Peripheral regional analgesia with femoral catheter versus intravenous patient controlled analgesia after total knee arthroplasty: a prospective randomized study

The aim of this study is to compare the effects of femoral analgesia (FA) with 0.25% levobupivacain and intravenous patient controlled analgesia (PCA) with morphine on postoperative pain assessed by a visual-analog scale (VAS) score and their complications during the first 24 postoperative hours after the a total knee arthroplasty in a prospective randomized study. Secondary outcomes included: morphine use, patient satisfaction, complication of analgesia and duration of hospital stay. We analyzed 71 patients with an ASA score of II or III. The patients were randomized into two groups: group PCA (n = 36) was given the PCA pump, which contained morphine; and group FA (n = 35) was given first a bolus dose, then a continuous infusion 0.25% levobupivacain via a femoral catheter. The assessment of VAS was performed every 2 hours. There were no differences between the PCA and FA groups regarding demographic characteristics, operation duration, ASA score distribution, duration of hospital stay and satisfaction with analgesia (although there were more satisfied patients in the FA group). Significant differences were noted in the quantity of morphine used (higher values were in the PCA group; p < 0.001). More complications were recorded in PCA group (p < 0.001). The VAS score was lower in the FA group (p < 0.001). The highest difference occurred 4 hours after the operation, with the PCA group having significantly higher VAS score values compared to the FA group. Femoral analgesia leads to a stronger pain relief with less side effects, less morphine use and more patient satisfaction than intravenous PCA with morphine.     

Postoperative analgesic requirements in patients exposed to positive intraoperative suggestions.

OBJECTIVE--To establish whether positive suggestions given to a patient under general anaesthesia reduce postoperative pain and analgesic requirements. DESIGN--Prospective double blind randomised study. SETTING--Operating theatre and gynaecology ward of a teaching hospital. PATIENTS--63 Woman undergoing elective abdominal hysterectomy were randomised to be played either a tape of positive suggestions or a blank tape during the operation through a personal stereo system. INTERVENTIONS--Three women were withdrawn from the study. Anaesthesia was standardised for all of the women. Postoperative analgesia was provided through a patient controlled analgesia system for the first 24 hours. Pain scores were recorded every six hours. MAIN OUTCOME MEASURES--Morphine consumption over the first 24 hours after the operation; pain scores. RESULTS--Mean morphine requirements were 51.0 mg (95% confidence interval 42.1 to 60.0 mg in the women played positive suggestions; and 65.7 mg (55.6 to 75.7 mg) in those played a blank tape. The point estimate (95% confidence interval) for the difference of means was 14.6 mg (22.4%) (1.9 (2.9%) to 27.3 mg (41.6%] (p = 0.028). Pain scores were similar in the two groups. CONCLUSION--Positive intraoperative suggestions seem to have a significant effect in reducing patients'' morphine requirements in the early postoperative period.     

Postoperative analgesia with controlled-release morphine sulphate: comparison with intramuscular morphine.

Fifty patients undergoing hysterectomy or cholecystectomy took part in a trail of postoperative analgesia provided by either intramuscular morphine or controlled-release morphine sulphate tablets orally. Respiratory function and plasma catecholamine concentrations were measured after operation and pain was assessed by using a linear analogue scoring method. Controlled-release morphine sulphate produced comparable pain relief with that of intramuscular morphine, and depression of respiratory function after operation was similar with the two analgesic regimens. The mean total dose of drug per patient given over 48 h to patients undergoing hysterectomy was 115 mg for morphine sulphate and 53 mg for morphine. Patients undergoing cholecystectomy received 130 mg morphine sulphate or 76 mg morphine. There was more sedation after operation in those patients undergoing hysterectomy who received morphine sulphate tablets. Morphine sulphate tablets produced satisfactory postoperative analgesia compared with intramuscular morphine: both regimens were acceptable to the patients.     

Use of the Brompton mixture in treating the chronic pain of malignant disease.

Physical, psychological, financial, interpersonal and spiritual factors all modify the appreciation of chronic pain. The Brompton mixture is a highly effective, flexible, safe and convenient means of controlling the chronic pain of malignant disease. The mixture is a solution containing morphine; the dose of narcotic can be varied with the need for analgesia. It is given regularly, usually every 4 hours, with a phenothiazine, the main aims of therapy being prevention of pain rather than treatment, an unclouded sensorium and a normal affect.     

