Robert K. Parker

Use of Ketorolac after Lower Abdominal Surgery Effect on Analgesic Requirement and Surgical Outcome

BackgroundKetorolac is a nonsteroidal antiinflammatory agent with opioid-sparing properties. The effect of ketorolac on postoperative opioid analgesic requirement and surgical outcome was evaluated in 198 women after abdominal hysterectomy procedures using a double-blind protocol design. MethodsPatients were randomly assigned to receive either 60 mg intravenous (2 ml) ketorolac, followed by 30 mg intravenously (in saline 20 ml) over 30 min every 6 h, or 2 ml intravenous saline, followed by saline 20 ml intravenously over 30 min every 6 h, for up to 72 h. The postoperative opioid analgesic requirement was assessed using a patient-controlled analgesia (PCA) device to self administer either morphine or meperidine. The authors also evaluated pain, sedation (or drowsiness), fatigue, quality of sleep, and postoperative side effects at 2–8-h intervals for up to 72 h after surgery. ResultsKetorolac decreased the PCA opioid usage on the night of operation and during the first postoperative day. Ketorolac also improved the quality of sleep during the first night after surgery. Although ketorolac- (vs. saline-) treated patients had a significantly shorter time to passage of bowel gas (50 ± 24 h vs. 61 ± 25 h), there were no clinically significant differences in the times to oral intake, unassisted ambulation, or hospital discharge. There were also no differences in the overall incidence of side effects in the ketorolac- (vs. saline-) treated patients. However, the use of ketorolac with opioid PCA was associated with a reduced need for antiemetic therapy on the postsurgical ward. ConclusionsThe authors conclude that the opioid-sparing effects of ketorolac contributed few clinically significant advantages after abdominal hysterectomy procedures.

Epidural patient-controlled analgesia: an alternative to intravenous patient-controlled analgesia for pain relief after cesarean delivery.

Epidural administration of an opioid analgesic by means of a patient-controlled analgesia (PCA) system was compared with conventional intravenous PCA for pain relief after cesarean delivery. One hundred seventeen healthy women were randomly assigned to receive hydromorphone either intravenously (IV-PCA) or epidurally (EPI-PCA) after cesarean delivery with epidural bupivacaine for operative anesthesia. The hydromorphone requirements were 3.4 and 4.2 times more in the IV-PCA group on the first (P less than 0.01) and second (P less than 0.01) postoperative days, respectively. The mean number (+/- SD) of PCA demands during the first 24 h after the operation was 105 (+/- 88) for the IV-PCA group and 33 (+/- 48) for the EPI-PCA group (P less than 0.01). This difference was also significant 24-48 h after surgery. Although the EPI-PCA group utilized significantly less opioid medication, pain and sedation scores were similar in the two treatment groups; however, a significantly larger percentage of patients in the IV-PCA group (46% vs 22%) stated that they felt drowsy during the first postoperative day. Pruritus was reported more frequently in the EPI-PCA (67%) than in the IV-PCA (33%) group. Nausea was experienced by only 10% of patients in the IV-PCA and 6% in the EPI-PCA group. There was no evidence of postoperative respiratory depression, with minimal oxygen saturation values of 93% (+/- 3%) and 94% (+/- 1%) in the IV-PCA and EPI-PCA groups, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Epidural patient-controlled analgesia : influence of bupivacaine and hydromorphone basal infusion on pain control after cesarean delivery

Epidural administration of hydromorphone was evaluated using a patient-controlled analgesia (PCA) delivery system in 170 healthy women undergoing elective cesarean delivery with epidural bupivacaine who were randomly assigned to one of four epidural PCA treatment groups: group I, hydromorphone alone by bolus administration; group II, hydromorphone, with a continuous (basal) infusion; group III, hydromorphone in combination with 0.08% bupivacaine by bolus administration; or group IV, hydromorphone and bupivacaine, with a concurrent infusion of both drugs. Patients in group I required significantly less opioid medication (2.1 +/- 1.1 mg [mean +/- SD]) during the first 24 h than patients in group II (3.3 +/- 1.3 mg). Similarly, patients in group III self-administered significantly less hydromorphone (2.0 +/- 1.0 mg) and bupivacaine (23.3 +/- 11.4 mg) during the first 24 h of PCA therapy, compared with patients in group IV (hydromorphone [2.7 +/- 1.1 mg] and bupivacaine [31.5 +/- 11.6 mg]). The concomitant use of a local anesthetic or basal opioid infusion with hydromorphone via epidural PCA did not decrease the number of PCA demands or delivered doses. In addition, patients in all four groups had similar pain, sedation, discomfort, fatigue, and anxiety scores. The frequency of awakening at night to self-administer analgesic medication was not decreased when a basal infusion was used.(ABSTRACT TRUNCATED AT 250 WORDS)

Sumatriptan in patients with postdural puncture headache.

