Il Ok Lee

Pain after laparoscopic cholecystectomy: the effect and timing of incisional and intraperitoneal bupivacaine.

PurposeTo examine the combined preemptive effects of somatovisceral blockade during laparoscopic cholecystectomy (LC).MethodsOne hundred fifty-seven patients under general anesthesia receiving local infiltration and/or topical peritoneal local anesthesia were studied. Patients were randomized to receive a total of 150 mg (0.25% 60 mL) bupivacaine via periportal (20 mL) and intraperitoneal (40 mL with 1:200,000 epinephrine) administration of each. Group A received preoperative periportal bupivacaine before incision and intraperitoneal bupivacaine immediately after the pneumoperitoneum. Group B received periportal and intraperitoneal bupivacaine at the end of the operation. Group C (preoperative) and Group D (postoperative) received only periportal bupivacaine and Group E (preoperative) and Group F (postoperative) received only intraperitoneal bupivacaine. The control group received no treatment. Pain and nausea were recorded at one, two, three, six, nine, 12, 24, 36, and 48 hr postoperatively.ResultsThroughout the postoperative 48 hr, incisional somatic pain dominated over other pain localizations in the control group (P < 0.05). The incisional pain of groups A, B, C and D was significantly lower than that of the control group in the first and second hours. The incisional pain of groups A and C was significantly lower than that of the control group in the first three hours.ConclusionIncisional pain dominated during the first two postoperative days after LC. Preoperative somato-visceral or somatic local anesthesia reduced incisional pain during the first three postoperative hours. A combination of somato-visceral local anesthetic treatment did not reduce intraabdominal pain, shoulder pain or nausea more than somatic treatment alone. Preoperative incisional infiltration of local anesthetics is recommended.RésuméObjectifVérifier les effets préventifs d’un blocage somato-viscéral combiné, réalisé pendant la cholécystectomie laparoscopique (CL).MéthodeCent cinquante-sept patients sous anesthésie générale ont reçu une infiltration locale et/ou une anesthésie locale péritonéale topique. Les patients, répartis de façon aléatoire, ont reçu au total 150 mg (0,25 % 60 mL) de bupivacaïne administrée par la voie périportale (20 mL) et intrapéritonéale (40 mL avec I: 200 000 d’épinéphrine). Les modalités intergroupes sont les suivantes: dans le groupe A, une dose préopératoire périportale avant l’incision et une dose intrapéritonéale immédiatement après le pneumopéritoine; dans le groupe B, une dose périportale et une intrapéritonéale à la fin de l’opération; dans les groupes C (préopératoire) et D (postopératoire), seulement une périportale et dans les groupes E (préopératoire) et F (postopératoire), seulement intrapéritonéale. Le groupe témoin n’a reçu aucun médicament. La douleur et les nausées ont été notées à une, deux, trois, six, neuf, 12, 24, 36 et 48 h après l’intervention.RésultatsPendant les 48 h d’observation postopératoire, la douleur somatique de l’incision a dominé toute autre douleur chez les patients témoins (P < 0,05). La douleur incisionnelle a été significativement plus faible dans les groupes A, B, C et D que dans le groupe témoin pendant les deux premières heures. Elle a aussi été significativement plus faible dans les groupes AetC que dans le groupe témoin pendant les trois premières heures.ConclusionLa douleur incisionnelle a dominé pendant les deux premiers jours qui ont suivi la CL. L’anesthésie préopératoire somatoviscérale ou somatique locale ont réduit la douleur incisionnelle pendant les trois premières heures postopératoires. Une combinaison d’anesthésiques locaux somatoviscéraux n’a pas réduit la douleur intra-abdominale, la douleur à l’épaule ou les nausées davantage que l’anesthésie somatique employée seule. L’Infiltration préopératoire d’anesthéslque local au site d’Incision est recommandée.

NMDA-R1 antisense oligodeoxynucleotides modify formalin-induced nociception and spinal c-Fos expression in rat spinal cord

