Hala Saad Abdel-Ghaffar

Effect of the addition of clonidine to locally administered bupivacaine on acute and chronic postmastectomy pain.

STUDY OBJECTIVES To investigate the analgesic effect of adding clonidine to topical bupivacaine for acute and chronic postmastectomy pain. DESIGN Randomized, prospective, double-blinded study. SETTING Cancer institute and university hospital. PATIENTS 140 ASA physical status 1 and II women, aged 30 to 50 years, scheduled for modified radical mastectomy with axillary dissection for breast carcinoma. INTERVENTIONS Patients were divided into 4 groups of 35 patients each, to receive either saline 0. 9% (control group), plain bupivacaine 0.5% (Bupivacaine group), plain bupivacaine 0.5% and 150 μg of clonidine (Clonidine150 group), or plain bupivacaine 0.5% and 250 μg of clonidine (Clonidine250 group). Study drugs were irrigated into the surgical field before skin closure. MEASUREMENTS AND MAIN RESULTS Pain severity, time to first request of rescue analgesia, analgesic consumption, hemodynamics, and side effects were recorded in the first 48 hours postoperatively. The frequency of neuropathic pain was assessed using the Douleur Neuropathique 4-question survey (DN4) in the first and second postoperative months. Mean time to first postoperative analgesic request was significantly prolonged in the Bupivacaine (5.76 ± 0.85 hrs), Clonidine150 (11.6 ± 2.38 hrs), and Clonidine250 (17.4 ± 3.27 hrs) groups compared with the control group (1.86 ± 0.65 hrs). Postoperative tramadol consumption and visual analog scores (VAS) were significantly reduced in the Bupivacaine, Clonidine150, and Clonidine250 groups. Clonidine250 group patients had the lowest VAS scores from 2 to 48 hours postoperatively. Lower mean DN4 scores (P = 0.000) and a significantly reduced frequency of neuropathic pain (P < 0.04) were recorded in the Bupivacaine, Clonidine150, and Clonidine250 groups, with a nonsignificant difference noted among the treatment groups. CONCLUSIONS The addition of clonidine to topical bupivacaine accentuated its early postoperative analgesic efficacy.

Efficacy of ketamine as an adjunct to lidocaine in intravenous regional anesthesia.

Background This study aims to compare and evaluate the effect of adding ketamine as an adjunct to lidocaine for intravenous regional anesthesia (IVRA) on intraoperative and postoperative analgesia, the onset and recovery times of sensory and motor block, and tourniquet pain. Methods Forty patients undergoing surgery of the hand or forearm under IVRA were randomly assigned to receive lidocaine 3 mg/kg (group 1) or lidocaine 3 mg/kg plus ketamine 50 mg (group 2) diluted to 40 mL with normal saline. Assessment parameters included the onset and recovery times of sensory and motor block, tourniquet pain, intraoperative hemodynamics, surgeon and patient satisfaction, postoperative pain, time of first analgesic request, total analgesic consumption, and adverse effects in the first 24 hours postoperatively. Results Groups 1 and 2 were comparable in demographic and surgical parameters. There were no differences between groups in intraoperative hemodynamics, onset and recovery times of sensory and motor block, or surgeon satisfaction index. Compared with group 1, group 2 patients showed less tourniquet pain, prolonged time to first request for postoperative rescue analgesia (5.5 ± 1.3 vs 20.4 ± 3.7 hours, P < 0.001), lower postoperative diclofenac consumption (120.00 ± 45.23 vs 55.1 ± 0.00 mg, P < 0.001), lower scores for postoperative pain as measured by the Verbal Rating Scale, higher patient satisfaction index, and a nonsignificant difference in the incidence of postoperative adverse effects between groups. Conclusions The addition of ketamine to lidocaine in patients receiving IVRA significantly reduced intraoperative and postoperative analgesic requirements and improved patient satisfaction without causing significant adverse effects.

Efficacy and safety of intraoperative dexmedetomidine in pediatric posttonsillectomy pain: Peritonsillar versus intravenous administration

