Joseph Kay

Adding Gabapentin to a multimodal regimen does not reduce acute pain, opioid consumption or chronic pain after total hip arthroplasty

Background: Gabapentin (GPN) is effective in reducing post‐operative pain and opioid consumption, but its effects with regional anesthesia for total hip arthroplasty (THA) are not known. We designed this study to determine whether (1) gabapentin administration reduces pain and opioid use after THA using a multimodal analgesic regimen including spinal anesthesia; (2) pre‐operative administration of gabapentin is more effective than post‐operative administration.

Rectal indomethacin reduces postoperative pain and morphine use after cardiac surgery.

PurposeTo evaluate the combination of rectal indomethacin with patient controlled intravenous morphine analgesia (PCA) on postoperative pain relief and opioid use after cardiac surgery.MethodsWith institutional ethics approval, 57 consenting adults undergoing elective aortocoronary bypass surgery were randomly assigned preoperatively in a double-blind fashion to receive either placebo (n = 26) or indomethadn 100 mg suppositories (n = 31), 2–3 hr postoperatively, and 12 hr later. Both groups utilized PCA morphine. Pain scores in the two treatment groups were assessed on a 10-cm visual analogue scale (VAS) (at rest and with cough) at 4, 6, 12, 18 and 24 hr after initial dosing, and were analyzed through a 2 × 5 repeated measures of variance. The 24 hr analgesic consumption, 12 and 24 hr chest tube blood loss, and time to tracheal extubation were also recorded, and compared for the two treatment arms through Student’s t test on independent samples.ResultsPostoperative morphine consumption in the first 24 hr was 38% less in the indomethadn group (22.40 ± 12.55 mg) than the placebo group (35.99 ± 25.84 mg), P= 0.019. Pain scores, measured with a VAS, were 26% to 66% lower in the indomethacinvs placebo group at rest (P=0.006), but not with cough, for all times assessed. There was no difference in blood loss (at 12 hr) or time to tracheal extubation for both groups.ConclusionThe combination of indomethacin with morphine after cardiac surgery results in reduced postoperative pain scores and opioid use without an increase in side effects.RésuméObjectifÉvaluer l’action combinée d’indométhacine rectale et d’analgésie contrôlée par le patient (ACP) avec de la morphine intraveineuse sur la douleur postopératoire et l’usage d’opioïde en cardiochirurgie.MéthodeAyant obtenu l’approbation du comité d’éthique de l’hôpital, 57 adultes consentants qui devaient subir un pontage aortocoronarien électif ont été répartis au hasard avant l’opération afin de recevoir en double insu, soit un placebo (n = 26), soit de l’indométhacine (n = 31) en suppositoires de 100 mg, 2–3 h après l’opération et 12 h plus tard. Tous ont utilisé de la morphine pour l’ACP. Les scores de douleur ont été évalués à l’aide d’une échelle visuelle analogue (EVA) de 10 cm (au repos et lors de la toux) à 4, 6, 12, 18 et 24 h après le dosage initial et analysés selon un plan 2 × 5 de mesures répétées de la variance. La consommation d’analgésique à 24 h, la perte sanguine au drain thoracique à 12 et 24 h et le moment de l’extubation endotrachéale ont été notés et comparés d’un groupe à l’autre par le test t de Student sur des échantillons indépendants.RésultatsLa demande postopératoire de morphine des 24 premières h a été de 38% moindre avec l’indométhacine (22,40 ± 12,55 mg) qu’avec le placebo (35,99 ± 25,84 mg),P = 0,019. Les scores de douleur de l’EVA ont été de 26% à 66% plus faibles pour l’indométhacine vs le placebo, au repos (P = 0,006), non lors de la toux, et ce, pour tous les temps de mesures. La perte sanguine a été semblable dans les deux groupes (à 12 h) ainsi que le temps total d’intubation.ConclusionAdministrée après une intervention cardiaque, la combinaison d’indométhacine et de morphine a réduit les douleurs et l’usage d’opioïdes sans augmenter les effets secondaires.

Gabapentin Does Not Reduce Preoperative Anxiety When Given Prior to Total Hip Arthroplasty

INTRODUCTION Gabapentin is an anti-epileptic drug which is also used for the treatment of postoperative pain and a variety of psychiatric diseases including chronic anxiety disorders. We tested the hypothesis that compared with a placebo control, gabapentin would reduce preoperative anxiety in patients undergoing total hip arthroplasty. METHODS Following ethics approval, patients participating in a larger double blind, randomized, trial of multimodal analgesia were given either gabapentin 600 mg (N = 22) or placebo (N = 48) 2 hours before spinal anesthesia. Prior to administering the study medication, baseline anxiety levels were measured using a visual analog scale (VAS). Two hours after the ingestion of gabapentin or placebo, and prior to surgery, patients again rated their anxiety using a VAS. RESULTS Anxiety scores did not differ significantly between the groups either before (P = 0.95) or 2 hours after (P = 0.61) ingestion of gabapentin or placebo. Baseline anxiety and postdrug anxiety scores failed to demonstrate a significant association with maximal postoperative pain at rest, maximal postoperative pain with movement, and cumulative morphine consumption 48 hours after surgery. CONCLUSIONS Administration of gabapentin 600 mg prior to surgery does not reduce preoperative anxiety.

Saddle block analgesia for high-dose-rate brachytherapy: A prospective study

PURPOSE To determine effective spinal anesthetic dosing of hyperbaric bupivacaine for patients undergoing high-dose-rate (HDR) brachytherapy for prostate cancer. METHODS A total of 199 HDR prostate brachytherapy sessions (n=115 patients) under spinal anesthesia with five doses of hyperbaric bupivacaine were prospectively analyzed. Patients received either 11.25mg (n=40 sessions), 15mg (n=63 sessions), 18mg (n=25 sessions), 18.75mg (n=17 sessions), or 20.25mg (n=54 sessions) of 0.75% of bupivacaine with 20microg of fentanyl in 8.25% of dextrose (Hospira, Healthcare Corporation, Montréal, Canada). Sensory block level, intraoperative hypotension, incidence of nausea and vomiting, time to ambulation, and time to discharge were recorded. We assessed for the presence of any transient neurologic symptoms post discharge. RESULTS The 11.25-mg group had a mean peak sensory block height of L1 at 90min, which was significantly lower than the other groups. Block heights were also decreased at the 5, 60, 120, 150, 180, and 300min time points (p<0.05). The mean time to ambulation was 403+/-92min and to discharge was 427+/-70min; no difference among groups was found. Hypotension was not observed in the 11.25-mg group, whereas the incidence of operative hypotension was 8% in each of the other groups. No transient neurologic symptoms were reported postoperatively. CONCLUSIONS The 11.25-mg dose of hyperbaric bupivacaine was sufficient to provide intraoperative anesthesia for catheter placement and sufficient postoperative residual analgesia for the duration that the catheters were left in situ and subsequently removed.