Results of Epispadias Repair Using the Modified Cantwell-Ransley Technique.

OBJECTIVE: To evaluate our results of epispadias repair with a modified Cantwell-Ransley (MCR) technique. METHODS: A retrospective Institutional Review Board-approved chart review of all patients who underwent an MCR epispadias repair was conducted between 1998 and 2015. Procedures were performed at birth or after the age of 8 months as part of the modern staged repair of exstrophy-epispadias complex (EEC) in patients with bladder exstrophy treated since birth, at presentation for older patients, and after the age of 6 months in isolated epispadias patients. Twenty-two children underwent MCR epispadias repair in our institute during the study period. Sixteen of them had EEC and 6 had isolated epispadias. Four patients underwent exstrophy and epispadias repair at the same session. Twelve children underwent epispadias repair as a second stage of modern staged repair at a mean age of 21 months (range 8-60). The procedures involved dissection of the corporeal bodies and urethral plate from the penile base to the tip of the penile glans. RESULTS: After a mean follow-up of 6.9 years (range 0.5-18), there were no complications in the isolated epispadias group and 4 complications in the bladder exstrophy group: urethrocutaneous fistula (n = 1), residual dorsal curvature (n = 1), and excess of penile skin (n = 2). The meatal location was orthotopic in all cases. All of the complications were successfully addressed in a single subsequent surgical session. CONCLUSION: MCR technique continues to be a reliable, reproducible option for epispadias repair in EEC patients and in cases of isolated epispadias.

Repeated and escalating preoperative subanesthetic doses of ketamine for postoperative pain control in patients undergoing tumor resection: a randomized, placebo-controlled, double-blind trial.

BACKGROUND: Ketamine induces a short-term effect on postoperative pain when administered intravenously immediately before or during acute pain. Repeated administration of low-dose ketamine may induce long-term pain relief in chronic pain syndromes. OBJECTIVE: The aim of our study was to determine whether ketamine's effect on acute postoperative pain could be enhanced and prolonged and analgesia consumption reduced if it was administered intramuscularly in repeated and escalating subanesthetic doses many hours before surgery. METHODS: Patients who were scheduled for tumor resection under general anesthesia were randomly and blindly given preoperative IM ketamine (K) or normal saline (placebo [P]) following 1 of 3 consecutive protocols (2 groups/protocol, 20 patients/group): 1 dose (25-mg ketamine or 1-mL saline) at 4 hours preoperatively (K1 or P1); 2 doses (10- and 25-mg ketamine or 1-mL saline twice) at 11 and 4 hours (K2 or P2); or 3 doses (5-, 10-, and 25-mg ketamine or 1-mL saline thrice) at 17, 11, and 4 hours preoperatively (K3 or P3). No other preoperative medications were given. Postoperatively, all patients received morphine (1.5 mg/bolus) via an intravenous patient-controlled analgesia (PCA) device. RESULTS: A total of 120 patients took part in the study. Patients' ages ranged from 15 to 75 years; mean weight (76 [14] kg; range, 50-120), gender (69 men, 51 women), and race were equally distributed among the groups. There were no significant differences in intraoperative parameters among the groups. The patients' mean self-rated 48-hour pain scores on a numerical rating scale were lower in the K2 and K3 groups than in their corresponding placebo groups (K2: 1.67 [1.04] vs P2: 3.62 [1.93] [P = 0.0004]; K3: 2.22 [1.37] vs P3: 3.25 [1.76] [P = 0.046]). These groups also used ∼35% less morphine compared with the placebo groups (K2: 28.4 [20.4] mg, K3: 26.6 [16.0] mg vs P2: 42.4 [30.4] mg, P3: 40.9 [21.2] mg [P ≤ 0.02]). Intravenous PCA usage among K2 and K3 patients was ∼50% less than the usage among their placebo counterparts (P < 0.05). The 1-ketamine-injection patients' pain scores and analgesic consumption were similar to those of their placebo groups. The 25-mg-ketamine injections caused dizziness that lasted up to 2 minutes. CONCLUSIONS: Our 48-hour data suggest that 2 or 3 escalating subanesthetic doses of IM ketamine injected consecutively hours before surgery attenuated postoperative pain and reduced morphine consumption in these subjects.

Immediate postoperative pain in orthopedic patients is more intense and requires more analgesia than in post-laparotomy patients.

