Does the opioid-sparing effect of rectal diclofenac following total abdominal hysterectomy benefit the patient?

BACKGROUND: The aim of this prospective, double-blind, randomized, placebo-controlled clinical trial was to investigate the opioid-sparing effects of rectal diclofenac following total abdominal hysterectomy. METHODS: Forty ASA I-II patients, aged 20-60 yr, were randomized to receive identical-looking suppositories of either diclofenac 75 mg or placebo, twice daily. All patients were given a standardized anaesthetic, with intravenous morphine via a patient-controlled analgesia device and either diclofenac or placebo for postoperative analgesia. RESULTS: The median 24 h morphine consumption (interquartile range) was significantly higher (P=0.02) in the placebo group [59 (45-85) mg] than in the diclofenac group [31 (14-65) mg]. In comparison with the placebo group, there were significant reductions in total pain score in the diclofenac group at rest (P=0.04) and on movement (P<0.01). Total (SD) sedation score was significantly lower (P=0.04) in the diclofenac group [90 (73) mm] than in the placebo group [148 (89) mm]. Total (interquartile range) nausea score was significantly lower (P<0.01) in the diclofenac group [14 (0-53) mm] than in the placebo group [64 (30-109) mm]. There was no significant difference between the two groups of patients in episodes of vomiting or number of rescue antiemetics. CONCLUSIONS: Rectal diclofenac reduces morphine consumption, improves postoperative analgesia, and reduces the incidence of adverse effects such as sedation and nausea.

Infiltration of the abdominal wall with local anaesthetic after total abdominal hysterectomy has no opioid-sparing effect.

We have measured the effect of infiltration of the deep and superficial layers of the abdominal wound on morphine consumption and pain for 48 h after operation, in 40 patients undergoing total abdominal hysterectomy, in a double-blind randomized study. Patients received wound infiltration with 0.9% normal saline 40 ml or 40 ml of 0.25% bupivacaine with epinephrine 1:200,000. There were no significant differences between groups in morphine consumption, linear analogue scores for pain at rest or on movement, nausea or sedation during the first 48 h after operation. We conclude that infiltration of the deep and superficial layers of the wound of a Pfannenstiel incision with local anaesthetic solution did not confer additional analgesia in patients undergoing major gynaecological surgery.

Intraperitoneal bupivacaine or lidocaine does not provide analgesia after total abdominal hysterectomy.

We have compared pain scores at rest and on standardized movement, and morphine consumption using patient-controlled analgesia in 60 patients who had undergone total abdominal hysterectomy. Patients were allocated randomly to one of three groups: in the saline group, 0.9% sodium chloride 50 ml was administered into the pelvic cavity before closure of the peritoneum; in the second group, the solution administered was 20 ml of 0.5% bupivacaine solution with epinephrine 1:200,000 diluted with saline to a final volume of 50 ml; in the third group, the solution used was 20 ml [corrected] of 2% lidocaine with epinephrine 1:200,000 diluted with saline to a final volume of 50 ml. We found that there was no significant difference between the three groups in visual analogue pain scores at 8, 12, 36 or 48 h after operation at rest or on movement, and no significant difference in sedation or dose of antiemetic administered. Mean morphine consumption in the first 24 h was 54.6 (SEM 5.9) mg in the saline group, 55.5 (6.4) mg in the bupivacaine group and 52.5 (5.3) mg in the lidocaine group. In the second 24 h, morphine consumption was 34.9 (6.6) mg, 28.1 (3.5) mg and 28.0 (3.5) mg in the three groups, respectively. We conclude that i.p. administration of local anaesthetic solution into the pelvic cavity did not confer appreciable analgesia in patients undergoing abdominal hysterectomy.

Intraperitoneal lignocaine for pain relief after total abdominal hysterectomy.

In this preliminary randomized study, we have measured pain scores at rest and on movement, 24 and 48 h after operation in 19 control patients, who received 50 ml of saline i.p., and in 20 test patients, in whom 50 ml of saline solution containing lignocaine 200 mg and adrenaline 1:500,000 were instilled into the peritoneal cavity after total abdominal hysterectomy. We found that there was no difference in linear analogue scores for nausea, pain on movement or morphine consumption after operation between the two groups, but pain scores at rest were significantly lower in the lignocaine group at 24 and 48 h compared with the saline group. In the lignocaine group, blood sampling over a 3-h period revealed a mean maximum serum concentration of 0.4 microgram ml-1 at 3 h and a highest concentration in any patient of 0.87 microgram ml-1.

Treatment of drooling by parotid duct ligation and submandibular duct diversion.

A new combination of operations is described for controlling drooling in patients with cerebral palsy. Fourteen patients underwent ligation of one parotid duct and diversion of both submandibular ducts at the same operation. Drooling was controlled in all. Transient oro-facial swelling was the commonest complication.

