Efficacy of Basal Infusion in Intravenous Patient-Controlled Analgesia after Mastectomy / 대한마취과학회지

BACKGROUND: Patient-controlled analgesia (PCA) is widely used for postoperative pain control. Theoretical advantages in maintaining an effective blood concentration of the analgesic medication using a basal infusion regimen is controversal. Therefore in this study, we compared the analgesic effect between PCA and PCA with a basal infusion and assessed whether the use of a basal infusion improves the analgesic effect in intravenous PCA or not. METHODS: Twenty six ASA physical status 1 or 2 female patients undergoing mastectomy were assigned randomly to the PCA group (group 1) or the PCA with basal infusion group (group 2). Group 1 was programmed to deliver 0.02 ml/Kg of bolus infusion with a 5 minute locKout interval. In group 2, 0.02 ml/Kg of basal infusion was added to the PCA regimen. The PCA analgesic solution contained 50 mg of nalbuphine and 150 mg of Ketorolac in a total volume of 200 ml. At sKin closure, 0.2 ml/Kg of a loading dose was given to all patients and a PCA was started according to the experimental group. A visual analogue scale (VAS) for pain, analgesic consumption, side effects and degree of satisfaction was assessed at postoperative 1 hour, 2 hours, 4 hours, 8 hours, 24 hours and 48 hours. RESULTS: Group 2 did not show any improvement in the VAS compared with group 1. Degree of satisfaction and incidence of complications were not different between two groups. Total infused amount of analgesics increased in group 2 (P < 0.05). CONCLUSIONS: The addition of basal infusion in a PCA after mastectomy did not show any improvement of postoperative pain control compared to the regimen of a PCA with only bolus infusion.

The Effect of Pretreated Ketorolac on Postoperative Pain and the Satisfaction of Patients / 대한마취과학회지

BACKGROUND: Postoperative pain is the principal acute pain and many trials have been done for it. The preemptive analgesic method is one of the trials and nonsteroidal antiinflammatory drugs (NSAIDs) have been under study to reduce the side effects of opioids and to gain some other advantages, and many positive results have been reported. The author therefore planned this study to evaluate whether or not NSAIDs could have a preemptive effect, to observe any difference in effect with increasing dose, and to identify any advantage to patients under preemptive analgesia. METHODS: Seventy-five patients undergoing open cholecystectomy or choledochocystostomy were randomly allocated into three groups, group K0, K30 and K60. In group K0 (n = 25), patients were given no medication before operation. In groups K30 and K60, patients were given ketorolac 30 mg and 60 mg by intravenous route at 15 minutes before operation respectively. After operation, one observer who didn't know which group the patients were allocated to recorded patients' pain score (visual analogus scale; VAS and Prince-Henry score; PHS), side effects and satisfactory score at postpoperative 0, 1, 6, 12, 24 and 48 hours. For VAS > 50 or PHS > 3, morphine 2.5 mg was given by intravenous route and pain score was reestimated after 10 minutes and this was repeated until VAS < 50 and PHS < 3. RESULTS: In group K60, VAS, PHS and dose of morphine were lower than in other groups (p < 0.05). Satisfaction score was higher in group K60 and the nurse's satisfaction score was higher than the patient's in group K0 and K30 (p < 0.05). There was no significant difference in hospital days between groups. Side effects were negligible. CONCLUSIONS: Preoperative intravenous administration of ketorolac 60 mg in open cholecystectomy or choledochocystostomy could have a preemptive analgesic effect and give more satisfaction to patients. In the immediate postoperative period, pain status may be highest, so more attention and evaluation will be needed by pain management staffs for the proper management of acute pain.