OBJECTIVE: To compare the immediate postoperative pain intensity between orthopedic and general surgery patients and evaluate the extent of severe pain in each group. DESIGN: Observational, open-label study. SETTING: Post-anesthesia care unit (PACU) in a tertiary, university-affiliated hospital. PATIENTS: Patients undergoing orthopedic surgery or laparotomy under general anesthesia over a one-year period. INTERVENTIONS: Follow-up of patient self-rated pain visual analog scale (VAS, 0-10), and observation of the efficacy of the routine analgesic protocol of morphine, ketamine, and diclofenac administration in the PACU. OUTCOME MEASURES: We followed pain scores and sorted patients according to morphine requirements during the PACU immediate postoperative stay. Patients whose pain was controlled with ≤120 µg/kg intravenous morphine were considered pain-controllable. Where this amount was insufficient to control pain (VAS ≥5/10), patients were categorized as suffering from severe pain. They were further treated with repeated doses of 1 mg morphine plus 350 µg/kg ketamine (M+K) and eventually diclofenac. PACU follow-up lasted 3 hours. RESULTS: The overall rate of immediate severe postoperative pain within the entire cohort (3,460 patients) was 9.4%: 123 (6.6%) of laparotomy patients and 202 (12.7%) of orthopedic patients. Pain in the laparotomy patients identified as suffering from severe pain was controlled with 1.21±0.45 doses of M+K compared with 1.37±0.62 (P<0.0001) in the orthopedic counterparts. One-fifth of these laparotomy patients demanded more than one injection of M+K compared with one-third of the orthopedic subgroup (P=0.045). Twenty-seven orthopedic vs nine surgical patients (P=0.036) required diclofenac. CONCLUSIONS: More orthopedic than laparotomy patients suffered from severe immediate postoperative pain. They required more analgesia than that dictated by existing PACU analgesia protocols. Ketamine and morphine co-administration proved effective in controlling severe postoperative pain after each type of surgery.

Effects of intravenous patient-controlled analgesia with buprenorphine and morphine alone and in combination during the first 12 postoperative hours: a randomized, double-blind, four-arm trial in adults undergoing abdominal surgery.

BACKGROUND: Intense pain in the first 12 hours after major abdominal surgery requires the use of large amounts of analgesics, mainly opioids, which may produce undesirable effects. Buprenorphine (BUP) is not typically used intravenously in this setting, particularly in combination with morphine (MO), due to concerns that BUP might inhibit the analgesic effect of MO. OBJECTIVE: This study compared the analgesic effect of BUP and MO separately and in combination for postoperative pain control in patients undergoing abdominal surgery. METHODS: In this double-blind study, adult patients were randomized to receive 1 of 4 regimens for 12 hours: a basal BUP infusion (BUP-i) of 0.4 microg/kg/h + BUP boluses (BUP-b) of 0.15 microg/kg each; a basal MO infusion (MO-i) of 10 microg/kg/h + MO boluses (MO-b) of 5 microg/kg each; a basal BUP-i of 0.4 microg/kg/h + MO-b of 5 microg/kg each; or a basal MO-i of 10 microg/kg/h + BUP-b of 0.15 microg/kg each. Bolus doses were delivered by intravenous patient-controlled anesthesia, with a bolus lockout time of 7 minutes. Diclofenac 75 mg IM q6h was available as rescue pain medication. Every 15 minutes during the first 2 postoperative hours and hourly thereafter, patients used visual analog scales to rate their pain (from 0 = totally free of pain to 10 = unbearable pain), level of sedation (from 1 = totally awake to 10 = heavily sedated), and satisfaction with treatment (from 1 = totally unsatisfied to 10 = fully satisfied). Blood pressure, heart rate, respiration rate, and arterial blood oxygen saturation (SpO(2)) were monitored, and adverse effects reported by patients or noted by clinicians were recorded at the same times. Study end points included total opioid consumption (infusion + boluses), demand:delivery ratio, and use of rescue medication. RESULTS: One hundred twenty patients (63 men, 57 women; age range, 21-80 years; weight range, 40-120 kg) were included in the study. Seventy-four percent had other mild, treated diseases (American Society of Anesthesiologists physical class 2). Pain visual analog scale ratings were comparably high in all groups during the first 2 postoperative hours. Pain intensity ratings at 3 to 12 hours were significantly lower in those who received BUP-i + BUP-b compared with the other treatment groups (P = 0.018). The drug requirement during the postoperative period decreased significantly in all groups (P = 0.01); however, there was a significant difference between groups in the demand:delivery ratio at 3 to 12 hours (group * psydrug interaction, P = 0.026). The numerically lowest demand:delivery ratio was seen with BUP-i + BUP-b. BUP-i was associated with a significantly lower heart rate compared with the other groups (P = 0.027); there were no drug-related differences in respiration rate, SpO(2), or sedation. Patients' level of satisfaction with treatment was significantly higher in the group that received BUP-i + BUP-b compared with the other 3 groups (P < 0.001). Postoperative nausea and vomiting were mild and occurred at a similar incidence in all groups, as did rescue diclofenac use. CONCLUSIONS: In these patients undergoing abdominal surgery, the BUP-i + BUP-b regimen controlled postoperative pain as well as did MO-i + MO-b or the combinations of BUP and MO. BUP neither inhibited the analgesia provided by MO nor induced undesired sedation or hemodynamic or respiratory effects.

