Darcy Paige

The efficacy of intramuscular ketorolac in combination with intravenous PCA morphine for postoperative pain relief

STUDY OBJECTIVE To examine the efficacy of intramuscular (IM) ketorolac used in combination with intravenous (IV) patient-controlled analgesia (PCA) morphine for postoperative pain relief following intra-abdominal gynecologic surgery. DESIGN Randomized, double-blind, placebo-controlled study. SETTING Patient care unit at a university medical center. PATIENTS Thirty-five healthy women undergoing intra-abdominal gynecologic surgery who requested postoperative PCA. INTERVENTIONS Postoperatively, all patients received IV PCA morphine, with the PCA device programmed to deliver a maximum of 1 mg every 6 minutes (maximum of 30 mg over 4 hours). In addition, patients received one of three regimens: (1) IM saline every 6 hours; (2) IM ketorolac 30 mg while in the postanesthesia care unit (PACU), followed by 15 mg every 6 hours; or (3) IM ketorolac 60 mg while in the PACU, followed by 30 mg every 6 hours. MEASUREMENTS AND MAIN RESULTS Patients were assessed at regular intervals. Visual analog scale (VAS) scores were used to assess analgesia and patient satisfaction with therapy. Data on morphine usage were obtained from the PCA device, and the frequency and severity of adverse effects were assessed for the presence or absence of side effects. Cumulative morphine dosages were lower (p less than 0.05) in both ketorolac groups at 12, 18, and 24 hours. VAS scores and the frequency of side effects did not differ significantly among groups. CONCLUSIONS IM ketorolac significantly decreased PCA morphine requirements. The analgesic effects of the two drugs appear to be additive.

A comparison of fentanyl, esmolol, and their combination for blunting the haemodynamic responses during rapid-sequence induction

The purpose of this randomized, double-blind study was to compare the ability of a combination of fentanyl and esmolol to blunt the haemodynamic effects of intubation with that of either agent alone. Patients received fentanyl or saline four minutes before, and esmolol or saline two minutes before rapid-sequence induction of anaesthesia. The F2 group (n = 24) received fentanyl 2 μg · kg−1, the E2 group (n = 24) received esmolol 2 mg · kg−1, the F2/E2 group (n = 25) received a combination of fentanyl 2 μg · kg−1 and esmolol 2 mg · kg−1, and the F5 group (n = 26) received fentanyl 5 μg · kg−1. Following tracheal intubation, the maximum percent change from baseline heart rate was less in the F2/E2 and F5 groups (12% and 16% respectively) than in the E2 group (34%)(P < 0.05). The maximum percent changes from baseline systolic blood pressure in the F2/E2 and F5 groups (15% and 6% respectively) were less than in the F2 and E2 groups (24% and 33% respectively) (P < 0.05). The combination of a low dose of fentanyl and esmolol provides an alternative to a higher dose of fentanyl for blunting the haemodynamic responses to laryngoscopy and tracheal intubation during rapidsequence induction in healthy patients.RésuméCette étude randomisée, à double insu, compare la capacité de blocage de la réponse hémodynamique à l’intubation de l’association fentanyl/esmolol avec celle des deux agents utilisés séparément. Les patients reçoivent soit du fentanyl ou du soluté physiologique, soit de l’esmolol ou du soluté physiologique, respectivement à quatre minutes et à deux minutes de l’induction d’une anesthésie à séquence rapide. Le groupe F2 (n = 24) reçoit fentanyl 2 μg · kg−1, le groupe E2 (n = 24) reçoit esmolol 2 mg · kg−1, le groupe F2/E2 (n = 25) reçoit une association de 2 μg · kg−1 de fentanyl et d’esmolol 2 mg · kg−1 et le groupe F5 (n = 26) reçoit fentanyl 5 μg · kg−1. Après l’intubation endotrachéale, le pourcentage maximal de variation de la fréquence cardiaque initiale est moindre pour les groupes F2/E2 et F5 (respectivement 15% et 16%) que pour le groupe E2 (34%) (P < 0,05). Le pourcentage maximal de variation de la tension systolique initiale pour les groupes F2/E2 et F5 (respectivement 15% et 6%) est moindre que pour les groupes F2 et E2 (respectivement 24% et 33%) (P < 0,05). L’association d’une faible dose de fentanyl et d’esmolol constitue une alternative valable aux doses élevées de fentanyl pour atténuer les effets hémodynamiques de la laryngoscopie directe et de l’intubation endotrachéale lors de l’induction à sequence rapide de l’anesthésie chez des sujets en bonne santé.

Comparison of epidurally administered sufentanil, morphine, and sufentanil-morphine combination for postoperative analgesia.