Abstract Background Although being used off-label, the utility of dexmedetomidine in pediatric settings is increasing. Alpha-2 agonists have peripheral analgesic effects. This prospective, randomized, double-blind, Placebo-controlled study was designed to evaluate the safety and efficacy of dexmedetomidine single intraoperative preincisional dose in pediatric patients undergoing tonsillectomy and adenoidectomy. Patients and methods Eighty-four children (5–12 years) were randomized into three groups: DEX.IV (n = 28) received dexmedetomidine 1 μg/kg iv. infusion in 10 min, DEX.PT (n = 28) received dexmedetomidine 1 μg/kg peritonsillar infiltration, and the Placebo controls (n = 28). Assessment parameters included pain, sedation, hemodynamics, and adverse effects. Results Intraoperative dexmedetomidine administration resulted in a significant reduction in pain scores postoperatively in the DEX.IV and DEX.PT groups, with no significant difference between them. The time to first postoperative analgesic request was significantly prolonged in DEX.IV (583.45 ± 157.94 min, P < 0.000) and DEX.PT (537.61 ± 106.17 min, P < 0.000) groups compared with the Placebo group (119.75 ± 43.44 min). Similarly, a significantly lower paracetamol consumption during the first postoperative day was recorded in the DEX.IV (459.37 ± 114.82 mg, P < 0.000) and DEX.PT (475.38 ± 143.11 mg, P < 0.000) groups, than in the Placebo group (705.00 ± 249.27 mg), with no significant difference between DEX.IV and DEX.PT groups. Patients in the DEX.IV group exhibited significantly prolonged extubation times ((13.83 ± 3.38 min, P < 0.000) and significantly higher mean Ramsay sedation scores at 15, 30, 60, 120, and 180 min postoperative (P < 0.000), compared with DEX.PT and Placebo groups. The mean intraoperative heart rates were significantly slower in DEX.IV group during and after the intravenous infusion of dexmedetomidine and at 15th min intraoperative (p < 0.05), compared with DEX.PT and Placebo groups, with no significant differences in mean heart rates among the groups in other time points measured. Patients in DEX.PT group had a significantly higher total oral intake in first day postoperative (P < 0.000) and a significantly higher family satisfaction (p < 0.000), compared with DEX.IV and Placebo groups. Conclusion Peritonsillar infiltration or iv. dexmedetomidine similarly enhanced the postoperative analgesia after tonsillectomy in pediatric patients. However, locally applied dexmedetomidine was associated with no systemic effects, higher total oral intake in first day postoperative, and higher family satisfaction.

Safety and efficacy of pre-incisional peritonsillar lornoxicam in paediatric post-tonsillectomy pain: a prospective double-blind, placebo-controlled, split-body clinical study.

To evaluate the risk of peri‐operative bleeding and re‐intervention with peritonsillar lornoxicam infiltration in paediatric tonsillectomy.

Preincisional peritonsillar vs. intravenous lornoxicam for posttonsillectomy analgesia: A clinical and platelet aggregometry comparative study

Abstract Background Lornoxicam is a fairly new short-half oxicam with an improved tolerability profile. Our objective was to investigate the safety and efficacy of intravenous and peritonsillar infiltration of 8 mg lornoxicam on pain relief in children undergoing tonsillectomy. Methods In a double-blinded, placebo-controlled trial, 60 children were randomized into three groups; intravenous group (n = 20), received lornoxicam 8 mg iv., infiltration group (n = 20) received lornoxicam 8 mg peritonsillar infiltration, and placebo controls (n = 20). The verbal rating pain scale, time to first postoperative analgesic request, total analgesic consumption during 1st 24 h postoperative, platelet aggregometry before, 15 min, 2 and 24 h after study drug administration, intraoperative blood loss, postoperative bleeding, and adverse effects were evaluated. Results The time to first postoperative analgesic request was significantly prolonged in intravenous (318.75 ± 67.37 min) and infiltration (214.50 ± 43.06 min) groups compared with placebo group (66.75 ± 26.95 min). A significantly lower mean postoperative VRS scores and significantly reduced 1st day postoperative diclofenac consumption were recorded in iv. group (44.73 ± 9.31 mg), compared with infiltration (69.80 ± 38.71 mg) and placebo (87.8 ± 24.40 mg) groups. An increased intraoperative blood volume losses and intraoperative bleeding complains were observed in infiltration group (34.25 ± 11.93 ml), rather than in iv. (28.85 ± 10.01 ml) and placebo (24.75 ± 8.70 ml) groups. The (%) of platelet aggregation with ADP, collagen, and arachidonic acid was significantly reduced 15 min and 2 h after study drug administration with highest decreases in iv. group compared with infiltration and placebo groups. No patients reported postoperative bleeding or GIT adverse effects in the study. Conclusion Intraoperative preincisional intravenous lornoxicam enhanced postoperative analgesia after tonsillectomy in children. In comparison, the analgesic efficacy of locally applied lornoxicam was inferior to intravenous administration and was associated with increased incidence of intraoperative bleeding.

Topical versus caudal ketamine/bupivacaine combination for postoperative analgesia in children undergoing inguinal herniotomy

Background: Multiple studies claim that caudal administration of ketamine causes effective postoperative analgesia. The aim of this study was to assess the clinical effectiveness of ketamine after caudal or topical administration in pediatric patients undergoing inguinal herniotomy. Patients and Methods: This randomized, comparative, double-blind study included eighty children (aged 6 months to 6 years) received either 1 ml/kg of 0.25% bupivacaine/ketamine 0.5 mg/kg for caudal analgesia (caudal group) or 0.3 ml/kg of 0.25% bupivacaine/ketamine 0.5 mg/kg sprayed by the surgeon around the spermatic cord and upon the ilioinguinal nerve before wound closure for topical analgesia (topical group). The duration of postoperative analgesia, pain scores, rescue analgesic consumption, sedation score, hemodynamic monitoring, and side-effects were evaluated 48 h postoperative. Results: Kaplan–Meier survival analysis of analgesia free time demonstrated a significant advantage of topical ketamine (TK) group over caudal ketamine (CK) group. The duration of postoperative analgesia was longer in TK group than in CK group (28.74 ± 2.88 vs. 21.43 ± 5.01 h, P < 0.000). Fewer children asked for oral analgesics in the topical group (24 of 36, 66.7%) than in the caudal one (28 of 32, 87.5%; P < 0.01). Postoperative pain scores at the 6th till 48th h were lower in topical group with comparable analgesic consumption between two groups. In the caudal group, four subjects suffered from retention of urine: Two presented with a residual motor block and two had photophobia. Conclusion: Wound instillation of bupivacaine/ketamine is a simple, noninvasive, and effective technique that could be a safe alternative to CK for postoperative analgesia in children undergoing inguinal hernia repair.