The Effect of Ketorolac on Propofol Injection Pain / 대한마취과학회지

BACKGROUND: Many strategies to reduce pain during propofol injection have been investigated. Inhibitors of cyclooxygenase are frequently used to provide post operative pain relief in patients undergoing minor gynecologic surgery. Therefore, in this study, we have investigated whether ketorolac injected intravenously reduces pain during propofol injection. METHODS: Fifty healthy female patients scheduled for minor gynecological surgery were randomly allocated to one of four groups. All patients were inserted 20 G Angiocatheter into the veins on the dorsum of the hands. After applying an arm tourniquet at an inflation pressure of 40-45 mmHg, the control group received 2 ml of 0.9% saline, and those in groups I, II, and III received ketorolac 0.5, 0.75, and 1.0 mg/kg mixed with 2 ml of 0.9% saline respectively. The tourniquet was released 2 minutes later. 2 mg/kg of 1% propofol bolus was then injected with an infusion pump intravenously. After 50 mg of propofol were injected, patients were assessed for visual analogue scale (VAS) scores and pain grades. RESULTS: VAS scores during propofol injection diminished significantly in group II (0.75 mg/kg ketorolac) and group III (1 mg/kg ketorolac) compared with the control (saline) group. CONCLUSIONS: Pretreatment with intravenous ketorolac more than 0.75 mg/kg during the 2 minutes tourniquet time can reduce pain elicited by profofol injection.

The Effects of Opioid Sparing and Treatment of Opoid Bowel Syndrome of Intravenous Ketorolac in Terminal Cancer Pain Management / 대한마취과학회지

BACKGROUND: Pain management in the terminal stage of advanced cancer is often complicated by opioid-related bowel syndrome and other problems. This study was conducted to investigate the safety and efficacy of ketorolac as an adjunctive analgesic in cancer pain management. METHODS: 10 acutely ill cancer patients suffering from pain, complications of advanced disease, and opioid side effects were included. Except one acute leukemia, all of the patients had metastatic solid tumors. Pain complaints consisted of visceral, somatic and opioid bowel syndrome. They were treated with intravenous morphine patient-controlled analgesia infused with a repeated ketorolac bolus dosing. Demographic data, cancer diagnosis, change of pre- and post-treatment morphine infusion rates, and days until pain control or relief of opioid bowel syndrome were evaluated. RESULTS: Excellent pain relief with improvement of opioid bowel syndrome was achieved in a majority of cases. Ketorolac showed good morphine sparing effects. None of the patients reported gastrointestinal side effects. CONCLUSION: Ketorolac appeared to be well-tolerated in the clinical dose range and for short-term use in acutely-ill terminal cancer pain patients. It also seems to be very effective in relieving opioid-related bowel syndromes.

Does Pretreated NSAIDs Decrease the Postoperative Consumption of Morphine? / 대한마취과학회지

BACKGROUND: NSAIDs (Nonsteroidal antiinflammatory drugs) had been known as having analgesic property and its mechanism is prostaglandin synthesis blocking action -peripheral mechanism-. Nowadays, central mechanism of NSAIDs were postulated by some animal or clinical studies, but the preemptive analgesic effects have been still in controversy. Thus, authors planned this study to evaluate whether NSAIDs have the preemptive analgesic effect by using propacetamol and ketorolac. METHODS: Seventy five patients undergoing laparoscopic vaginal hysterectomy were subjected and randomly allocated into three groups according to drugs given. Group P (n=25) and group K (n=25) were given propacetamol 2 gm or ketorolac 30 mg intravenous respectively at 15 minutes before induction. Group C (n=25) had no medication. Pain control using morphine were started in all three groups before skin incision. One anesthesiologist who didn't know which group the patients were allocated visited the patients when the patient arrived at recovery room after operation, postoperative 1 hour, 6 hours, 12 hours, 24 hours and 48 hours and estimated pain score and side effects. Parameters using pain score were visual analogue score (VAS; 100 mm) -subjective parameter- and Prince-Henry score (PHS) -objective parameter-. If VAS>50 or PHS>3, morphine 2.5 mg were given by i.v. and pain score were reestimated after 5 minutes and same dose of morphine were given until VAS<50 and PHS<3. RESULTS: Demographic data of three groups were insignificant. In group P, lower VAS, PHS and morphine consumption were observed than the other groups. Significant changes according to time were observed until postoperative 6 hours in each groups. Side effects occurred as nausea, vomiting and somnolence but statistical significance between groups were absent. CONCLUSIONS: Preoperative i.v. administration of propacetamol 2 gm in laparoscopic vaginal hysterectomy could have preemptive analgesic effects. But we think that determining the proper dosage and timing of administration that could have preemptive analgesic effect of NSAIDs are subjects demands further study.

