Bilge Karsli

Early postoperative pain management after thoracic surgery; pre- and postoperative versus postoperative epidural analgesia: a randomised study

OBJECTIVES Effective analgesia and blockade of the perioperative stress response may improve outcome and epidural analgesia plays a role in the reduction of pulmonary complications following thoracic surgery. In this study, we assessed preoperative and postoperative thoracic epidural analgesia (Preop-TEA and Postop-TEA) techniques on post-thoracotomy pain in 61 patients undergoing posterolateral thoracotomy. METHODS A thoracic epidural catheter was inserted into all the patients before surgery. In Group I, 8 mL of 0.25% bupivacaine plus fentanyl 50 microg in 2 mL was administered preoperatively. In Group II, no medication was administered via the epidural catheter preoperatively and intraoperatively. Postoperative analgesia was maintained with patient-controlled epidural analgesia with bupivacaine and fentanyl solution in both groups. Pain was evaluated at 2, 4, 8, 12, 24 and 48 h at rest and coughing. RESULTS Preop-TEA Group was associated with decreased pain compared with the Postop-TEA Group. CONCLUSIONS In conclusion, preoperative epidural analgesia is an appropriate method for post-thoracotomy pain and is more effective in preventing acute postoperative pain.

Superior cluneal nerve entrapment eight years after decubitus surgery.

Background and Objective:  Superior cluneal nerve (SCN) entrapment is one of the infrequent etiologies of low back pain (LBP), which is rarely diagnosed. Few clinical reports have been published in the literature. We present a case of severe LBP radiating to the ipsilateral buttock after decubitus surgery.

Intravenous single-dose tramadol versus meperidine for pain relief in renal colic.

BACKGROUND AND OBJECTIVE Comparison of the effectiveness of tramadol with meperidine given intravenously to emergency patients with suspected renal colic. METHODS A double-blind, randomized clinical trial was performed in the Emergency Department of a tertiary-care university hospital. Consecutive patients with suspected renal colic (n = 47) were randomized to receive intravenously an initial dose of tramadol 50 mg (n = 23) or meperidine 50 mg (n = 24). After 30 min, additional doses of meperidine 50 mg were given intravenously as a rescue medication in an open fashion. Pain relief was assessed using a 10 cm visual analogue scale, the primary outcomes being pain relief at 15 and 30 min after the analgesics. Secondary outcomes were the frequency of rescue meperidine use and the development of side-effects. RESULTS Visual analogue scale pain scores after 15 and 30 min decreased in both tramadol and meperidine groups (P < 0.05). However, pain relief was better in the meperidine group at the 15 and 30 min evaluations (P < 0.05). Only 11 patients (48%), initially receiving meperidine, needed more meperidine compared with 16 patients (67%) initially receiving tramadol. Both drugs were well tolerated with no adverse effects occurring in either group. CONCLUSIONS Meperidine 50 mg was superior to tramadol 50 mg for acute pain relief in patients with suspected renal colic when given intravenously. Because many patients in both groups received supplemental meperidine and the response to tramadol alone cannot be predicted, clinicians may want to choose higher doses of meperidine alone or other alternative combinations.

The analgesic and sedative effects of intrathecal midazolam in perianal surgery

Background and objective: Our purpose was to evaluate the analgesic and sedative effects of intrathecal midazolam when added to spinal bupivacaine in patients undergoing perianal surgery under spinal anaesthesia. Methods: Forty-four patients were randomly allocated into two equal groups: Group I (B) received hyperbaric bupivacaine 0.5% 2 mL + saline 0.9% 1 mL in a total volume of 3 mL intrathecally; Group II (BM) received hyperbaric bupivacaine 0.5% 2 mL + 1 mL of 2 mg preservative-free midazolam in a total volume of 3 mL intrathecally. In both groups, the onset and recovery times of sensory block, the degree and recovery times of motor block as well as the sedation and visual analogue pain scores were recorded, and statistically compared. Results: In Group BM, the postoperative visual analogue pain scores were significantly lower at the first 4 h (P < 0.05), the average time until the first dose of additional analgesic requirement was significantly longer (P < 0.05), and sedation scales were significantly higher (P < 0.05), compared to Group B. There were no statistically significant differences in the onset and the full recovery times of sensory and motor blocks in the two groups. Conclusion: The use of intrathecal midazolam combined with intrathecal bupivacaine produces a more effective and longer analgesia with a mild sedative effect in perianal surgery.

Intrathecal fentanyl added to hyperbaric ropivacaine for transurethral resection of the prostate

Background:  Our purpose was to evaluate the effect of intrathecal fentanyl 25 µg added to 18 mg of 6 mg ml−1 hyperbaric ropivacaine on the characteristics of subarachnoid block and postoperative pain relief in patients undergoing TURP surgery.

Effects of hyperbaric spinal ropivacaine for caesarean section: with or without fentanyl.