Local Infiltrative Analgesia is Equivalent to Fascia Iliaca Block for Perioperative Pain Management for Prophylactic Cephalomedullary Nail Fixation

BackgroundImpending pathologic fractures of the femur due to metastatic bone disease are treated with prophylactic internal fixation to prevent fracture, maintain independence, and improve quality of life. There is limited data to support an optimal perioperative pain regimen.MethodsA proof of concept comparative cohort analysis was performed: 21 patients who received a preoperative fascia iliacus nerve block (FIB) were analyzed retrospectively while 9 patients treated with local infiltrative analgesia (LIA) were analyzed prospectively. Primary outcomes included: visual analog scale (VAS) pain scores, narcotic requirements and hospital length of stay. Patient cohorts were compared via two-sample t-tests and Fischer’s exact tests. Differences in VAS pain scores, length of stay and morphine milligram equivalents (MME) were assessed with Wilcoxon rank sum.ResultsThe LIA group had more patients treated with preoperative narcotics (p=0.042). There were no significant differences between the FIB and LIA groups in MME utilized intraoperatively (30.0 vs 37.5, p=0.79), on POD 0 (38.0 vs 30.0, p=0.93), POD 1 (46.0 vs 55.5, p=0.95) or POD 2 (40.0 vs 60.0 p=0.73). There were no significant differences in analog pain scale at any time point or in hospital length of stay (78 vs 102 hours, p=0.86).ConclusionDespite an increased number of patients being on preoperative narcotics in the LIA group, use of LIA compared with FIB is not associated with an increase in VAS pain scores, morphine milligram equivalents (MME), or length of hospital stay in patients undergoing prophylactic internal fixation of impending pathologic femur fractures.Level of Evidence: III     

Drug management of pain in cancer patients.

Chronic severe cancer pain is often not well controlled because both patient and physician have a poor understanding of the nature of the pain and of the actions of various potent analgesics. Physicians often fail to tailor analgesic dosages to the needs of the individual and unnecessarily limit the dosage because they have an ill founded fear that the patient will become addicted. The basis of rational management of cancer pain with drugs is an appropriate analgesic given regularly in doses adequate to suppress pain continuously. This review compares the potent analgesics and identifies and discusses those that have a role in treating chronic cancer pain. It emphasizes the value of morphine sulfate and gives information on starting and individualizing dosages and managing side effects.     

Improved pain relief after thoracotomy: use of cryoprobe and morphine infusion.

In a randomised controlled trial carried out during the first to days after thoracotomy patients who had had intercostal nerves frozen with a cryoprobe or were given morphine by continuous intravenous infusion had significant less pain at rest than patients given intramuscular morphine. Differences between the groups with respect to pain on movement and during physiotherapy were not significant. Pain was estimated using visual analogue scales, and an arc sine transformation was carried out on values obtained from these scales before comparison using an analysis of variance. The trial did not distinguish between the cryoprobe and infusion treatment. The simplicity of the cryoprobe had much to commend it, but in units without access to this equipment a small infusion pump offers a satisfactory alternative.     

Relief of pain by infusion of morphine after operation: does tolerance develop?

To see whether continuous intravenous infusion of opiates provides more effective postoperative relief of pain than conventional intramuscular injection these regimens were compared in a prospective double blind trial. Thirty patients undergoing elective cholecystectomy were allocated randomly to receive an infusion of morphine or an infusion of placebo (control group) for 24 hours. Both groups were allowed supplementary morphine boluses as requested. During the first 48 hours after operation the degree of pain was almost identical between the groups. Surprisingly, the group that was given the infusion of morphine received as much supplementary morphine as the control group during the first 24 hours and appreciably more during the 24 hours after the infusion had been withdrawn. Nausea and vomiting were more prevalent among the patients given the infusion of morphine. These results suggest that continuous infusion of morphine may be an inferior regimen to intermittent bolus administration in the relief of postoperative pain. This may be explained by the development of tolerance in patients who received the infusion of morphine.     

Morphine withdrawal modifies antinociceptive effects of acute morphine in rats

Repeated opioid use is known to cause tolerance of antinociceptive effects. Whether opioid abstinence modifies antinociceptive effects is unknown. Here we reported that morphine withdrawal for 18 h and 4 days after repeated morphine treatment largely reduced tail-flick latencies compared with control, while the rats showed severe withdrawal syndromes. However, the latencies and withdrawal syndromes were restored to control level at 20 days withdrawal. Similarly, antinociceptive effects of acute morphine were decreased at 18 h and further decreased at 4 days but restored to control level at 20 days withdrawal. Behavioral stress that was given to the rats at 18 h withdrawal further reduced tail-flick latencies and antinociceptive effects. Conversely, the glucocorticoid receptor antagonist RU38486 increased tail-flick latencies and antinociceptive effects at 4 days withdrawal. These results suggest that morphine withdrawal could evoke behavioral stress to modify antinociceptive effects, implicating a significant influence of opioid abstinence on chronic pain treatment.     

