Ris Dirksen

The intensity of preoperative pain is directly correlated with the amount of morphine needed for postoperative analgesia

UNLABELLED The aim of this study was to examine whether severity of preoperative pain intensity is related to postoperative pain and morphine consumption. Sixty consecutive patients scheduled for total hip surgery during intrathecal anesthesia were studied. Preoperative visual analog scale (VAS) scores and analgesic intake was assessed 1 day before surgery. Three groups of patients were identified: those with mild pain (n = 12, VAS score 0-4), moderate pain (n = 18, VAS score 4-7), and severe pain (n = 28, VAS score 7-10). Postoperative pain scores were recorded in the first 24 h, as was the amount of morphine delivered by the patient-controlled analgesia pump. There were no differences among the groups in VAS scores at any time. Severe preoperative pain levels correlated with significantly greater postoperative morphine intake. The mean morphine intake during the first 24 h postoperatively was 19.2 mg in the mild pain group, 21.2 mg in the moderate pain group, and 29.5 mg in the severe pain group (P < 0.05 compared with both other groups). We conclude that patients with severe preoperative pain self-medicate to achieve postoperative pain scores equivalent to those of patients with mild and moderate pain and require a greater postoperative morphine intake for adequate analgesia than patients with mild or moderate preoperative pain. IMPLICATIONS In this study, we showed that severity of preoperative pain intensity relates to postoperative pain levels and morphine consumption. Patients scheduled for total hip surgery with severe preoperative pain require more postoperative morphine in the first 24 h.

Optimization of the Dose of Intrathecal Morphine in Total Hip Surgery: A Dose-Finding Study

UNLABELLED We designed this study to determine the optimal intrathecal dose of morphine in total hip surgery. The optimal intrathecal dose was defined as that providing effective analgesia and minimal side effects 24 h after total hip surgery. Patients (n = 143) scheduled for total hip surgery were randomized to four double-blinded groups with a standardized bupivacaine dose but different doses of intrathecal morphine (Group I = 0.025 mg, Group II = 0.05 mg, Group III = 0.1 mg, and Group IV = 0.2 mg). Pain scores, i.v. morphine intake (patient-controlled analgesia), and morphine-related side effects (respiratory depression, postoperative nausea and vomiting, itching, urinary retention) were recorded for 24 h after surgery. Excellent postoperative pain relief was present in all groups. The highest pain scores were found in Group I. The mean use of systemic morphine administered by patient-controlled analgesia infusion pump was 23.7, 17.8, 10.9, and 9.9 mg in Groups I-IV, respectively (P < 0.01 for Groups III and IV versus Group I). We conclude that 0.1 mg of intrathecal morphine is the optimal dose for pain relief after hip surgery with minimal side effects. IMPLICATIONS Earlier studies showed excellent postoperative pain relief after intrathecal morphine. However, the severity of side effects resulted in decreased enthusiasm for this anesthesia technique. In the present study, we show that an intrathecal dose of 0.1 mg of morphine can be used safely in total hip surgery with excellent postoperative pain relief.

An algorithm to reduce allogenic red blood cell transfusions for major orthopedic surgery

In a previous prospective study, we confirmed that transfusion-related immunosuppression predisposes to postoperative infections, impairs the postoperative healing of wound and thereby prolongs hospitalization. This increases the well-known risks, such as transmission of infection or transfusion reactions, and has obliged us to revise our transfusion guidelines. We used a relational database containing information about 28,861 orthopedic surgery patients was used to determine when and how to improve these guidelines for transfusions. The survey showed the circumstances surrounding a high incidence of allogenic red cell infusions: failure to follow the guidelines, the preoperative use of nonselective NSAIDs, low preoperative Hb level, failure to retrieve blood, and high cut-off values for allogenic red cell transfusion. The first step was to determine the Hb level before giving red cell infusions and ensure compliance with predefined cut-off values. Subsequent measures included: use of COX 2-selective NSAIDs alone in the perioperative period; erythropoietin and iron therapy when the Hb level fell below 13 g/dL; use of cell salvage during and after surgery; administration of aprotinin to patients expected to have a high blood loss. The type of anesthesia had no blood-sparing effect. Although these steps can not be regarded as a new approach, we show that by following a strict rules with appropriate steps and in a concerted fashion, the use of allogenic red blood cells was reduced by 80%. Moreover, the amount of blood saved had other effects - e.g., the incidence of deep wound infections was reduced by 40%. The outcome is described in an algorithm summarizing the steps in a comprehensive perioperative diagram for giving blood.

Does ibuprofen increase perioperative blood loss during hip arthroplasty

Background and objective: To determine whether prior exposure of non-steroidal anti-inflammatory drugs increases perioperative blood loss associated with major orthopaedic surgery. Methods: Fifty patients scheduled for total hip replacement were allocated to two groups (double blind, randomized manner). All patients were pretreated for 2 weeks before surgery: Group 1 with placebo drug, Group 2 with ibuprofen. All patients were injected intrathecally with bupivacaine 20 mg plus morphine 0.1 mg, in a total volume of 4 mL, to provide surgical anaesthesia. Results: The presence of severe adverse effects caused eight patients in the ibuprofen group and six in the placebo group to terminate their participation in the trial. The perioperative blood loss increased by 45% in the ibuprofen group compared with placebo. The total (±SD) blood loss in the ibuprofen group was 1161 (±472) mL versus 796 (±337) mL in the placebo group. Conclusions: Pretreatment with ibuprofen before elective total hip surgery increases the perioperative blood loss significantly. Early discontinuation of non-selective non-steroidal anti-inflammatory drugs is advised.