Noxious peripheral stimuli (thermal, mechanical, or chemical) produce long-term adaptations in the sensitivity of central nociceptive neurons to subsequent noxious stimuli. The mechanisms responsible for this central sensitization are multifactorial, but the activation of spinal N-methyl-D-aspartate (NMDA) receptors plays a pivotal role. Using antisense oligodeoxynucleotides, we tested the role of the NR1 subunit of the NMDA receptor in the nociception and expression of the immediate early gene c-fos following formalin-induced pain. Rats received NMDA-R1 antisense, sense, or missense oligodeoxynucleotides intrathecally three times over a 48-h interval. The day after the last injection of the oligodeoxynucleotide, the formalin test was performed. Pain-related behavior was quantified by counting the incidence of flinching of the injected paw for 60 min, and the animals were perfused and the spinal cord removed for c-Fos immunohistochemistry 60 min later. Immunopositive cells were counted in the laminae I/II(0) and V of the lumbar enlargement. Treatment with NR1 antisense oligodeoxynucleotide resulted in a marked decrease in flinching. Similarly, the antisense oligodeoxynucleotide virtually abolished formalin-induced expression of c-Fos-like immunoreactivity (Fos-IR) in the spinal cord dorsal horn ipsilateral to injection. In contrast, the corresponding sense or missense oligodeoxynucleotides had no effect on either formalin-evoked behavior or c-Fos immunoreactivity. We conclude that an NR1 antisense oligodeoxynucleotide inhibits both nociceptive behavior and c-fos expression following formalin injection in rats, demonstrating that NR1 plays an important role in the development of noxious stimulation induced c-fos expression in this model.

Effects of Different Concentrations and Volumes of Formalin on Pain Response in Rats

BACKGROUND Formalin test is commonly used in animal model to assess injury-produced pain response. If the total amount of formaldehyde is fixed, its concentration and volume can be easily adjusted. We evaluated the effect of two sets of three solutions of formalin (one set of same dose of formaldehyde at different concentration and volume, i.e. 2.5%--100 microL, 5%--50 microL, 10%--25 microL, and another set of same volume but at different concentrations, i.e. 2.5%--100 microL, 5%--100 microL, and 10%--100 microL) on the injury-produced pain response in rat. METHODS Male Sprague-Dawley rats weighing 250-300 g were used. Following injection of formalin (n = 8 in each group) or saline (n = 6, control), the flinching frequencies and time spent in licking or biting the injected hind-paw in the early phase 1 (0-5 min after injection) and the late phase 2 (20-60 min after injection) were recorded. Sham-injection rats (n = 5) underwent subcutaneous insertion of the needle, but no substance was injected. RESULTS Flinching in phase 1 and 2 was more frequent in the 2.5%--100 microL and 5%--50 microL groups than in the control group (P < 0.05). Licking (or biting) time in phase 2 in all these three groups was longer than the control group (P < 0.05). In the groups of another set of three different solutions (2.5%--100 microL, 5%--100 microL, and 10%--100 microL), flinching in phase 1 and phase 2 was also more frequent than the control group (P < 0.05). Regarding lick behavior of another set, it occurred more frequently in 2.5%--100 microL group in phase 1 and in 2.5%--100 microL group as well as 5%--100 microL group in phase 2 than the control group (P < 0.05). CONCLUSIONS The 10%--25 microL formalin produces fewer flinching responses than other concentrations. Flinching was a biphasic behavior which was more spontaneous and active than was licking. The volume of formalin was a more important factor than the concentration of formalin in the generation of the active biphasic flinching response in the rat model.

Comparison of Surgical Pleth Index-guided Analgesia with Conventional Analgesia Practices in Children: A Randomized Controlled Trial.

Background:To compare surgical pleth index (SPI)-guided analgesia with conventional analgesia by evaluating intraoperative analgesic requirements, postoperative pain, and emergence agitation in children. Methods:This study was designed as a parallel, two-arm, double-blind, randomized controlled trial. Forty-five children undergoing elective adenotonsillectomy were randomly allocated to SPI-guided group (SPI-guided analgesia group, n = 21) or control group (conventional analgesia group, n = 24). Anesthesia was maintained with sevoflurane 2 to 3 vol% in 50% nitrous oxide and oxygen to achieve state entropy between 40 and 60. Intraoperative fentanyl 0.5 &mgr;g/kg was administered for the first event persisting 3 min and subsequent events persisting 5 min. An event was defined as an SPI over 50 (SPI-guided group) or a blood pressure or heart rate 20% above the baseline (control group). The primary outcome was intraoperative fentanyl requirement. Secondary outcomes included intraoperative sevoflurane consumption, postoperative emergence agitation and pain score, and postoperative rescue analgesic requirements. Results:Intraoperative fentanyl requirement was lower in SPI-guided group than in control group (0.43 ± 0.53 vs. 1.73 ± 0.59 &mgr;g/kg; P < 0.001). Intraoperative sevoflurane consumption was similar. The proportion of patients with high emergence agitation scores (4 to 5) was greater in SPI-guided group (61.9 vs. 25.0%; P = 0.01). The postoperative pain score and rescue fentanyl consumption were higher in SPI-guided group (7 [4.5; 9] vs. 3 [2; 6.75]; P = 0.002; 0.50 ± 0.34 vs. 0.29 ± 0.30 &mgr;g/kg; P = 0.04). Conclusions:As currently constructed, SPI does not appear to be valid in children. This may be due to both differences in blood vessel distensibility and baseline increased heart rates in children versus adults.