Background and objective: Adding various opioids to the local anaesthetic solution administrated intrathecally improves the analgesic potency of spinal analgesia. The purpose of this study was to evaluate the efficacy and safety of intrathecal fentanyl 10 μg added to 15 mg hyperbaric ropivacaine in patients undergoing caesarean section under spinal anaesthesia. Methods: Thirty‐seven healthy, full‐term parturients were randomly assigned into two groups: Group S (saline group, n = 17) received 15 mg hyperbaric ropivacaine in 2.5 mL + 0.5 mL saline; Group F (fentanyl group, n = 20) received 15 mg hyperbaric ropivacaine in 2.5 mL + 10 μg fentanyl in 0.5 mL, intrathecally. Characteristics of spinal block, intraoperative quality of spinal anaesthesia, time to first feeling of pain (complete analgesia), time to first request of analgesics postoperatively (effective analgesia), side‐effects and fetal outcomes were evaluated. Results: Regression of sensory block to L5 was significantly prolonged in the fentanyl group compared with the saline group (P = 0.001). Time to the first feeling of pain (130.6 ± 15.8 min vs. 154.3 ± 31.1 min; P = 0.008) and the first analgesic requirement (161.2 ± 32.6 min vs. 213.0 ± 29.3 min; P < 0.001) were significantly shorter in the saline group compared with the fentanyl group. Side‐effects, umbilical arterial and venous blood gases did not differ between the groups. Apgar scores were similar in both groups and no infants had an Apgar score ≤7 at 5 min. Conclusions: The addition of fentanyl 10 μg, to hyperbaric ropivacaine 15 mg, for spinal anaesthesia increased the duration of analgesia in the early postoperative period in patients undergoing caesarean delivery.

Evaluation of the Outcomes of Ice Application for the Control of Pain Associated with Chest Tube Irritation

The aim of this study was to evaluate the effectiveness of the use of ice for the control of pain associated with chest tube irritation. The randomized and single-blinded study consisted of 40 patients (20 in the control and 20 in the study group) who underwent thoracotomy with chest tube placement. The same general anesthesia protocol was used for all patients, and the procedure was performed by the same surgery team. Procedures such as decortication and thoracic wall resection were not included in the study. Standard postoperative analgesic methods were applied to all patients. Additionally, ice (in flexible and bendable cold gel packs wrapped in fine cloth sheaths) was applied to the chest tube insertion site at the 24th, 28th, 36th, and 40th postoperative hours for 20 minutes. To assess the effectiveness of ice application, Verbal Category Scale and Behavioral Pain Scale methods were used to measure the severity of pain. Average pain severity scores during the mobilization activities, including coughing and walking, were compared and found to be significantly lower in the study group patients who received cold therapy than in the control group patients (p < .05). Additionally, analgesic consumption was lower in the study group than in the control group patients (p < .05). As a result, the application of ice to the chest tube insertion site reduced pain associated with irritation along with the need for analgesics.

Pain Relief for Children after Adenotonsillectomy

Effective pain relief following adenotonsillectomy in children remains a challenge. This study evaluated the effects of intramuscular 0.5 mg/kg ketamine, 1 mg/kg tramadol or 1 mg/kg meperidine on post-operative pain and recovery in 45 children aged 1-7 years undergoing adenotonsillectomy. Anaesthesia was induced with thiopental or sevoflurane (with succinylcholine for intubation) and was maintained with sevoflurane in oxygen and nitrous oxide. Post-operative pain was scored blind using a modified Toddler–Preschooler Post-Operative Pain Scale 30, 60, 120 and 240 min after tracheal extubation. Post-operative agitation scores were also recorded. Mean post-operative pain score was significantly higher in the tramadol-treated group compared with the meperidine-treated group 120 min after extubation. At all other time-points after extubation, mean post-operative pain scores were similar for the three treatment groups. Ketamine was associated with a significantly higher mean agitation score compared with tramadol and meperidine. We conclude that the effects of ketamine, meperidine and tramadol on post-operative pain following adenotonsillectomy in children were similar.

Analgesic effects of intrathecal neostigmine in perianal surgery.

Background and objective: In recent human and animal studies, intrathecal administration of various doses of neostigmine produces analgesia without neurotoxicity. The aim was to examine the effects of intrathecal neostigmine and bupivacaine in patients undergoing perianal surgery under spinal anaesthesia. Methods: The patients were randomly allocated into three groups of 15: Group 1 (controls) received hyperbaric bupivacaine 10 mg + dextrose 5%, 1 mL, to a total volume of 3 mL; Group 2 received hyperbaric bupivacaine 10 mg + neostigmine 25 μg in dextrose 5%, 1 mL, to a total volume of 3 mL; and Group 3 received hyperbaric bupivacaine 10 mg + neostigmine 50 μg in dextrose 5%, 1 mL, to a total volume of 3 mL. Results: The onset of sensory block was significantly earlier for Group 2 and 3 patients compared with Group 1 patients (P < 0.05). The full time to recovery of motor block and sensory block was significantly longer in Group 3 compared with Group 1 (P < 0.05). In Group 3, the average time until the first dose of tramadol was longer than Group 1 (P < 0.05). The incidence rate of nausea and vomiting was significantly higher in Groups 2 and 3 than in Group 1 (P < 0.05). Conclusions: The use of intrathecal neostigmine as an analgesic drug in perianal surgery is unsatisfactory because of prolonged motor blockade and nausea.

In Vitro Effects of Opioids on Pregnant Uterine Muscle

Opioids are often used for obstetric analgesia. Ideal obstetric analgesia is attained with optimal pain relief and minimal risk for the parturient. Therefore, investigators in the present study explored the effects of different opioids on the myometrium of pregnant rats. Myometrial strips were exposed to increased concentrations of fentanyl (10-8 M to 10-6 M), alfentanil (10-8 M to 10-4 M), remifentanil (10-8 M to 10-4 M), and meperidine (10-8 M to 10-4M). Decreased contractile activity was observed in myometrial strips isolated from pregnant rats at cumulative concentrations of fentanyl, alfentanil, remifentanil, and meperidine. The amplitude of contractions was reduced with increasing concentrations of opioids; this effect was statistically significant at a concentration of 10-4 M. When administered at higher concentrations, opioids may decrease contractions in pregnant rat myometrium.