Intrathecal morphine as sole analgesic during labour.

In 12 consecutive unselected patients admitted to a consultant maternity unit one single injection of subarachnoid morphine sulphate 1.5 mg abolished pain during the first stage of labour. Pain in the second stage was abolished in four patients and lessened in three. During the early puerperium, pain at the site of the episitotomy was much reduced. Side effects included itching of the face, nausea and vomiting, and frontal headache, but these were mild and simply treated. They were even less severe in the last four patients, in whom barbotage was not used in administering the morphine. The high rate of forceps delivery and caesarean section (three cases of each) was not thought to be associated with the use of intrathecal morphine. These findings show that intrathecal morphine can abolish the pain of labour, whether spontaneous or induced, while preserving the mother''s full awareness of labour and her co-operation in the second and third stages of labour. Further, controlled, trials are warranted.     

Changes in succinic dehydrogenase activity in the central nervous system of mice during morphine dependence development, withdrawal and naloxone treatment

The possible role of succinic dehydrogenase (SD) in producing physical dependence to morphine by affecting tissue respiration was investigated in Swiss albino mice during the development of morphine tolerance through a period of addiction and naloxone withdrawal therapy. Tolerance and physical dependence were induced by injecting the mice with morphine sulfate subcutaneously at 8-hour intervals, increasing the dose from 10 mg/kg BW every 24 h for 15 days. The animals were considered to be addicted when they were able to tolerate an otherwise lethal dose of 150 mg/kg 3 times a day. Results indicated that succinic dehydrogenase was inhibited throughout the 15-day period of morphine administration and that this effect was greatest in tolerant animals. Increasing the dose and duration of treatment did not cause further decreases in enzyme activity; instead, after 15 days levels of enzyme activity increased in addicted animals compared with tolerant mice. Furthermore, morphine abstinence for 2 days, markedly increased the levels of SD activity, while 6 days of abstinence had little effect. Naloxone withdrawal at each stage was associated with increased SD activity, but the increase was significant only in tolerant mice.     

Contribution of atenolol,bendrofluazide, and hydrallazine to management of severe hypertension.

The efficacy of various combinations of atenolol, bendrofluazide, and hydraliazine given twice daily was assessed in a double-blind trial on 39 patients with moderate to severe essential hypertension. Concurrent treatment with all three drugs proved most effective and produced a mean reduction in blood pressure of 43/31 mm Hg. In the dosage used, hydrallazine affected only the diastolic blood pressure, and when added to either bendrofluazide or bendrofluazide plus atenolol it produced a further mean reduction in pressure of 6 mm Hg. Once-daily treatment with atenolol and bendrofluazide was as effective in reducing blood pressure as the same combination given twice daily, and the hypotensive effect was still present at least 24 hours after the last dose of tablets. A combined tablet of atenolol and bendrofluazide taken once daily would be a simple regimen to follow and would provide almost as much hypotensive effect as a twice-daily regimen incorporating a modest dose of hydrallazine. The hypotensive effect of atenolol was equal to that of bendrofluazide on systolic pressure but significantly better than that of bendrofluazide on diastolic pressure. Atenolol reduced plasma renin and urate concentrations but increased plasma potassium levels. The biochemical effects of atenolol, therefore, may be an advantage over those of bendrofluazide when deciding on first-line treatment for essential hypertension.     