Objective.–To determine the efficacy of sumatriptan in the management of patients presenting for an epidural blood patch for the management of postdural puncture headache.

Comparison of epidural fentanyl versus epidural sufentanil for analgesia in ambulatory patients in early labor

Epidural sufentanil, after a lidocaine and epinephrine test dose, provides adequate analgesia and allows for ambulation during early labor. Epidural fentanyl has not been evaluated in this setting. The current study was designed to determine whether there is an analgesic difference between epidural fentanyl and epidural sufentanil in laboring patients. Forty-six laboring nulliparous women, at <5-cm cervical dilation, who requested epidural analgesia were enrolled. After a 3-mL test dose of lidocaine with epinephrine, patients were randomized to receive either sufentanil 20 &mgr;g or fentanyl 100 &mgr;g. After administration of the analgesic, pain scores and side effects were recorded for each patient at 5, 10, 15, 20, and 30 min and every 30 min thereafter, by an observer blinded to the technique used. There were no demographic differences between the two groups. Pain relief was rapid for all patients. The mean durations of analgesia were similar between the sufentanil group (138 ± 50 min) and the fentanyl group (124 ± 42 min). Side effects were similar between the two groups. In early laboring patients, epidural fentanyl 100 &mgr;g, after a lidocaine and epinephrine test dose, provides analgesia comparable to that of sufentanil 20 &mgr;g. Implications In early laboring patients, epidural fentanyl 100 &mgr;g, after a lidocaine and epinephrine test dose, provides analgesia comparable to that of sufentanil 20 &mgr;g.

Anesthetic management of the exit (ex utero intrapartum treatment) procedure

The EXIT (ex utero intrapartum treatment) procedure is used to maintain fetal-placental circulation during partial delivery of a fetus with a potentially life-threatening upper airway obstruction. We performed the EXIT procedure on a fetus with a large intra-oral cyst. Sevoflurane was used as the anesthetic because of its rapid titratability. Sevoflurane provided excellent maternal and fetal anesthesia. Modifications to previously described monitoring techniques for the EXIT procedure were also used.

Nitroglycerin for Rapid Tocolysis: Development of a Protocol and a Literature Review

OBJECTIVE:A protocol for nitroglycerin (NTG) use based on experiences with regard to new and previously described obstetric cases is presented. The efficacy of NTG tocolysis for obstetric emergencies is clinically evaluated.STUDY DESIGN:Hemodynamically stable parturients requiring acute tocolysis were treated with intravenous NTG and closely monitored. Clinical information was subsequently abstracted from medical records and compared with data from previous reviews.RESULTS:Tocolytic treatment was successful in all cases (22 of 22, 100%). Complications were clinically insignificant. The most common problem was transient hypotension, which occurred in 9 of 22 (41%) cases.CONCLUSION: NTG is an effective tocolytic with minimal complications, rapid onset, and a brief half-life. These characteristics favor its use during select obstetric procedures. However, strict adherence to protocols for administration is advised.

Patient-controlled Epidural Analgesia: Interactions Between Nalbuphine and Hydromorphone

