[ comparison of the efficacy of intra-articular injection of morphine with marcaine in patients to relief the pain associated with knee arthroscopy]

Knee arthroscopy is an approved technique for the diagnosis and treatment of intra-articular lesions. Moderate to severe pain is experienced after surgery; thus, relieving pain post arthroscopy, will help patients in performing their daily activities as soon as possible. Many studies have been performed for reducing pain after arthroscopy. The aim of this study is to compare the efficacy of intra-articular injection of morphine with marcaine in patients for pain relief after arthroscopy. 30 patients were considered for arthroscopic surgery, due to the tearing of the menisci. In this simple non-probability trial, patients were divided in two groups. The first group received 7cc intra-articular marcaine at 0.5% and the second group received 10mg of intra-articular morphine after the arthroscopy. The response was measured by VAS in hours 6, 12, 18, 24 postoperatively and by flexion, extension and walking. The results showed that there was no significant statistical difference between the two groups, except in hour 6 after surgery, indicating marcaine is more effective than morphine. There were no side effects experienced within the two groups. Age, gender, height and weight also had no effect in reducing the pain in patients. Intra-articular Injection of marcaine is more effective than morphine six hours after surgery; however, there are no differences between them after that time frame. More research is needed in order to reduce pain after arthroscopy

Combination of oral ketamine and midazolam versus midazolam alone as a premedication in children undergoing tonsillectomy

Premedication with oral midazolam is a common practice in paediatric anaesthesia. Combining oral ketamine to midazolam has been tried with different dosing regimens and proved to give good results. The aim of this study was to compare the combination of oral ketamine and midazolam to oral midazolam alone as regard sedation and postoperative pain relief. A prospective randomized double-blind study was carried out in 60 children who were randomly allocated into two groups. Group M received 0.5 mg.kg-1 oral midazolam and group MK received 0.25 mg.kg-1 oral midazolam with 4 mg.kg-1 oral ketamine as a premedication 20 minutes preoperatively. A five points-sedation score [1 asleep to 5 agitated] on arrival to the operating room and a three points-acceptance score of separation from the parents and a three points-mask cooperation score at induction of anesthesia [1 easy to 3 markedly resistant] were used. The time to recovery from anesthesia and to achieve satisfactory Aldrete score was recorded. Time to supplementary analgesia defined as achieving a pain score of 4 or more was used to compare the two groups. At 30 min, 1, 2, and q4h postoperative, pain score was recorded by a blinded observer. Pain was treated with morphine 25 ug.kg-1 intravenously for pain score more than 4, and cumulative morphine consumption in 24hrs was used to compare postoperative analgesic requirements in both groups. Acceptable sedation scores were seen in both groups, without any serious side effects. However, the combination of Ketamine and Midazolam offered significantly more children in an awake, calm and quiet state, who were easily separated from their parents. The separation and cooperation scores were comparable between the groups. The time to recovery from anaesthesia and time to achieve satisfactory Aldrete score were also comparable between the two groups. Time to supplementary analgesia was significantly prolonged in the KM group than in the M group. Total morphine consumption was significantly less in the KM group than in the M group. Adding oral Ketamine to midazolam as a premedication in children provides good quality of sedation and decreases post operative analgesic requirements after tonsillectomy

Postoperative control of pain after total knee replacement: epidural infusion of bupivacaine-sufentanil and levobupivacaine-sufentanil mixtures

Regional anasthesia [particulary epidural technique] leads to reduction in intraoperative and postoperative complications thus improving morbidity and mortality after major surgery [1-2], minimizing or preventing side effects and risk are economic benefits which can be balanced against, or purchased by costs, especially in terms of postoperative morbidity and hospital stay [3-4-5]. Racemic bupivacaine has been widely used as a local anesthetic beacuse of its long duration of action and beneficial ratio of sensory to motor block when used for epidural analgesia. However there have been reports of death attributable to bupivacaine-induced cardiotoxicity in patients after accidental intravascular injection [6] or during intravenous regional anaesthesia [7]. Levobupivacaine was developed because of concern regarding bupivacaine cardiotoxicity and preclinical evidence suggesting that there is stereospecificity with regard to blockade of impulse conduction in the cardiovascular system. Clinical studies have shown that levobupivacaine is equipotent to bupivacaine in vitro and in vivo in terms of anaesthesia efficacy. This study was conducted on fort patients classified into two groups, each of twenty, undergoing total knee replacement, comparing the analgesic efficacy, effects on hemodynamic parameters and the occurrence of side effects, between two groups receiving either bupivacaine sufentanil or levobupivacaine-sufentanil mixtures for post operative control of pain. This study revealed non-significant difference between the two groups as regard the effectiveness of pain control as determined by monitoring the 100 mm visual analogue scale, degree of sedation as detected by the four points sedation score also changes in the hemodynamic parameters were comparable between the two groups as well as the prevalence of side effects