The effects of intrathecal cyclooxygenase-1, cyclooxygenase-2, or nonselective inhibitors on pain behavior and spinal Fos-like immunoreactivity.

BACKGROUND: Prostaglandins are synthesized by cyclooxygenase (COX) and are thought to play an important role in nociceptive transmission in the spinal cord. Fos expression is an indicator of spinal neuron activation. We examined the role of intrathecal selective and nonspecific COX inhibitors on spinal C-Fos expression. METHODS: To evaluate the relative contribution of COX-1 and COX-2 in nociceptive transmission in the spinal cord, we assessed the effects of the selective COX-1 inhibitor SC 560, the selective COX-2 inhibitor celecoxib, and the nonselective COX inhibitor ketorolac on formalin-evoked behavior and spinal c-Fos-like immunoreactivity (FLI). Rats received each of the drugs (30, 60, or 90 &mgr;g) intrathecally before the subcutaneous administration of formalin (5%, 50 &mgr;L) to the plantar surface of a hindpaw. The control group received vehicle intrathecally before the administration of formalin. RESULTS: Phase 1 flinching behavior decreased in rats given celecoxib or ketorolac 90 &mgr;g. Phase 2 flinching behavior decreased in rats given all doses of ketorolac or celecoxib 90 &mgr;g (P < 0.05). The FLI was significantly reduced in rats given celecoxib or ketorolac 90 &mgr;g for laminae I–II (P < 0.05). By contrast, for laminae V–VI, only the ketorolac 60 or 90 &mgr;g treatment group demonstrated a larger decrease in FLI (P < 0.05). The FLI expression in laminae V–VI had a significant correlation with phase 2 flinching behavior (P < 0.05). CONCLUSIONS: A dual inhibitor of COX-1 and COX-2 suppressed both responses of formalin-evoked behaviors and FLI expression of whole laminae in the lumbar spinal cord. FLI expression of laminae I–II alone may not be a good indicator of the ability to produce anti-hypersensitivity; however, the FLI of laminae V–VI correlates with phase 2 responses.

Antihistamine pretreatment to reduce incidence of withdrawal movement after rocuronium injection.

The purpose of this study was to determine the effectiveness of antihistamine therapy for withdrawal movements caused by rocuronium injection. One hundred seventy one ASA I-II adults undergoing elective surgery were randomly assigned to one of two groups. Patients in the control group (Group C) were premedicated with 2 mL normal saline, and those in the antihistamine group (Group A) were pre-medicated with 2 mL (45.5 mg) pheniramine maleate. After the administration of thiopental sodium 5 mg/kg, rocuronium 0.6 mg/kg was injected. Withdrawal movements were assessed using a four-grade scale. The administration of antihistamine reveals lower grade of withdrawal movement after rocuronium injection.

Reducing the Pain of Microemulsion Propofol Injections: A Double-Blind, Randomized Study of Three Methods of Tourniquet and Lidocaine

BACKGROUND Although the new formulation of lipid-free microemulsion propofol (MP) has some advantages over the lipid emulsion, it reportedly produces more injection pain than lipid-based propofol. Intravenous lidocaine with application of a rubber tourniquet before administration of propofol is considered to be the best method for reducing injection pain; however, this technique is not perfect. OBJECTIVE The goal of this study was to evaluate the effect of different methods of tourniquet application and lidocaine administration on MP injection pain. METHODS This single-center, randomized controlled clinical trial was conducted in 140 patients aged 18 to 65 years. Patients were randomly divided into 4 groups (n = 35 each). Group A received MP (2 mg/kg) after lidocaine (0.6 mg/kg) with a tourniquet with arm down (venous engorgement); group B received MP after lidocaine with a tourniquet with arm up (venous gravity drainage); group C received MP with a tourniquet with arm down; and group D (control group) received MP only (with no tourniquet). In groups A and C, the tourniquet was released after MP; in group B, the tourniquet was released before MP. Injection pain was evaluated by using a verbal pain score (VPS). The bispectral index, the time from the beginning of drug injection to the loss of eyelash reflex, and time to the lowest bispectral index value were recorded. RESULTS Group A showed significantly less incidence of pain than the control group when MP was injected. The mean VPS was significantly lower in groups A, B, and C than in group D (the control group). The VPS of group A was significantly lower than that in group B. Other observed values were not significantly different. CONCLUSIONS We concluded that intravenous retention of lidocaine with the application of a rubber tourniquet under venous engorgement of the arm reduces the incidence and intensity of MP injection pain. CLINICAL TRIAL REGISTRY UMIN000010725.