The Analgesic Effect of Ketorolac Administered in a Hemorrhoidectomy / 대한마취과학회지

BACKGROUND: Moderate to severe postoperative pain is still treated with an intermittent intramuscular injection of narcotics. Recently introduced ketorolac is a nonsteroidal anti-inflammatory drug that has analgesic property comparable to morphine and does not increase opioid-associated side effects such as respiratory depression, nausea and vomiting. We evaluate the analgesic effect of ketorolac directly injected around the anal sphincter muscle during a hemorrhoidectomy. METHODS: Forty adult patients undergoing hemorrhoidectomy were randomly assigned to one of two groups. Both groups received the operation under saddle block and by one surgeon. We administered 60 mg of ketorolac to one group (ketorolac group, n = 20) and the other group (control group, n = 20) received no pain medication intraoperatively. Postoperative visual analogue pain scores (VAS), analgesic requirements and side effects were examined and compared between two groups. RESULTS: VAS at 6 hours after surgery were significantly less (P<0.05) in the ketorolac group (3.1+/-1.5) than in the control group (6.0+/-1.2) and demerol consumption during the first 6 hours after surgery in the ketorolac group was significantly less (P<0.05) than in the control group (35 mg vs 62.5 mg). The ketorolac group also showed significantly less incidence of urinary retention than the control group (P <0.05). CONCLUSIONS: 60 mg of ketorolac administered during hemorrhoidectomy was partially effective for postoperative pain control and the incidence of urinary retention was significantly reduced.

Effects of Caudal Bupivacaine, Bupivacaine/Morphine, and Intravenous Ketorolac for Postoperative Analgesia in Pediatric Day Surgery Patients / 대한마취과학회지

BACKGROUND: For outpatient pediatric anesthesia, pain has perhaps been the main cause of hospitalization. Caudal blocks have been used to treat postoperative pain after low abdominal surgery. The purpose of this study was to evaluate and compare the analgesic effect and the incidence of side effect of caudal bupivacaine alone, a bupivacaine-morphine mixture, and intravenous ketorolac in pediatric day surgery patients. METHODS: Forty three patients, aged 1 to 7 years, were divided into three groups after the induction of general anesthesia. Caudal blocks were performed with 0.2% bupivacaine 0.7 ml/kg alone (group B), 0.2% bupivacaine 0.7 ml/kg and morphine 0.03 mg/kg (group M), and normal saline 0.7 ml/kg (group K). Ketorolac 0.8 mg/kg (group K) or normal saline 2 ml (group B and M) was injected intravenously before incision. Postoperative pain/discomfort scales and 4-point patient sedation scores were assessed, and the incidences of side effects were observed after recovery. RESULTS: Pain/discomfort scores in the group B and K were significantly greater than in group M. There was no difference among the groups in the 4 point patient sedation score. The incidences of nausea/vomiting and urinary retention were more frequent in group M but discharge was not delayed by the side effect. CONCLUSIONS: The addition of morphine to bupivacaine for caudal block provides more effective postoperative analgesia than caudal block with bupivacaine alone and intravenous ketorolac administration in day surgery. Side effects such as nausea/vomiting and urinary retention must be considered after use of morphine during caudal block.