Effect of morphine, verapamil or morphine plus verapamil on lidocaine brachial block anaesthesia for orthopaedic surgery

Calcium channel blockers [CCBs] potentiate the analgesic properties of both local anaesthetics and opioids. We examined the analgesic effects of administering morphine, verapamil or its combination into the brachial plexus sheath with lidocaine in 64 unpremedicated patients of physical status 1 or 11, aged 20 - 55 yr and weighing 50 - 80 kg, undergoing upper extremity orthopaedic surgery. All patients received brachial plexus anaesthesia with 40 ml of 1.5% lidocaine and epinephrine 5 ug/ml. in addition, patients were randomly allocated to 1 of 4 groups; Group 1: patients received lidocaine solution, Group 2; patients received morphine 5 mg was added to lidocaine solution; Group 3; patients received verapamil 2.5 mg was added to lidocaine solution and Group 4; patients received morphine 5 mg and verapamil 2.5 mg were added to lidocaine solution. Onset of sensory block, duration of anaesthesia and analgesia were recorded. Postoperatively patients rated their pain [0 - 10] at 1, 6, 12, and 24 hr. Patients were instructed to take paracetamol tablets, every 6 hrs when pain score exceeded 3, and total postoperative analgesia requirements was recorded. Onset of sensory block was similar in the four treatment groups. Duration of anaesthesia [time of abolition of pinprick response] was significantly [p<0.001] increased in those patients receiving brachial plexus blocks with verapamil [groups 3 and 4]. Analgesic duration was significantly increased [p<0.001] in those patients receiving brachial plexus block with morphine [groups 2 and 4]. The total 24hr paracetamol use was also less in those groups [2 and 4], which was significant [p<0.05]. We conclude that, the addition of verapamil to brachial plexus block with lidocaine can prolong the duration of sensory anaesthesia, but it had no effect on analgesic duration of morphine used when both were administered with lidocaine via a brachial plexus route

Regional delivery of local anesthetic agents for postoperative analgesia following femoropopliteal arterial reconstruction

This study describes a new concept for postoperative analgesia following femoropopliteal arterial reconstruction by placing an indwelling catheter along the surgical wound, through which pulses of a local anesthetic agent can be delivered in the postoperative period. Twenty-five patients undergoing femoropopliteal bypass grafting with saphenous vein for superficial femoral arterial occlusive disease were included [16 males, 9 females. Mean age 59 +/- 6 years]. Patients were randomized into two groups for postoperative pain relief: Group I [n=12]: were assigned to regional delivery of Bupivicaine 0.25% 5cc every 8 hours via an indwelling catheter placed along the wound for 48 hours. Group II [n-13]: received Pethidine 1mg/Kg IM every 8 hours for 48 hours. Patients experiencing breakthrough pain during the 8-hour period between doses received IM injection of Diclofenac potassium 75mg. Postoperative pain was rated by means of a visual analog scale. The pain score during the first 48 hours following surgery was 3.25 +/- 0.87 for Group I compared to 5.08 +/- 1.04 for Group II, p<0.0001. Only two patients in Group I required Diclofenac doses for breakthrough pain compared to 8 patients in Group II, p < 0.05. The mean dose of Diclofenac per patient was 31.25 +/- 74.7mg for Group I vs 103.85 +/- 89.5mg for Group II, p < 0.05. There was no significant difference between the two groups regarding wound problems or hospital stay. Regional delivery of a local anesthetic [Bupivicaine] via an indwelling catheter following femoropopliteal bypass surgery is a simple, safe and effective method for providing prolonged postoperative analgesia. This technique should be considered for wider use among these patients

Post-operative analgesia for arthroscopic menisectomy by intra-articular, neostagmine, morphine and pethidine