Morphine with adjuvant ketamine vs higher dose of morphine alone for immediate postthoracotomy analgesia.

BACKGROUND: Thoracotomy is associated with severe pain. We hypothesized that the concomitant use of a subanesthetic dose of ketamine plus a two-third-standard morphine dose might provide more effective analgesia with fewer side effects than a standard morphine dose for early pain control. METHODS: We conducted a 6-month randomized, double-blind study in patients undergoing thoracotomy for minimally invasive direct coronary artery bypass or for lung tumor resection. After extubation, when objectively awake (>or= 5/10 visual analogue scale [VAS]) and complaining of pain (>or= 5/10 VAS), patients were connected to patient-controlled IV analgesia delivering 1.5 mg of morphine plus saline solution (MO) or 1.0 mg of morphine plus a 5-mg ketamine bolus (MK), with a 7-min lockout time. Rescue IM diclofenac, 75 mg, was available. Follow-up lasted 4 h. RESULTS: Forty-one patients completed the study. MO patients (n = 20) used 6.8 +/- 1.9 mg/h (mean +/- SD) and 5.5 +/- 3.6 mg/h of morphine during the first and second hours, respectively; MK patients (n = 21) used 3.7 +/- 1.2 mg/h and 2.8 +/- 2.3 mg/h, respectively (p < 0.01). The 4-h activation rate of the device was double in the MO patients than in the MK patients (66 +/- 54 vs 28 +/- 20, p < 0.001). The maximal self-rated pain score was 5.6 +/- 1.0 for the MO group vs 3.7 +/- 0.7 for the MK group (p < 0.01). Four MO patients vs one MK patient required diclofenac; 6 MO patients but no MK patients had oxygen saturation by pulse oximetry < 94% on a fraction of inspired oxygen of 0.4 (p < 0.01); two MO patients required reintubation. Paco(2) was higher in the MO group (40 +/- 6 mm Hg vs 33 +/- 5 mm Hg, p < 0.05). Heart rate, BP, and incidence of nausea/vomiting were similar; no ketamine-related hallucinations were detected. CONCLUSIONS: Subanesthetic ketamine combined with a 35%-lower morphine dose provided equivalent pain control compared to the standard morphine dose alone, with fewer adverse side effects and a 45% reduction in morphine consumption. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00625911.

Ketamine for acute and subacute pain in opioid-tolerant patients.

Prolonged acute pain, especially that of oncologic neurological origin, is at times difficult to control; it is seldom entirely alleviated by opioids. We report eight patients with severe pain, three of whom suffered from new onset oncologic metastatic bone pain, others had previous pain syndromes and presented with exacerbation of pain. Pain was associated with hyperalgesia and allodynia phenomena in two patients and with phantom pain in a third one. Tolerance to opioids had developed, and high IV doses of morphine, meperidine or fentanyl, and patient-controlled intravenous and epidural analgesia were insufficient. Several patients became dependent on opioids and could not be weaned from assisted ventilation. Pain was controlled with decreasing adjunct doses of ketamine. Within 5-10 days of ketamine and opioid protocols, pain was controlled and after an additional 5-7 days, ketamine could be stopped and pain controlled on oral regimens compatible with outpatient care. Ketamine is an efficient adjuvant analgesic for intractable severe pain, caused by metastasis, trauma, chronic ischemia, or central neuropathic pain. It is effective even when mega doses of IV, epidural, or oral opioids prove ineffective and when signs of tolerance have developed.