Postoperative analgesia provided by epidurally administered sufentanil and/or morphine was evaluated in 45 patients recovering from major gynecologic surgery. At the first complaint of pain in the Postanesthesia Care Unit, patients received a single epidural bolus of 30 μg sufentanil (group A), 5 mg morphine (group B), or 30 μg sufentanil plus 3 mg morphine (group C) in a randomized blinded fashion. Analgesic efficacy was assessed throughout the 24-h study period with 10-cm visual analog scales. The need for additional postoperative analgesia (patient‐controlled analgesia, 1 mg of morphine every 6 min as necessary) and the incidence of adverse effects were also assessed.Patients receiving sufentanil (groups A and C) had significantly faster onset of analgesia than did patients given morphine alone (group B, P<0.05). Group B subjects experienced the longest duration of analgesia (B us A and C, P<0.05) and required significantly less patient‐controlled analgesia (morphine) than patients in group A (P<0.05). No patient developed clinically significant respiratory depression or excessive sedation, and there were no intergroup differences in incidence of pruritus or nausea (P value not significant). The data indicate that a mixture of sufentanil and morphine provides either a more rapid onset of epidural analgesia or reduced patient‐controlled analgesia narcotic requirement than respective doses of each agent administered alone.

Intravenous Ketorolac as an Adjunct to Patient-Controlled Analgesia (PCA) for Management of Postgynecologic Surgical Pain

STUDY OBJECTIVE To determine whether intravenous (IV) doses of ketorolac tromethamine provide safe and effective augmentation of postsurgical analgesia for patients using IV patient-controlled analgesia (PCA) with morphine. DESIGN Randomized, double-blind, placebo-controlled, dose-response evaluation. SETTING Patient care unit at a university medical center. PATIENTS 62 ASA physical status I-III females recovering from intra-abdominal gynecologic surgery with general anesthesia who requested postoperative PCA. INTERVENTIONS Following initial pain assessment in the recovery room, patients were randomized to receive either IV saline (placebo) followed by IV saline every 6 hours (Group 1); IV ketorolac 30 mg loading dose followed by IV ketorolac 15 mg every 6 hours (Group 2); or IV ketorolac 60 mg loading dose followed by IV ketorolac 30 mg every 6 hours (Group 3). All patients were provided IV PCA, which was programmed to provide 1.2 mg of morphine with a 6-minute lockout interval. MEASUREMENTS AND MAIN RESULTS Visual analog scale (VAS) resting pain and satisfaction scores were measured every 2 to 12 hours. Cumulative PCA with morphine and the frequency and severity of side effects also were assessed. IV ketorolac showed no clinically significant side effects. Group 2 patients experienced significant reductions in VAS resting pain scores (p < 0.05), and a trend toward decreased morphine self-administration in both active groups was noted. Group 2 and Group 3 patients reported greater satisfaction with postsurgical analgesia than Group 1 patients. (p < 0.05). CONCLUSIONS IV ketorolac used as an analgesic adjunct provided safe and effective augmentation of PCA with morphine in patients recovering from intra-abdominal gynecologic surgery.

Transdermal Fentanylfor Postoperative Pain Management in Patients Recovering from Abdominal Gynecologic Surgery

The current placebo-controlled double-blinded study was undertaken to assess the safety and efficacy, as well as the potential clinical role, of the transdermal therapeutic system (TTS) of fentanyl delivery in the postoperative setting. TTS patches releasing 25 micrograms.h-1 or 50 micrograms.h-1 or placebo were applied to 95 women 1 h before abdominal gynecologic surgery during general anesthesia. Postoperatively, patients self-administered intravenous morphine as required using patient-controlled analgesia with a 1-mg incremental dose and a 6-min lockout interval. Each was assessed upon admission to the postanesthesia care unit and at intervals over the following 72 h with respect to vital signs, visual analogue scale pain and satisfaction scores, side effects, and cumulative morphine use. Data were analyzed using analysis of variance, Kruskal-Wallis, and chi-square. P less than 0.05 was considered significant. There were no demographic differences among groups. Beginning 32 h after TTS application, a statistically significant morphine-sparing effect was seen with the 50 micrograms.h-1 patch. There were no significant differences among groups with regard to visual analogue scale pain scores at rest, patient satisfaction, or the incidence of side effects; a significant reduction in pain upon movement was noted at 24 h in patients treated with TTS 50 micrograms.h-1. This finding constituted the only benefit noted with this form of analgesic therapy in the present investigation.