Arthroscopic Surgery of the knee is a common day-case surgery depends on the provision of udequate analgesia. In this study sixcty pataients in similar age, weight, sex and duration of operation were allocated randomaly in four groups each of 15 both sex. The first [control group] received 30ml saline intra-articular, the second [morphine group] received 5mg morphine in 30ml saline,k the third [pethidine group] received 50mg pethidine in 30ml saline, and the fourth [neostagmine group] received 750ug neostagmine in 30ml saline. Above knee tournequet was applied for at least 10 minutes after intra-articular injection. Post-operative pain was assessed using an internal visual analogue scale [VAS] and measuring analgesic scale [VAS] and measuring analgesic requirements. All the three treated groups had highly significant lower pain scores compared with the control group. Patients in pethidine group had a significant lower pain scores than those in the morphine group up to 2 hours postoperative, but after that it had a significant increase pain scores than morphine group, also neostagnine group patients had significant lower pain score than morphine group up to 3 hours postoperatively after that it had a significant increase in pain score than morphine group but it had significant increase in pain score than pethidine up to 2 hours postoperative, after that a significant lower pain score than pethidine group. These exact findings explained by pethidine does its effect through its local anesthetic, peripheral opiate receptor systemic and active metabolite effects. Morphine does its effect through a peripheral opiate receptors and active metaboliotes Neostragmine has long lasting analgesic effect than morphine through a peripheral muscarinic respecters

Pain relief after hemorrhoidectomy value of continuous perfusion of the anal canal with bupivacaine and modified closed technique

In this research, we studied the effect of continuous perfusion of the anal canal with the long acting local anesthetic bupivacaine as well as a modified technique of closed hemorrhoidectomy, on post-operative pain. The modification used here is closure of the wounds in a circumferential direction rather than the classic radial manner. This work included 112 patients with 2nd., 3rd and 4th degrees hemorrhoids. They were divided randomly into 4 equal groups; [A1] open hemorrhoidectomy with continuous perfusion of anal canal with 500cc. Normal saline for 8-10 hours, [control group] [A2] like [A1] with the addition of 20cc. Bupivacine 0.5% to the saline. [B1] modified closed technique + perfusion with 500cc saline, [B2] like [B1] with the addition of bupivacaine to the saline. Post-operative pain was evaluated according to the demand for analgesia during the first postoperative day and also the first week. Continuous bupivacaine perfusion reduced significantly the need for analgesia during the first day; as shown in group A1 vs. A2 and also B1 vs. B2 [P<0.01]. Urine retention which is caused mainly by post-operative pain, was lower in the groups with bupivacaine perfusion [A2] and B2] but the difference was significant only between [B2] and [A1] [P<0.05]. During the first post-opeative week, patients managed by closed techniaue [B1] and B2] experienced lesser pain than the open group [A1 and A2] [P<0.001]. Comparing also the closed versus the open hemorrhoidectomy regarding wound healing and anal stenosis revealed, better results, with the former procedure through the first post-operative month [P<0.05]. From this study we recommend the use of continuous perfusion of the anal canal with bupivacaine and the use of closed technique for hemorrhoidectomy as this will decrease the post-operative pain and urine retention, and also the wounds will heal faster with lower tendency for anal stenosis

Analgesic effect of intra-articular neostigmine after operative knee arthroscopy comparative study of neostigmine, tenoxicam, morphine and placebo

This study was designed to compare the postoperative peripheral analgesic effect of intra-articular [IA]: neostigmine, tenoxicam, morphine and placebo. The study included forty unpremedicated adult patients with ASA status 1 or 2, scheduled for operative knee arthroscopy under general anaesthesia. Patients were randomly allocated into four equal groups [each 10 patients] Group A received 500 micro g neostigmine in 30 ml saline IA, group B received 20 mg tenoxicam in 30 ml saline IA. group C received 2 mg morphine in 30 ml saline IA, and group D received 30 ml saline [placebo control group]. Postoperative pain was assessed using a 10-cm visual analogue scale [VAS] at 1.4,8,24 and 48 hours and at time of dem and ing analgesia. Time to first analgesic administration and the total amount of analgesic consumption over 48 hrs were compared in the four groups. There was a significant reduction in VAS in the neostigmine group at 1,4 hrs compared to tenoxicam. morphine or saline groups, and at 8, 24 hrs compared to morphine and saline groups. At 48 hrs no intergroup difference was detected. Time to first analgesic administration was significantly longer in the neostigmine group, also, the total amount of analgesic consumption per 48 hrs was significantly less in the neostigmine group in comparison to tenoxicam. morphine or saline groups. It can be concluded that neostigmine induces effective postoperative analgesia at peripheral sites of about 8-9 hrs, provided no atropine was given, with no side effects. Analgesic efficacy of intra-articular neostigmine is better than either tenoxicam or morphine given intra-articuLarly