Effect of intrathecal glycine and related amino acids on the allodynia and hyperalgesic action of strychnine or bicuculline in mice

Background The intrathecal (IT) administration of glycine or GABAA receptor antagonist result in a touch evoked allodynia through disinhibition in the spinal cord. Glycine is an inhibitory neurotransmitter that appears to be important in sensory processing in the spinal cord. This study was aimed to evaluate the effect of glycine-related amino acids on antagonizing the effects of IT strychnine (STR) or bicuculline (BIC) when each amino acid was administered in combination with STR or BIC. Methods A total of 174 male ICR mice were randomized to receive an IT injection of equimolar dose of glycine, betaine, β-alanine, or taurine in combination with STR or BIC. Agitation in response to innocuous stimulation with a von Frey filament after IT injection was assessed. The pain index in hot-plate test were observed after IT injection. The effect of IT muscimol in combination with STR or BIC were also observed. Results The allodynia induced by STR was relieved by high dose of glycine or betaine. But, allodynia induced by BIC was not relieved by any amino acid. Whereas the STR-induced thermal hyperalgesia was only relieved by high dose of taurine at 120 min after IT injection, the BIC-induced one was relieved by not only high dose of taurine at 120 min but also low dose of glycine or betaine at 60 min after IT injection. The BIC-induced allodynia and thermal hyperalgesia was relieved by IT muscimol. Conclusions This study suggests that IT glycine and related amino acids can reduce the allodynic and hyperalgesic action of STR or BIC in mice.

Thoracic spinal cord stimulation for neuropathic pain after spinal meningioma removal: a case report.

Spinal cord stimulation (SCS) is highly successful for treating neuropathic pain but its effect is limited for central origin pain caused by cord injury. The authors describe a case in which pain was successfully controlled by SCS implantation in a patient with intractable chronic neuropathic pain after T5 meningioma removal. The authors tried lead insertion over the T5 level passing through postoperative adhesions to produce adequate stimulation to the patients painful areas fully enough without any complications. This case showed good response to SCS even though it was a central type of neuropathic pain by spinal cord injury.

Sugammadex for reversal of rocuronium-induced neuromuscular blockade in pediatric patients: A systematic review and meta-analysis.

Background:Previous studies have shown that sugammadex, a modified &ggr;-cyclodextrin, is a well-tolerated agent for the reversal of neuromuscular blockade (NMB) induced by a steroidal neuromuscular blocking drug in adult patients. However, its use has not been reviewed in pediatric patients. The aim of this meta-analysis was to evaluate the efficacy and safety of sugammadex in the reversal of rocuronium-induced NMB during surgery under general anesthesia in pediatric patients. Methods:A literature search was performed using the Pubmed, EMBASE: Drugs and pharmacology, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews. Analysis was conducted using RevMan 5.3. Data collected from different trials were pooled; the weighted mean difference or the pooled risk ratio and the corresponding 95% confidence interval (CI) were used for analysis, and heterogeneity (I2) assessment was performed. Results:Six randomized controlled trials comparing 253 pediatric patients (age range, 2–18 years) were included in the final analysis. The mean time taken to reach a train-of-four ratio of ≥0.9 was significantly shorter in the sugammadex groups (2 and 4 mg/kg) than in the control group (neostigmine or placebo), although the heterogeneity was high. The weighted mean differences of the 2 and 4 mg/kg sugammadex groups were −7.15 (95% CI: −10.77 to −3.54; I2 = 96%; P = 0.0001) and −17.32 (95% CI: −29.31 to −5.32; I2 = 98%; P = 0.005), respectively. The extubation time in the sugammadex group was shorter than that in the control group; the weighted mean difference of the sugammadex group was −6.00 (95% CI: −11.46 to −0.53; I2 = 99%; P = 0.03). There was no significant difference between the groups in terms of the incidence of postanesthetic adverse events; the pooled risk ratio was 0.67 (95% CI: 0.27–1.71; I2 = 59%; P = 0.41). Conclusion:We suggest that sugammadex is fast and effective in reversing rocuronium-induced NMB in pediatric patients. Although there was no evidence of a higher incidence of adverse events with sugammadex compared to that with neostigmine or placebo, much more data regarding the safety of sugammadex in pediatric patients may be still required.