Patient-controlled analgesia with sufentanil: A comparison of two different methods of administration

STUDY OBJECTIVE To examine the safety and analgesic efficacy of sufentanil administered via either epidural or intravenous (i.v.) patient-controlled analgesia (PCA) in patients recovering from gynecologic surgery. DESIGN Randomized, double-blind comparison. SETTING Patient care unit at a university medical center. PATIENTS 29 healthy women presenting for major intraabdominal gynecologic surgery with epidural anesthesia who requested postoperative PCA. INTERVENTIONS Following completion of surgery performed using epidural anesthesia with 2% lidocaine and i.v sedation, patients were assigned to one of three treatment groups: Group 1-epidural PCA (EPCA) with sufentanil: 0.3 microgram/kg bolus followed by 8 micrograms/hr infusion plus epidural PCA boluses of 4 micrograms every 6 min as needed; Group 2-i.v. PCA with sufentanil: 0.3 microgram/kg bolus followed by 8 micrograms/hr infusion plus IV PCA boluses of 4 micrograms every 6 min as needed; or Group 3-i.v. PCA with morphine: 0.1 mg/kg bolus followed by 0.5 mg/hr infusion plus i.v. PCA boluses of 1 mg every 6 min as needed. MEASUREMENTS AND MAIN RESULTS Patients were observed at regular intervals during a 24-hour evaluation period. Visual analog scale (VAS) scores were used to assess analgesia and satisfaction with therapy. Pulmonary function was assessed by monitoring respiratory rate, oxygen (O2) saturation, and forced expiratory flow. Total opioid dose delivered and the presence/severity of side effects was also collected. Sufentanil plasma levels were measured in a subset of eight patients. Patients receiving either EPCA or i.v. PCA sufentanil experienced equivalent analgesia that was more rapid in onset than i.v. PCA morphine. Total dose administered and plasma concentration of drug were similar in both sufentanil groups; however, a greater number of patients in the i.v. delivery group experienced clinically significant O2 desaturation. CONCLUSIONS The main advantage of EPCA sufentanil in this postsurgical setting was its ability to provide a more rapid onset of analgesia than traditional i.v. PCA with morphine while offering greater safety than i.v. sufentanil.

Influence of promethazine on symptom-therapy scores for nausea during patient-controlled analgesia with morphine.

We assessed whether adding promethazine to the syringe containing morphine for patient-controlled analgesia (PCA) decreases nausea after gynecologic surgery. Patients were assigned randomly to receive PCA (morphine 1.5 mg, 6-min lockout interval) with or without promethazine (0.625 mg/PCA dose, providing an average of 17.6 mg/24 h). Assessments included a visual analogue scale (VAS) for nausea (0 = none, 10 = worst possible) at scheduled times, rescue therapy requirements, and a maximum symptom-therapy score that provided an aggregate assessment of nausea intensity, duration, and response to rescue therapy (0 = no nausea; 1 = mild; 2 = moderate, requiring droperidol; 3 = severe or persistent, requiring droperidol; 4 = requiring droperidol + transdermal scopolamine; 5 = unrelieved). Nausea scores on the visual analogue scale at 2, 6, 8, and 24 h and use of rescue droperidol identified no significant differences between the groups. However, symptom-therapy scores differed significantly, with median values of 0 and 2, respectively, for the promethazinetreated and control groups. We conclude that simultaneous titration of morphine and promethazine de-creases nausea associated with PCA therapy; the difference may best be appreciated with use of the combined symptom-therapy score.

Postoperative analgesia with parenteral opioids: does continuous delivery utilizing a transdermal opioid preparation affect analgesic efficacy or patient safety?

STUDY OBJECTIVES To compare, in patients who underwent major orthopedic surgical procedures, the efficacy of intravenous (IV) patient-controlled analgesia (PCA) with morphine combined with continuous administration of two doses of fentanyl or placebo via transdermal therapeutic system with fentanyl (TTSF) patches. DESIGN Randomized, double-blind, placebo-controlled study. SETTING University teaching hospital. PATIENTS 62 patients aged 18 to 65 years, presenting for elective orthopedic surgery and general anesthesia. INTERVENTIONS Patients were randomized to one of three groups: group 1 received two placebo patches; group 2 received a 20 cm2 active patch delivering 50 micrograms/hr of fentanyl and a 30 cm2 placebo patch; group 3 received a 30 cm2 active patch delivering 75 micrograms/hr of fentanyl and a 20 cm2 placebo patch. All patches were placed approximately two hours prior to induction of general anesthesia. General anesthesia was induced with thiopental, intubation facilitated by the use of vecuronium or pancuronium, and anesthesia was maintained with isoflurane in an oxygen/nitrous oxide mixture (O2/N2O). Following surgery, IV morphine was provided using IV PCA with 1.5 mg of morphine with a 6-minute lockout and a 4-hour maximum dosage of 30 mg. MEASUREMENTS AND MAIN RESULTS The time and dosage of morphine administered was recorded. Vital signs, pain intensity at rest, level of sedation, and arterial oxygen saturation (SpO2) were measured at intervals throughout the 72-hour study period and at 6 and 12 hours following patch removal. The presence of side effects was noted. Visual analog pain scores throughout the 72 hours of the study were not significantly different among groups. Patients receiving active TTSF required less IV PCA morphine at all time intervals. However, total opioid consumption was comparable among groups. The incidence of side effects was similar in all groups. CONCLUSIONS There is no significant advantage to the routine use of continuous transdermal opioid delivery in patients receiving IV PCA after major orthopedic surgery.