Hak Y. Wong

A Randomized, Double-blind Evaluation of Ketorolac Tromethamine for Postoperative Analgesia in Ambulatory Surgery Patients

BackgroundGiven he trend toward early discharge of patients after surgery and the inherent adverse effects of opioid analgesics, we compared a new nonsteroidal antiinflammatory drug, ketorolac tromethamine, given intravenously (iv) and then orally, with two commonly prescribed opioid analgesics in ambulatory patients for up to 1 week after surgery. MethodsIn this study Incorporating a double-blind, multidose design, 221 patients who had moderate or severe pain after surgery were randomized to one of three treatment groups: group K30 received 30 mg iv ketorolac twice, then 10 mg iv every 30 min as required to control pain, up to six doses, followed by 10 mg oral ketorolac every 4–6 h; group F50 received 50 μg iv fentanyl at the same time intervals as in group K30, followed by 60 mg codeine plus 600 mg acetaminophen (C + A) orally every 4–6 h; and group F10 received the same combination as did group F50, but only 10 Mg fentanyl per dose. ResultsCompared with 50 Mg fentanyl iv, 30 mg iv ketorolac provided delayed but otherwise equivalent analgesic effects and was associated with similar side effects. Compared with C + A, 10 mg oral ketorolac was associated with a lower Incidence of nausea and somnolence and earlier return of bowel function but not better pain relief, drug tolerabllity, quality of life, or psychologic well-being. ConclusionsKetorolac, when used in an iv and then oral sequence, is a safe and effective analgesic in the ambulatory surgery setting. It has a slower onset than fentanyl, but causes fewer side effects than C + A.

The effect of a new NPO policy on operating room utilization

STUDY OBJECTIVES To prospectively assess the impact of a liberalized preoperative fasting policy on operating room (OR) utilization. STUDY DESIGN Prospective cohort study involving data collection before and after a change in nil per os (NPO) policy. SETTING Academic teaching hospital. PATIENTS 5,420 consecutive outpatients and AM admissions. INTERVENTIONS Data collection was done on all adult patients who presented to our OR suite over two 15-week periods. During the first 15-week period, patients were instructed to drink no liquids after midnight (control group, n = 2,646). In the second 15-week period, patients were allowed to consume unlimited clear fluids until 2 to 3 hours prior to surgery (study group, n = 2,774). MEASUREMENTS AND MAIN RESULTS We found no difference between the control and study groups in the number of cases cancelled (0 in each group) or delayed (8 vs. 9; relative risk [RR] = 1.07, 95% confidence interval [CI] = 1.000 to 1.148) due to noncompliance with fasting guidelines. There was no difference between the groups in the number of cases of aspiration (0 in each group). In the control group, significantly more episodes of regurgitation were noted (12 vs. 9; RR = 0.715, 95% CI = 0.535 to 0.955) and more rapid-sequence/awake intubations were performed (119 vs. 51; RR = 0.409, 95% CI = 0.306 to 0.546) than in the study group. CONCLUSIONS Liberalizing a preoperative fasting policy and allowing patients to consume unrestricted clear fluids up until 3 hours before their scheduled time of surgery did not affect their compliance with fasting requirements. No increase in cancellations or delays of surgical procedures due to inappropriate oral intake was observed.

The effect of low-dose bupivacaine on postoperative epidural fentanyl analgesia and thrombelastography