Epidural opioid analgesia can offer advantages over intravenous administration, however, opioid-related side effects are common after epidural administration. We studied the effect of adding nalbuphine (NB), an opioid agonist-antagonist, to hydromorphone (HM) for patient-controlled epidural analgesia (PCEA) in 78 healthy women after elective cesarean delivery. Patients were randomly assigned to one of four treatment groups. The control group received preservative-free HM (Dilaudid [R]) alone, 0.075 mg/mL, while the three study groups received HM, 0.075 mg/mL, containing preservative-free NB (Nubain [R]) 0.02, 0.04, or 0.08 mg/mL. Intraoperatively, all patients received epidural bupivacaine 0.5%. Postoperatively, a patient-controlled anesthesia (PCA) device was connected to the epidural catheter and programmed to deliver a 3-mL loading dose of the analgesic solution. Subsequently, patients could self-administer 2 mL bolus doses on demand with a 30-min lockout interval. Patients were encouraged to ambulate approximately 8 h after surgery, and PCEA therapy was discontinued when a clear liquid diet was tolerated. Visual analog scale scores were used to assess pain at 8-h intervals while using PCEA therapy. Although the overall incidences of nausea (19%-35%) and pruritus (32%-62%) were similar in all four groups, the addition of NB decreased the need for bladder catheterization. The highest NB concentration resulted in increased PCA demands during the 32-h study period. In conclusion, the combination of HM 0.075 mg/mL and NB 0.04 mg/mL resulted in lower nausea scores and a decreased incidence of urinary retention compared with HM alone, without increasing the opioid analgesic requirement. (Anesth Analg 1997;84:757-63)

A microscopic analysis of cut-bevel versus pencil-point spinal needles.

An in vitro examination of 25-gauge Quincke and 25-gauge and 27-gauge Whitacre spinal needles was performed after insertion in 210 consenting adult patients. In addition, 300 unused Quincke needles and 300 unused pencil-point needles were examined under a dissecting microscope. When the microscopic evaluation was performed on the needles after spinal blockade, burrs or blunting of the needle tip were noted in 24% of the Quincke needles compared with only 3% of the 25-gauge Whitacre needles and 10% of the 27-gauge Whitacre (P < 0.05). Bony contact with 25-gauge Quincke and 27-gauge Whitacre needles resulted in an increased incidence of microscopic tip damage (versus 25-gauge Whitacre). Needle-tip damage with the Whitacre needles was limited to blunting of the tip. The analysis of unused needles revealed significant differences among manufacturers of the cut-bevel needles with respect to stylet-to-needle length and burrs on the end of the stylet. The leading edge of the stylet protruded beyond the opening of the needle tip in 7% of the Quincke needles. However, only minor needle-tip abnormalities were noted with the pencil-point needles (i.e., variability in the side-port opening to needle tip distance, side-port opening integrity). In conclusion, bony contact produced more damage to the cut-bevel than to the pencil-point needle tips. In addition, fewer inherent manufacturing defects were noted with the pencil-point versus cut-bevel needles. Implications: It has been suggested that damaged needle tips may contribute to a higher incidence of headaches after spinal anesthesia. A microscopic examination revealed that the pencil-point (versus cut-bevel) needles had fewer manufacturing flaws and were less susceptible to tip damage when bony contact occurred during the placement of the spinal needle. (Anesth Analg 1997;85:1101-4)

Epidural clonidine added to a bupivacaine infusion increases analgesic duration in labor without adverse maternal or fetal effects

PurposeMany obstetric patients receiving epidural analgesia are encouraged to ambulate. This current study was designed to determine the potential for maximizing the time to first epidural supplement when adding clonidine to a 0.625 mg·ml−1 bupivacaine continuous epidural infusion following epidural fentanyl bolus in early labor for patients allowed to ambulate. Maternal and fetal effects secondary to clonidine were also evaluated.MethodsSixty-eight laboring primigravid women received a 3-ml epidural test dose of lidocaine with epinephrine, followed by a fentanyl 100-µg bolus (in a 10 ml-volume). The patients then received a 0.625 mg·ml−1 bupivacaine continuous epidural infusion, either with or without clonidine (5 µg·ml−1), at a rate of 10 ml·h−1. Pain scores and side effects were recorded for each patient.ResultsThe overall quality of analgesia was similar in both groups. The mean duration prior to request for additional analgesia was significantly longer in the clonidine group (269 ± 160 min), compared to the control group (164 ± 64 min). No patient in either group experienced any detectable motor block; one patient (clonidine group) complained of mild thigh numbness and was not allowed to ambulate. While mean blood pressure was approximately 6 mmHg lower in the clonidine group at 1, 1.5, and 3.5 h, this was not clinically significant. No adverse effects on maternal heart rate or fetal heart rate were noted.ConclusionIn early laboring patients, addition of clonidine prolongs the analgesia duration of a 0.625 mg·ml−1 bupivacaine continuous epidural infusion following 100 µg epidural fentanyl (after a lidocaine-epinephrine test dose) without a clinically significant increase in side effects.