Effects of Caudal Bupivacaine, Bupivacaine/Morphine, and Intravenous Ketorolac for Postoperative Analgesia in Pediatric Day Surgery Patients / 대한마취과학회지

BACKGROUND: For outpatient pediatric anesthesia, pain has perhaps been the main cause of hospitalization. Caudal blocks have been used to treat postoperative pain after low abdominal surgery. The purpose of this study was to evaluate and compare the analgesic effect and the incidence of side effect of caudal bupivacaine alone, a bupivacaine-morphine mixture, and intravenous ketorolac in pediatric day surgery patients. METHODS: Forty three patients, aged 1 to 7 years, were divided into three groups after the induction of general anesthesia. Caudal blocks were performed with 0.2% bupivacaine 0.7 ml/kg alone (group B), 0.2% bupivacaine 0.7 ml/kg and morphine 0.03 mg/kg (group M), and normal saline 0.7 ml/kg (group K). Ketorolac 0.8 mg/kg (group K) or normal saline 2 ml (group B and M) was injected intravenously before incision. Postoperative pain/discomfort scales and 4-point patient sedation scores were assessed, and the incidences of side effects were observed after recovery. RESULTS: Pain/discomfort scores in the group B and K were significantly greater than in group M. There was no difference among the groups in the 4 point patient sedation score. The incidences of nausea/vomiting and urinary retention were more frequent in group M but discharge was not delayed by the side effect. CONCLUSIONS: The addition of morphine to bupivacaine for caudal block provides more effective postoperative analgesia than caudal block with bupivacaine alone and intravenous ketorolac administration in day surgery. Side effects such as nausea/vomiting and urinary retention must be considered after use of morphine during caudal block.

A Comparison of Intravenous Morphine and Ketorolac Using Patient-Controlled Analgesia after Total Abdominal Hysterectomy / 대한마취과학회지

BACKGROUND: Intravenous (IV) morphine is commonly used for postoperative pain management. Ketorolac has been proposed as a potent analgesic for treatment of moderate to severe pain. The purpose of this study was to determine the equianalgesic dose of morphine and ketorolac using intravenous patient-controlled analgesia (IV-PCA) system in human volunteers. METHODS: Fourty-five patients undergoing elective total abdominal hysterectomy were randomly assigned to receive either morphine (n=22) or ketorolac (n=23) when postoperative pain first increased to 40/100 mm (by visual analogue scale; VAS). Until postoperative pain decreased to 40/100 mm, morphine and ketorolac group received repeated IV boluses of 3 mg of morphine and 18 mg of ketorolac respectively and then followed by a IV-PCA with morphine (basal infusion 0 mg/hr, PCA dose 1 mg/1 ml, lock-out interval 5 min) and ketorolac (basal infusion 0 mg/hr, PCA dose 5 mg/1ml, lock-out interval 5 min). Analgesic efficacy with VAS (0~100 mm), PCA demand ratio and rate, analgesics consumptions, patient satisfaction and side effects were compared. RESULTS: There were no significant differences in VAS, PCA demand ratio and patient satisfaction. Mean 48-hour morphine and ketorolac consumptions were 35 (SEM=2.9) mg and 224 (SEM=16.5) mg, respectively (ratio=1:6.4). Morphine group experienced side effects such as pruritus (45%), nausea and vomiting (41%) and respiratory depression (5%). However, ketorolac group only showed side effects such as nausea and vomiting (26%). CONCLUSION: We concluded the ratio of equianalgesic dose of morphine versus ketorolac using intravenous patient-controlled analgesia (IV-PCA) after total abdominal hysterectomy was 1 versus 6.4.

