperative hospital stay was almost equal for the two groups (E vs. FC: 11.1 ± 4.5 vs. 10.3 ± 4.8 days, p = 0.315). The operating room stay other than for surgery was significantly shorter for group FC (E vs. FC: 128.7 ± 30.5 vs. 107.2 ± 17.0 min, p < 0.001). Neither group experienced complications, apart from one group FC patient, who suffered transient nausea and vertigo.

CONCLUSIONS

The new analgesic protocol using fentanyl plus celecoxib is an effective and time-saving strategy for LCR.

A comparison between fentanyl plus celecoxib therapy and epidural anesthesia for postoperative pain management following laparoscopic gastrectomy

PURPOSE

To clarify the efficacy of postoperative pain management following laparoscopic gastrectomy (LG), we retrospectively compared pain assessments in patients who received fentanyl plus celecoxib with those who received epidural anesthesia.

METHODS

From 2011 to 2012, 55 consecutive LG patients at our institution received 48 h of epidural anesthesia for postoperative pain management (group-E). Since September 2013, epidural anesthesia was replaced with 24 h of intravenous fentanyl and 4 days of oral celecoxib. Thirty-three consecutive LG patients who received this analgesic method (group-FC) were included in this analysis. The severity of postoperative pain as assessed by the FACES Pain Rating Scale and the frequency of rescue pain medication were retrospectively compared between the two groups.

RESULTS

No significant difference in the severity of postoperative pain on postoperative day (POD) 0 or 1 was observed between the two groups. In contrast, pain was significantly lower in group-FC than group-E on PODs 2, 3, 4, and 7. The total use of rescue pain medications during the first 7 days following LG did not differ between the two groups.

CONCLUSION

Pain management using 24 h of intravenous fentanyl and 4 days of oral celecoxib is comparable to epidural anesthesia following LG.

Influence of genetic polymorphisms on the pharmacokinetics of celecoxib and its two main metabolites in healthy Chinese subjects

Celecoxib is a selective cyclooxygenase-2 inhibitor used extensively for the treatment of rheumatism and osteoarthritis. The aim of this study was to evaluate the influence of the genetic polymorphisms of CYP2C9, CYP2D6 and CYP3A4 on the pharmacokinetics (PK) of celecoxib and its two main metabolites, hydroxyl-celecoxib and carboxy-celecoxib, in healthy Chinese subjects, based on a bioequivalence study of celecoxib. This study was an open-label, two-period, crossover study. 52 healthy Chinese male subjects were recruited and were genotyped for CYP2C9*3, CYP2C9*13, CYP2D6*10 and CYP3A4*18 by using polymerase chain reactions (PCR). They were randomly divided into two groups and each group received either 200mg test formulation followed by reference formulation or vice versa with a one-week washout period. Safety and tolerability were monitored throughout the study and no severe adverse events were observed. Genotyping using PCR revealed that none of the subjects carried the CYP3A4*18 and CYP2C9*13. Therefore, the influence of the CYP2C9*3 and CYP2D6*10 on the PK of celecoxib and its metabolites in Chinese was studied. Compared with CYP2C9*1/*1 group, pharmacokinetic parameters of celecoxib such as AUC0-48 and Cmax was increased by 90.6% and 45.8%, the t1/2 was extended by 21.8% and the CL/F was decreased by 51.1% in CYP2C9*1/*3 group. In terms of hydroxy-celecoxib, compared with CYP2C9*1/*1 group, the Cmax was decreased by 17.2%, the t1/2 prolonged 42.1% in CYP2C9*1/*3 group. In terms of carboxy-celecoxib, the AUC0-48 was increased by 25.2%, the t1/2 prolonged 16.1% and the CL/F was decreased by 21.2% in CYP2C9*1/*3 group. Except for the t1/2 of hydroxy-celecoxib, no statistically significant difference was observed in other pharmacokinetic parameters of hydroxy-celecoxib and carboxy-celecoxib between the two CYP2C9 genotypic groups. This study revealed that there was no significant influence of CYP2D6*10 on the metabolism of celecoxib, and the expression of CYP2C9*3 led to increased drug exposure and slowed drug disposition in healthy Chinese male subjects.

Enhanced water-soluble derivative of PC407 as a novel potential COX-2 inhibitor injectable formulation

PC407 is an effective COX-2 inhibitor in non-steroidal anti-inflammatory drug development but the poor solubility limits their usefulness. The aim of the study was to prepare and evaluate 4-oxo-4-[4-(5-(naphthalen-2-yl)-3-(trifluoromethyl)-1H-pyrazol-1-yl)benzenesulfonamido]butyrate disodium, a derivative of PC407 with enhanced water solubility for injectable formulation. The prepared derivative displayed interesting high aqueous solubility (20.3 mg/mL, much superior to the parent compound PC407, 1.6 μg/mL) with confirmed in vivo analgesic activity. This derivative represents the profiles of prodrug and potential candidate of PC407 for the development of injectable COX-2 inhibitor due to extraordinary water solubility, low toxicity, and impressive analgesic activity.