Intrathecal addition of morphine to bupivacaine is not the cause of postoperative nausea and vomiting

Background and Objectives. Postoperative nausea and vomiting after anesthesia is an distressing side effect. This study was undertaken to determine to what extent spinal opioids contribute to postoperative nausea and vomiting (PONV) and secondly to how effectively metoclopramide can reduce the incidence of PONV after intrathecal administration of morphine. Methods. Patients were allocated to three groups all undergoing major joint surgery of the lower limb. In group 1 (n = 200), intrathecal anesthesia was assessed by administration of 20 mg bupivacaïne and 0.2 mg morphine. In Group 2 (n = 100) intrathecal anesthesia was assessed in the same way and in addition, 20 mg metoclopramide intramuscular during maintenence of anesthesia and a second dose of 20 mg metoclopramide was administered intramuscular after arrival at the recovery room. Finally, in group 3 (n = 100), intrathecal anesthesia was assessed after administration of 20 mg bupivacaïne. Results. The maximum PONV percentages were 41.1%, 32.7%, and 37% in groups 1, 2, and 3, respectively. The consumption of antiemetics was similar in all groups. The number of patients who needed one or more additional antiemetics during the first 24 hours after surgery was 112 (56.6%), 57 (58%), and 60 (60%) in groups 1, 2, and 3, respectively. Conclusions. Administration of metoclopramide did not reduce the overall incidence of PONV. Our study shows no relationship between the use of intrathecal morphine and the incidence of PONV during the first 24 hours postoperative.

Prior ibuprofen exposure does not augment opioid drug potency or modify opioid requirements for pain inhibition in total hip surgery

PurposeIn previous animal studies, a prior exposure to nonsteroidal anti-inflammatory drugs (NSAID) augmented opioid drug potency. This study was designed to answer the question whether a similar effect can be attained in man. The objective was to use NSAID for preoperative pain reduction and at the same time use the NSAID exposure to reduce opioid requirements for pain inhibition in major orthopedic surgery.MethodsIn this double-blind, randomized study, 50 patients scheduled for total hip surgery were included. Patients of Group I received a placebo drug three times a day two weeks before surgery, and those allocated to Group II received ibuprofen (600 mg) three times a day. For surgical anesthesia, all patients received intrathecal bupivacaine 20 mg plus 0.1 mg morphine in a total volume of 4 mL.ResultsThe preoperative or postoperative visual analogue scale pain scores or the amount of iv morphine showed no differences between the two groups in the first 24 hr after surgery. The median total blood loss in the ibuprofen group was 1161 mL vs 796 mL in the placebo group (P < 0.01).ConclusionPretreatment with ibuprofen before major hip surgery does not improve the pain scores or reduce morphine requirement but significantly increases blood loss. Considering the presence of relevant adverse effects, pretreatment with a nonselective NSAID is not recommended.RésuméObjectifDes études antérieures sur des animaux ont démontré qu’une exposition préalable aux anti-inflammatoires non stéroidiens (AINS) renforce l’effet des opiacés. Cette étude a été conçue pour savoir si le même effet peut être obtenu chez l’homme. L’objectif était de prescrire un traitement antalgique préopératoire aux AINS et en même temps, profitant de l’exposition aux AINS, de réduire le besoin d’opiacés pour diminuer la douleur après des opérations orthopédiques majeures.MéthodeCinquante patients opérés pour la mise en place d’une prothèse totale de la hanche ont été inclus dans cette étude randomisée et en double aveugle. Les patients du Groupe I prenaient un placebo trois fois par jour pendant deux semaines avant l’opération tandis que les patients du Groupe Il prenaient de l’ibuprofène (600 mg) trois fois par jour. L’anesthésie pratiquée à l’ensemble des patients consistait en l’injection intrathécale de 20 mg de bupivacaïne et 0,1 mg de morphine dans un volume total de 4 mL.RésultatsAucune différence n’a été constatée entre les deux groupes dans les degrés de douleur mesurée par échelle visuelle analogique aussi bien en préopératoire qu’en postopératoire ou dans la dose de morphine injectée par voie iv pendant les 24 premières heures après l’opération. La perte totale de sang dans le groupe ibuprofène s’élevait à I 161 mL et dans le groupe placebo à 796 mL.ConclusionUn traitement préalable à l’ibuprofène en chirurgie majeure de la hanche n’améliore pas la douleur et ne diminue pas le besoin de morphine postopératoire, mais est associé avec une perte de sang signifcativement plus élevée. Vu ces conséquences fâcheuses, il nous apparaît judicieux de s’abstenir d’un traitement préalable aux AINS non sélectifs avant ce type de chirurgie.