A Comparison of Intravenous Morphine and Ketorolac Using Patient-Controlled Analgesia after Total Abdominal Hysterectomy / 대한마취과학회지

BACKGROUND: Intravenous (IV) morphine is commonly used for postoperative pain management. Ketorolac has been proposed as a potent analgesic for treatment of moderate to severe pain. The purpose of this study was to determine the equianalgesic dose of morphine and ketorolac using intravenous patient-controlled analgesia (IV-PCA) system in human volunteers. METHODS: Fourty-five patients undergoing elective total abdominal hysterectomy were randomly assigned to receive either morphine (n=22) or ketorolac (n=23) when postoperative pain first increased to 40/100 mm (by visual analogue scale; VAS). Until postoperative pain decreased to 40/100 mm, morphine and ketorolac group received repeated IV boluses of 3 mg of morphine and 18 mg of ketorolac respectively and then followed by a IV-PCA with morphine (basal infusion 0 mg/hr, PCA dose 1 mg/1 ml, lock-out interval 5 min) and ketorolac (basal infusion 0 mg/hr, PCA dose 5 mg/1ml, lock-out interval 5 min). Analgesic efficacy with VAS (0~100 mm), PCA demand ratio and rate, analgesics consumptions, patient satisfaction and side effects were compared. RESULTS: There were no significant differences in VAS, PCA demand ratio and patient satisfaction. Mean 48-hour morphine and ketorolac consumptions were 35 (SEM=2.9) mg and 224 (SEM=16.5) mg, respectively (ratio=1:6.4). Morphine group experienced side effects such as pruritus (45%), nausea and vomiting (41%) and respiratory depression (5%). However, ketorolac group only showed side effects such as nausea and vomiting (26%). CONCLUSION: We concluded the ratio of equianalgesic dose of morphine versus ketorolac using intravenous patient-controlled analgesia (IV-PCA) after total abdominal hysterectomy was 1 versus 6.4.

Comparison of Intravenous Administration and Surgical Site Infiltration of Ketorolac Combined with Preincisional Infiltration of Bupivacaine / 대한마취과학회지

BACKGROUND: We postulated that ketorolac as a component of surgical site infiltration would result in better analgesia than intravenous ketorolac. METHODS: Sixty patients who scheduled for elective total abdominal hysterectomy received ketorolac 60 mg (2 ml) either via surgical site infiltration directly (n=30) or parenteral route (n=30) with surgical site infiltration of 0.25% bupivacaine 18 ml 20 min before skin incision. RESULTS: Postoperative analgesic requirement, 48 hour total infusion dose and first 12 hour infusion dose of PCA fentanyl, were significantly lower in surgical site group. There were no significant differences in VAS score and side effects between two groups. CONCLUSION: Ketorolac improves analgesia when it is administered in the surgical site.

The Effects of Preemptive Intravenous Ketorolac for Total Hip Replacement Patients / 대한마취과학회지

BACKGROUND: The purpose of this study is to examine the effect of intravenous ketorolac administration before surgical stimulation for postoperative pain control. METHODS: Forty four patients scheduled for total hip replacement were randomly assigned to one of three groups of prospectively designed study. Group 1 (n=14) received intravenous saline (placebo) and Group 2 (n=15) received intravenous ketorolac (30 mg) at one hour after skin incision and Group 3 (n=15) received intravenous ketorolac (30 mg) before induction. Postoperative pain relief was provided with intravenous morphine from PCA system. Postoperative visual analogue pain score (VAS), analgesic requirement and side effects were evaluated and compared between groups for postoperative two days. RESULTS: VAS at rest were significantly less in Group 2,3 than in Group 1 at 3 hours after surgery (p<0.05) and significantly less in group 3 than in group 1 at 6 and 9 hours after surgery (p<0.05). VAS on movement were significantly less in group 3 than group 1 at 1 hour and significantly less in group 2,3 than group 1 at 3 and 6 hours after surgery (p<0.05). Patient controlled morphine consumption in group 1 was significantly higher than in group 2,3 for 12 hours after surgery. After administration of intravenous ketorolac any side effect did not occur. CONCLUSIONS: Administration of intravenous ketorolac before skin incision as a pre-emptive analgesia has better analgesia than those of 1 hour after skin incision and no administration of ketorolac.