全膝关节置换术后多模式镇痛中非选择与选择性COX-2抑制剂的对比应用研究

目的：评价全膝关节置换术后病人早期功能锻炼过程中应用选择性环氧化酶-2（COX-2）抑制剂帕瑞昔布钠与非选择性环氧化酶（COX）抑制剂氟比洛芬酯之间的镇痛效果是否存在差异,以及对早期功能锻炼结果的影响。方法：前瞻性、随机、双盲、平行对照研究,根据纳入/排除标准,连续选取2009年6月至2010年3月在我科行单侧人工全膝关节置换术的病人60名。手术均采用腰麻联合硬膜外阻滞麻醉,由同一组手术医师完成,术中假体安装前关节周围软组织注射＂鸡尾酒＂镇痛液（罗哌卡因注射液150mg＋肾上腺素（1：1000）0.5ml,由生理盐水稀释为100ml）。手术结束后进行病人自控静脉镇痛（PCIA）。术后当天患者在护士的指导下进行股四头肌收缩功能锻炼及直腿抬高功能锻炼。术后第一天起行膝关节被动伸屈功能锻炼（CPM）及主动伸屈功能锻炼。术后第3至5天患者停PCIA镇痛后,进行试验干预。帕瑞昔布钠组给予注射用帕瑞昔布钠40mg,静注1/12小时。氟比洛芬酯组给予氟比洛芬酯注射液100mg,静注1/12小时。观察病人术后第3至5天静息状态下和活动锻炼时膝关节最大主动屈曲时的疼痛强度（VAS评分）,手术侧膝关节的主动伸屈活动度及术后1月复查时的手术侧膝关节的主动伸屈活动度,KSS评分,术后第2天与第6天的血红蛋白值。结果：两组病人给药后在静息状态及膝关节最大主动屈曲时,在不同时间点的VAS评分、膝关节主动活动度及术后1月患者膝关节的主动活动度和KSS评分的差异均无统计学意义（P〉0.05）。应用抗凝治疗后,帕瑞昔布钠组患者血红蛋白下降值与氟比洛芬酯组存在差异（P=0.042）。结论：尚不能认为人工全膝关节置换术后多模式镇痛中同时抑制COX-1和COX-2与选择性抑制COX-2之间存在差异。但应用选择性COX-2抑制剂（帕瑞昔布钠）镇痛更安全,因其有利于减少全膝关节置换术后患者抗凝治疗过程中的隐性失血。     

Delayed onset of single dose tolerance to morphine analgesia

Rats received either 20 mg/Kg of morphine sulfate I.P. or 5 μgm of morphine sulfate microinjected into the periaqueductal gray area of the brain. The analgesic effect of the morphine was determined by comparing pre- and postinjection tailflick latencies. To test for tolerance following a single injection, the procedure was repeated 6, 12 or 24 hours after the first injection and tests. Tolerance was not observed 6 hours after the original injection, tolerance was observed at 12 hours and increased tolerance was present at 24 hours. Single dose tolerance to morphine appears to develop slowly over a period of several hours and during much of this time, the amount of opiate present in the brain was insufficient to produce analgesia. Similarity between central and peripheral administration suggests a central mechanism of single dose tolerance.     

Immunologic effects of morphine administration in rabbits.

Long-term effects of morphine administration or immunologic test responses were studied in female rabbits. Implantation of morphine-containing pellets was found to be more effective than injection of morphine sulfate solutions in promoting increased serum binding of 140-morphine. A large part of the increased morphine binding by sera associated with administration of morphine was found in serum fractions containing gamma-globulin and was absent in gamma-globulin-free fractions. These sera showed some degree of specificity for the morphine configuration in tests with other narcotics. They also gave positive immunologic test reactions in passive hemagglutination and radial immunodiffusion tests involving serum albumins conjugated with morphine derivatives. Other evidence for immunologic responsiveness against morphine by morphine-pretreated rabbits was shown by cutaneous hypersensitivity reactions against morphine-carrier conjugates and by a diminution of the serum morphine-binding response in rabbits given an immunosuppressive dose of cyclophosphamide. Failure of naloxone, a morphine antagonist, to alter the serum morphine-binding response suggested that serum levels of the morphine-binding globulin studied here were not direclty related to morphine withdrawal.     

The effect of pentobarbital on the antinociceptive action of morphine in morphine-tolerant and non-tolerant rats

The interaction of sodium pentobarbital with morphine sulfate in both morphine-tolerant and non-tolerant rats was investigated using the tail-compression test for analgesia. Male Sprague-Dawley rats (300–350 g) were given pentobarbital (4, 8, or 16 mg/kg) 5 min before morphine (2, 4, 6, or 8 mg/kg). Control animals received two saline injections, or pentobarbital plus saline, or saline plus morphine. All injections were subcutaneous. Prior to the first injection, a baseline nociceptive threshold was determined for each rat by applying a modified micrometer to its tail and increasing the pressure until a squeak was elicited. Test readings were taken every half-hour for 2 hr beginning 30 min after the second injection. For the chronic studies, animals were first made tolerant to morphine by the administration of the narcotic twice a day for 3 days, increasing the dose from 10 to 50 mg/kg/injection. Identical testing procedures were then followed with these rats except that the test dose of morphine given on day 4 was in the range 8–128 mg/kg. It was found that Na pentobarbital, in the subanesthetic doses used, had neither antinociceptive nor hyperalgesic properties. Furthermore, the barbiturate had no effect on the antinociceptive action of morphine in either morphine-tolerant or non-tolerant rats.     