Changes in plasma catecholamine concentrations following infiltration with large volumes of local anaesthetic solution containing adrenaline.

Plasma catecholamine concentrations have been measured in nine patients undergoing rhinoplasty following infiltration to the facial area of 21 ml of 0.5% lignocaine with adrenaline 1:200,000 and in seven patients undergoing brachial plexus blockade with 40 ml of 0.5% lignocaine, 0.25% bupivacaine and adrenaline 1:200,000. In the rhinoplasty group there was a 566% increase in plasma adrenaline concentration 2 min after cessation of infiltration, whilst in the brachial plexus group a 112% increase in the plasma concentration of adrenaline occurred at 10 min after completion of the block. There was no change in plasma noradrenaline concentration in either group. It is concluded that the so-called safe dose of adrenaline (1.0 microgram kg-1 during halothane anaesthesia) is meaningless unless the site of administration is specified.

Barrier pressure and muscle relaxants. Comparison of the effects of pancuronium and vecuronium on the lower oesophageal sphincter.

The effects of pancuronium and vecuronium on the lower oesophageal sphincter pressure were studied in 24 healthy patients anaesthetised with 0.5% halothane in nitrous oxide and oxygen. Following pancuronium 0.1 mg/kg intravenously, there was a significant increase in barrier pressure from a control value of 2.0 (SEM 0.14) kPa to 3.0 (SEM 0.27) kPa 1 minute after injection (p less than 0.05). This increase was sustained throughout the 15 minute period of recording and was accompanied by a significant increase in heart rate (p less than 0.001). Following administration of vecuronium 0.1 mg/kg intravenously there was an initial modest, though not significant increase in barrier pressure. This increase was significant (p less than 0.05) at 15 minutes. There were no cardiovascular changes following vecuronium.

Comparison of the effects of pancuronium and atracurium on the lower esophageal sphincter.

The effects of pancuronium and atracurium on the lower esophageal sphincter pressure (LESP) were studied in 24 healthy patients anesthetized with 0.5% halothane in 66% nitrous oxide in oxygen. After pancuronium (0.1 mg X kg-1) given intravenously there was a significant increase in LESP from a control value of 36 +/- 4.0 cm H2O to 50 +/- 4.6 cm H2O at 1 min. This produced an increase in barrier pressure (BRP) from 26 +/- 3.7 cm H2O to 41 +/- 4.3 cm H2O. These changes were sustained for 5 min accompanied by a significant increase in arterial pressure and heart rate. Atracurium (0.6 mg X kg-1) had no cardiovascular effects and produced little changes in either LESP or BRP. The findings of this study suggest that pancuronium may be of benefit in a rapid sequence induction.

Pain relief after abdominal surgery--a comparison of i.m. morphine, sublingual buprenorphine and self-administered i.v. pethidine.

One hundred and twenty-six patients undergoing upper and lower abdominal surgery were studied after operation to compare the analgesic effects of i.m. morphine, sublingual buprenorphine and self-administered i.v. pethidine by Cardiff Palliator. There were no significant differences between analgesic regimens in respect of subjective linear analogue pain scores or static and dynamic lung volumes assessed at 24 and 48 h after operation and 5 days after operation in patients who underwent upper abdominal surgery. Sublingual buprenorphine produced more nausea and sedation than the other two treatments, but the differences were not clinically important. However, it offered considerable advantages in terms of ease of administration.

Effect of oral diazepam on lower oesophageal sphincter pressure.

The effect of diazepam 10 mg orally was investigated on lower oesophageal sphincter pressure in a random double-blind study of nine healthy volunteers. Barrier pressure decreased to a small but statistically significant extent. The reduction in barrier pressure was not related to the level of drowsiness.

Single and combined effects of atropine and metoclopramide on the lower oesophageal sphincter pressure.

The effects of atropine and metoclopramide on the lower oesophageal sphincter pressure (LOSP) were studied in 12 healthy volunteers using oesophageal pressure transducers. Atropine decreased LOSP significantly at 5 min after i.v. injection (P less than 0.005) and this change was sustained for 60 min. Metoclopramide increased LOSP significantly at 3 min after administration i.v. (P less than 0.05) and this change was sustained for 40 min. Following consecutive administration of the drugs the effects of atropine predominated.

Comparison of the effects of atropine and glycopyrrolate on lower oesophageal sphincter pressure.

Lower oesophageal sphincter pressure (LOSP) has been measured on three separate occasions in nine healthy volunteers using oesophageal pressure transducers. Atropine 0.6 mg decreased LOSP significantly at 5 min after i.v. injection (P less than 0.025) and this change was sustained for 40 min. Glycopyrrolate 0.3 mg or 0.2 mg decreased LOSP significantly at 3 min after i.v. injection (P less than 0.0025). This change was sustained for 60 min and was similar for both doses and also similar in magnitude to the change produced by atropine.