We performed a prospective, randomized, double-blind study to determine the effect of bupivacaine on postoperative epidural fentanyl analgesia and thrombelastography in 120 patients who underwent extensive gastrointestinal or genitourinary surgery. The patients were randomized into four groups, 30 patients per group: Group I = epidural fentanyl (EF), 10 micrograms/mL in saline; Group II = EF with 0.1% bupivacaine; Group III = EF with 0.15% bupivacaine; and Group IV = EF with 0.2% bupivacaine. Pain relief was evaluated by a visual analog scale (VAS), both at rest and during coughing, and by a visual rating scale (VRS). The VAS, VRS, degree of sedation, and side effects (nausea, vomiting, and pruritus) were evaluated every 2 h from 8:00 AM to 6:00 PM, for 24 h after surgery. Forced vital capacities (FVCs) were determined before surgery and at 24 h after surgery. Blood was withdrawn for thrombelastography (TEG) measurements preoperatively, in the recovery room (PARR), and 24 h postoperatively. The VAS, VRS, sedation scores, changes in postoperative FVCs, and the incidence of side effects were not statistically different among the four groups. The 24-h total volumes of infusion in the four groups (146 +/- 40 mL, 140 +/- 38 mL, 142 +/- 40 mL, 124 +/- 21 mL, respectively) were not statistically different from each other. There were no significant differences in the TEG values [reaction time (R), coagulation time (K), angle (alpha), and maximum amplitude (mA)] among the four groups at anytime nor was there any difference between the baseline, PARR, and 24-h TEG values within any group.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of lidocaine on bacterial growth in propofol.

UNLABELLED Extrinsically contaminated propofol has been associated with multiple infectious complications. Injection of propofol is associated with pain that is diminished by the addition of lidocaine. Lidocaine has antibacterial properties at high concentrations, but low concentrations of lidocaine (0.1%) have not been studied. We examined the growth rates of Staphylococcus aureus, Serratia marcescens, Pseudomonas aeruginosa, and Candida albicans in propofol containing disodium edeteate with and without added lidocaine 0.1% 2, 5, and 24 h after inoculation. There was no significant difference in the number of colony-forming units between propofol with and without added lidocaine at any time after inoculation. IMPLICATIONS The addition of lidocaine to propofol in concentrations clinically effective in reducing pain on injection had no effect on microbial growth. Adherence to strict aseptic technique is further emphasized.

Dose-finding Study of Intramuscular Midazolam Preanesthetic Medication in the Elderly

Intramuscular midazolam frequently results in excessive sedation in elderly patients. The effects of preanesthetic medication with intramuscular midazolam were examined in 100 elderly patients, aged 60-86 yr, given 1, 2, or 3 mg midazolam or placebo using a randomized, double-blind study design. Level of sedation and anxiety were assessed every 15 min for 1 h. Picture cards were presented at the same times in order to assess recall of these cards 24 h later. All three doses of midazolam produced rapid onset of sedation, anxiolysis, and anterograde amnesia. These effects decreased in intensity by 60 min after drug injection. The intensity and extent of these effects were comparable with those reported with higher doses in younger patients, although with the 1-mg midazolam dose the effects were shorter-lived, and a difference from placebo was not consistently seen. Three patients (3%), all older than 70 yr, became unresponsive to vocal and tactile stimuli. This level of drowsiness was unrelated to body weight, age, or ASA physical status. We conclude that in adults between 60-69 yr old, midazolam 2 or 3 mg intramuscularly can be effective as preanesthetic medication without causing excessive drowsiness. However, intramuscular midazolam should be used cautiously, under continuous observation, in patients aged 70 yr and older because excessive drowsiness may occur.

PENTAMORPHONE FOR MANAGEMENT OF POSTOPERATIVE PAIN

The efficacy, duration, and safety of the synthetic opioid pentamorphone in the treatment of acute postoperative pain were evaluated in a randomized, double-blind study of 72 patients given 0.08, 0.16, or 0.24 μg/kg of pentamorphone or a placebo intravenously in the recovery room after major abdominal or orthopedic surgery. Only patients given 0.24 μg/kg of pentamorphone experienced decreased pain intensity and increased sedation, both transient in duration. Although the two higher doses of pentamorphone delayed the patients request for supplemental morphine, the total amount of morphine required within the first hour was not different between treatments. No acute cardiores- piratory changes were observed. Pentamorphone (0.08–0.24 μg/kg) was ineffective for treating acute postoperative pain after major surgery.