Postoperative analgesia for total knee replacement: comparing between pre-and postoperative "3-in-1" femoral nerve block.

BACKGROUND: Total Knee Replacement (TKR) produces severe postoperative pain. Pre- and postoperative single-shot "3-in-1" Femoral Nerve Block (FNB) were reported to improve analgesia and reduce morphine consumption post TKR. OBJECTIVE: To find out the most beneficial time for injection of single shot "3-in-1" FNB for TKR between preoperative and postoperative in a prospective controlled trial. MATERIAL AND METHOD: In a Randomized, double-blind Controlled Trial (RCT), 48 patients undergoing TKR received either pre- or postoperative "3-in-1" FNB using 30 mL of bupivacaine 0.25% after a standardized general anesthesia. Morphine consumption, Numeric Pain-Rating Scale (NPRS) at rest and during movement, tension in the back of the knee, nausea/vomiting, pruritus, sedation, and respiratory depression at 1, 4, 24 and 48 hr after TKR were compared RESULTS: There were no significant differences in 48-hr morphine consumption [46.5 (20.0) vs 45.0 (23.6) mg, p = 0.809], NPRS both at rest and during movement, tension in the back of knee, nausea/vomiting, pruritus, sedation, and respiratory depression at any time during 48-hr postoperative TKR between groups. CONCLUSION: Preoperative single-shot "3-in-1" FNB using 30 mL of bupivacaine 0.25% is not better than postoperative single-shot "3-in-1" FNB using the same drug in postoperative pain and morphine reduction in patients undergoing elective TKR under general anesthesia.

A double-blind, randomized study comparing postoperative pain management using epidural ropivacaine with intravenous ketorolac or intravenous ketorolac alone following transabdominal hysterectomy.

OBJECTIVE: The aim of this study is to compare the effect on postoperative pain of epidural ropivacaine in combination with intravenous ketorolac with intravenous ketorolac alone following transabdominal hysterectomy. DESIGN: A multi-center, randomized, double-blind study was conducted in Thailand and the Philippines to assess postoperative pain management in 107 patients given ketorolac alone or in combination with epidural ropivacaine following transabdominal hysterectomy. Pain score was assessed using a 100-mm visual analogue pain scale (VAS). RESULTS: The VAS scores for pain on coughing and at rest were significantly better in the ropivacaine group. The number of patients who asked for morphine in addition was higher in the ketorolac group compared to the ropivacaine + ketorolac group. The time taken to carry out the first three ambulatory steps was similar for both the two treatment groups. A higher degree of motor block was observed in the ropivacaine group over time. The adverse events observed were similar in both groups. CONCLUSION: We demonstrated that epidural infusion of ropivacaine in addition with intravenous ketorolac gave superior pain relief at rest and on coughing in patients undergoing transabdominal hysterectomy when compared to the group receiving intravenous ketorolac alone.

Anesthesia for one-stage bilateral pheochromocytoma resection in a patient with MEN type IIa: attenuation of hypertensive crisis by magnesium sulfate.

Multiple endocrine neoplasia (MEN) type IIa, manifesting as an autosomal dominant trait, consists of medullary thyroid carcinoma, parathyroid adenoma or hyperplasia, and pheochromocytoma. We report our experience of a 42-year-old woman, MEN type IIa with a large bilateral pheochromocytoma, who underwent one-stage bilateral tumor resection under a combined continuous epidural technique with 0.25 per cent bupivacaine and general anesthesia using vecuronium, fentanyl, nitrous oxide, and isoflurane. An initial intra-operative hypertensive response was acceptably controlled by nitroprusside and a beta-blocker but during tumor handling the hypertensive crisis worsened and she developed acute pulmonary edema despite a continuing high dose of nitroprusside infusion. After receiving intermittent i.v. MgSO4 up to 3 g in 15 min, her condition gradually improved and the cardiovascular response was under control throughout the period of tumor handling. Hypotension encountered post-pheochromocytoma resection was treated by volume replacement, metaraminol, CaCl2, and dopamine infusion. The patient's post-operative course was uneventful.