唑来膦酸联合硫酸吗啡缓释片治疗多发骨转移性疼痛的疗效及耐受性观察

目的:探讨唑来膦酸联合硫酸吗啡缓释治疗多发骨转移性疼痛的疗效及耐受性。方法:选择恶性肿瘤伴多发性骨转移、初始为重度疼痛、经硫酸吗啡缓释片治疗14天以上疼痛未达到中度以上缓解者。共入组患者52例,给予唑来膦酸联合硫酸吗啡缓释片治疗,比较联合治疗前后疗效及不良反应。结果:联合治疗前疼痛评分为7.3,联合治疗后降至1.4(P<0.001),联合治疗总有效率76.9%,生活质量良好者比例由9.6%增至71.2%(P<0.001)。8例出现发热,对症处理后体温当日降至正常。结论:唑来膦酸联合硫酸吗啡缓释片治疗多发骨转移性顽固性疼痛,明显提高患者生活质量,副反应未见增加,疗效及耐受性好。     

保守疗法治疗腰椎间盘突出症的短期临床疗效分析

目的:分析保守疗法治疗腰椎间盘突出症的短期临床疗效。方法:选取2013年1月~2013年12月来我科就诊并采取保守疗法治疗的69例腰椎间盘突出症患者,对其临床资料进行回顾性分析。其中,37例采用了电针、推拿、中频、牵引和功能锻练等综合疗法(综合疗法治疗组),32例仅采用了药物治疗(单纯药物对照组),比较两组治疗前后的JOA评分及VAS疼痛评分,并比较其临床疗效。结果:治疗后,两组患者的腰椎功能JOA评分均较治疗前明显改善(P0.05),且综合保守治疗组的JOA评分明显高于单纯药物对照组(p0.05);两组患者的VAS疼痛评分均较治疗前明显降低(P0.05),且综合保守治疗组患者的VAS疼痛评分降低程度明显高于单纯药物对照组(P0.05)。单纯药物对照组的总有效率为71.87%,而综合保守治疗组的总有效率为91.89%,较单纯药物对照组显著升高(P0.05)。结论:与单纯药物治疗相比,采用综合保守疗法治疗腰间盘突出症的短期临床疗效更好,可更有效改善患者的腰椎功能并缓解其疼痛。     

Growth hormone therapy in GH-deficient adults: continuous vs alternate-days treatment.

In the present report, we have compared 12 months of rhGH therapy given daily (D) at the beginning and then on alternate days (A) to 20 subjects with severe adult-onset GH deficiency (GHD). Aim of the study was to establish whether the lower frequency injection regimen is as effective as the daily dose. Measurements included: IGF-I levels, body composition (BF%), lipid profile, insulin sensitivity by homeostasis model assessment (HOMA-IR) and quantitative insulin check index (QUICKI), as well as thyroid function. Evaluation on A therapy was performed both 12 and 36 hours after the last rhGH injection. The final rhGH dose was 0.3 +/- 0.1mg/day. During A, the dose used in D was doubled and given on alternate days. Recombinant hGH given during the A period induced changes in IGF-I levels, BF% and lipid profile comparable to daily treatment. HOMA-IR increased similarly after both regimens, though QUICKI did not significantly change. A significant reduction in serum FT4 levels occurred after both D and A therapy, so that an adjustment of L-T4 replacement dose in 5 of 20 patients was necessary. No differences were found in the various parameters after 12 and 36 hours post rhGH injection. In conclusion, rhGH therapy given on alternate days is clinically effective and may result in improved patient compliance. Monitoring glucose tolerance and thyroid function while on rhGH is essential.     

Postoperative morphine requirements of free TRAM and DIEP flaps

In a review of the charts of 158 patients who had undergone breast reconstruction with free transverse rectus abdominis musculocutaneous (TRAM) or deep inferior epigastric perforator (DIEP) flaps and who were treated for postoperative pain with morphine administered by a patient-controlled analgesia pump, the total dose of morphine administered during hospitalization for the flap transfer was measured. Patients whose treatment was supplemented by other intravenous narcotics were excluded from the study. The mean amount of morphine per kilogram required by patients who had reconstruction with DIEP flaps (0.74 mg/kg, n = 26) was found to be significantly less than the amount required by patients who had reconstruction with TRAM flaps (1.65 mg/kg; n = 132; p < 0.001). DIEP flap patients also remained in the hospital less time (mean, 4.73 days) than did free TRAM flap patients (mean, 5.21 days; p = 0.026), but the difference was less than one full hospital day. It was concluded that the use of the DIEP flap does reduce the patient requirement for postoperative pain medication and therefore presumably reduces postoperative pain. It may also slightly shorten hospital stay.