Comparison of small dose ketoprofen and ketorolac added to lidocaine during intravenous regional anaesthesia for post operative analgesia

Non-steroidal anti-inflammatory drugs have a predominantly peripheral site of action by blocking the local synthesis of prostagl and ins. The aim of this study was to compare and evaluate whether the additional of small dose ketoprofen and ketorolac to lidocaine during intravenous regional anaesthesia [IVRA] would improve the quality of postoperative analgesia. Sixty patients undergoing upper limb IVRA for minor sugery were randomly assigned to three double-blind groups, group A [placebo], group B where 15 mg ketoprofen was mixed with lidocaine 0.5% for IVRA administered i.v. after toumiquet inflation and group C where 5 mg ketorolac was added to the local anesthetic for IVRA. Mean dose of fentanyl consumption intra operatively was significalltly lower [P < 0.05] in groups B and C when compared with group A durationl of post operative analgesic was significantly longer [P 0<005] in group B [14 +/- 11] and group C [15 +/- 10] when compared with group A [1.4 +/- 0 7], but not significant [P < 0.50] between group B and C. Analgesic requirements remained significantly lower in groups B and C when compared with group A but not significant between groups B and C Pain scores were significantly lower in groups B and C when compared with group A, but was not significant between groups B and C We concuoded that 15 mg ketoprofen and 5 mg ketorolac added to lidocaine 0.5% during IVRA improves the quality of intraoperative and postoperative analgesia and ketoprofen was as efficacious as ketorolac

Thoracic epidural versus intraperitoneal local anaesthetic for postoperative pain relief after laparoscopic or open cholecystectomy

Laparoscopic cholecystectomy [LPC] is increasingly used to treat symptomatic cholelithiasis. In this study, we compared the effects of cholecystectomy by subcostal incision to those of LPC on lung function and endocrine metabolic response. The effects of thoracic epidural analgesia and intraperitoneal local anaesthetics [0.25%] bupivacaine 20 ml for LPC were studied as well. Forty patients undergoing elective cholecystectomy under general anaesthesia were allocated into four study groups, group I, cholecystectomy by subcostal incision [CSI], group II, LPC, group III, LPC and epidural analgesia with 0.5% bupivacanie followed by continuous epidural infusion of 6 ml of 0.5% bupivacaine. Group IV, 0.25% bupivacaine 20 ml administered I.P., forced vital capacity [FVC] and forced expiratory volume in one second [FEV 1] were measured with the patients in a half-setting position. In all groups, sustained decrease in FVC, FEV1 were observed up to 24 hours after surgery. Reduction of FVC was significantly more in group I compared with groups II, III and IV [p < 0.05]. Two hours after surgery, FVC was decreased significantly in groups I, II, III and IV to 29.1, 58.3, 63.6 and 59% of the preoperative values respectively. At that time, FEV1 decreased to 27, 55, 60 and 56% of the preoperative values in groups I, II, III and IV respectively [p < 0.05]. In all groups, plasma glucose and cortisol levels increased after surgery compared with the baseline levels [p <0.05]. At 240 minutes after surgery, a small but significant decrease of cortisol was measured in group III [p < 0.05]. Patients in groups I, II and IV, received significantly more fentanyl during surgery and morphine postoperatively compared with patients in group III [p <0.05]. In group III, epidural analgesia decreased visual analogue pain scores [p <0.05], but there was no difference in pain scores between group I, II and IV. In conclusion, the endocrine metabolic response is not abolished after LPC. Thoracic epidural analgesia decreased postoperative pain and attenuated the metabolic endocrine response, but it did not improve lung function after LPC. Nevertheless, pulmonary function is significantly better after LPC than after cholecystectomy via subcostal incision

Effect of pre-incisional versus post incisional lidocaine infiltration on early post-operative pain after cesarean section

The effect of preincisional versus postincisional wound infiltration with lidocaine on pain after cesarean section in 40 adult female patients under general anesthesia was studied, they were divided into two equal groups. The surgical area was infiltrated with 1.5% lidocaine plain [30 ml] either 5 min. before skin incision [group 1] or immediately before skin closure [group 2] pain was evaluated for 6 hours after skin incision [zero time] using verbal rating scale and visual analogue scale at rest, during cough and during mobilization. The results revealed a beneficial effect which was evident in group 1. In group 2, there was significantly more number of patients needed analgesics, with significantly earlier demand and significantly more number and type of analgesic doses requirement. Also, there were higher pain scores in group 2 but they were not significant