Effect of Topical Morphine on Acute and Chronic Postmastectomy Pain: What Is the Optimum Dose?

Background and Objectives Poorly controlled postoperative pain is strongly associated with the development of chronic pain. We aimed to investigate the effect of topical morphine (in 1 of 3 doses: 5, 10, or 15 mg) on acute and chronic neuropathic pain after modified radical mastectomy for cancer breast. Methods In this registered clinical trial (ClinicalTrials.gov identifier: NCT02462577), 90 patients were allocated to receive 10 mL plain bupivacaine 0.5% plus either 5, 10, or 15 mg morphine (designated by the group names Morphine5, Morphine10, and Morphine15, respectively). The combination was diluted by saline 0.9% to 20 mL and irrigated in the wound before skin closure. Groups were compared for the following: time to first postoperative analgesia; intravenous patient-controlled analgesia (PCA) morphine consumption; pain scores; hemodynamics; sedation; adverse events in first postoperative 48 hours; and Leeds Assessment of Neuropathic Symptoms and Signs scores in first and third postoperative months. Results No patient in the Morphine15 group requested postoperative PCA morphine versus 19 and 8 in the Morphine5 and Morphine10 groups, respectively (P < 0.002). Time to first analgesic request and total consumption of PCA morphine analgesia were 7.31 ± 3.12 hours versus 14.00 ± 3.54 hours (P < 0.000) and 1.42 ± 0.50 mg versus 1.00 ± 0.00 mg (P = 0.371) in the Morphine5 and Morphine10 groups, respectively. Lowest scores on visual analog pain scale at rest (P < 0.001) and visual analog pain scale during movement (P < 0.01) were recorded in the Morphine15 group, followed by Morphine10 then Morphine5 group. Lowest Leeds Assessment of Neuropathic Symptoms and Signs scores were recorded in the Morphine15 group in the first month (1.10 ± 0.37 vs 5.76 ± 3.26 and 4.73 ± 2.87, P < 0.0001) and third postoperative month (4.40 ± 1.77 vs 6.33 ± 3.21 and 5.43 ± 2.67, P < 0.006) compared with Morphine5 and Morphine10 groups, respectively. No patient in the Morphine15 group developed chronic pain versus 4 and 2 in Morphine5 and Morphine10 groups, respectively. Conclusions Topical morphine controlled acute postmastectomy pain in a dose-dependent manner and reduced the incidence and severity of chronic postmastectomy pain syndrome.

Cetamina como adjuvante de bupivacaína em bloqueio do nervo infraorbitário para analgesia após correção de lábio leporino

OBJECTIVES We conducted this study to investigate the safety and analgesic efficacy of the addition of Ketamine to Bupivacaine in bilateral extra-oral infra-orbital nerve block in children undergoing cleft lip surgeries. METHODS Sixty patients were randomly allocated into two groups (n=30), Group B received infra-orbital nerve block with 2mL of 0.25% Bupivacaine and Group BK received 0.5mg.kg-1 Ketamine for each side added to 1mL of 0.5% Bupivacaine solution diluted up to 2mL solution to 0.25% Bupivacaine concentration. Assessment parameters included; hemodynamics, recovery time, time to first oral intake, postoperative Faces Legs Activity Cry Consolability (FLACC) scores, Four-point Agitation scores, analgesic consumption and adverse effects. RESULTS Patients in Group BK showed lower postoperative FLACC scores during all recorded time points (p<0.0001). Two patients in Group BK versus 12 in Group B requested for postoperative rescue analgesia (p<0.001). There were no differences between groups in time, minutes (min), to first request for rescue analgesia. Patients in Group BK reported lower analgesic consumption (366.67±45.67 vs. 240.0±0.0mg, p<0.04). The time to first oral intake was significantly reduced in Group BK (87.67±15.41 vs. 27.33±8.68min, p<0.001). Lower postoperative Agitation scores were recorded in Group BK patients that reached a statistical significance at 45min (0.86±0.11 vs. 0.46±0.16, p<0.04) and in the first hour (h) postoperatively (1.40±0.17 vs. 0.67±0.14, p<0.003). Higher parent satisfaction scores were recorded in Group BK (p<0.04) without significant adverse effects. CONCLUSIONS The addition of Ketamine to Bupivacaine has accentuated the analgesic efficacy of infra-orbital nerve block in children undergoing cleft lip repair surgeries.