Comparison of tramadol versus tramadol with paracetamol for efficacy of postoperative pain management in lumbar discectomy: A randomised controlled study.

PURPOSE: Despite developments in the treatment of pain, the availability of new drugs or increased knowledge of pain management, postoperative pain control after different surgeries remains inadequate. We aimed to compare the postoperative analgesic efficacy of tramadol versus tramadol with paracetamol after lumbar discectomy. DESIGN, SETTING, PARTICIPANTS: Sixty patients undergoing lumbar discectomy were randomly assigned into two groups. METHODS: Patients in Group T (n = 30) received tramadol (1 mg/kg), and patients in Group TP (n = 30) received tramadol (1 mg/kg) with paracetamol (1 g) 30 minutes before the end of surgery and paracetamol was continued during the postoperative period at 6 hours intervals for the first 24 hours. Patient-controlled analgesia with tramadol was used during the postoperative period. MAIN OUTCOME MEASURES: Duration, postoperative pain scores, Ramsay sedation scores, analgesic consumption, and side effects were recorded in all patients during the postoperative period. Continuous random variables were tested for normal distribution using the Kolmogorov-Smirnov test, than Student's t-test was used for means comparisons between groups. For discrete random variables chi-square tests and McNemar test was used. RESULTS: Demographic data, mean duration of anaesthesia and surgery were similar in both groups. Postoperative pain scores were significantly higher in Group T than Group TP at 5; 15; 20; and 30 minutes (P = .021, P = .004, P = .002, P = .018). Late postoperative pain scores were similar. Total tramadol consumption in Group T (106.12 ± 4.84 mg) was higher than Group TP (81.20 ± 2.53) during the 24 hours postoperative period. However, continuing the paracetamol at 6 hours interval did not change late postoperative pain scores. CONCLUSION: The administration of tramadol with paracetamol was more effective than tramadol alone for early acute postoperative pain therapy following lumbar discectomy. Therefore, while adding paracetamol in early pain management is recommended, continuing paracetamol for the late postoperative period is not advised.

Effect of the degree of head elevation on the incidence and severity of venous air embolism in cranial neurosurgical procedures with patients in the semisitting position.

OBJECTIVE The semisitting position of a patient confers numerous advantages in various neurosurgical procedures, but venous air embolism is one of the associated complications of this position. To date, no prospective studies of the relationship between the degree of head elevation and the rate and severity of venous air embolism for patients undergoing a procedure in this position have been performed. In this study, the authors compared changes in the severity of venous air embolism according to the degree of head elevation (30° or 45°) in patients undergoing an elective cranial neurosurgical procedure in the semisitting position. METHODS One hundred patients undergoing an elective infratentorial craniotomy in the semisitting position were included, and each patient was assigned to 1 of 2 groups. In Group 1, each patient's head was elevated 30° during surgery, and in Group 2, each patient's head elevation was 45°. Patients were assigned to their group according to the location of their lesion. During surgery, the standard anesthetic protocol was used with total intravenous anesthesia, and transesophageal echocardiography was used to detect air in the blood circulation. Any air embolism seen on the echocardiography screen was classified as Grade 0 to 4. If multiple events occurred, the worst graded attack was used for statistical analysis. During hemodynamic changes caused by emboli, fluid and vasopressor requirements were recorded. Surgical and anesthetic complications were recorded also. All results were compared statistically, and a p value of < 0.05 was considered statistically significant. RESULTS There was a statistically significant difference between groups for the total rates of venous air emboli detected on transesophageal echocardiography (22.0% [n = 11] in Group 1 and 62.5% [n = 30] in Group 2; p < 0.0001). The rate and severity of air embolism were significantly lower in Group 1 than in Group 2 (p < 0.001). The rates of clinically important venous air embolism (Grade 2, 3, or 4, venous air embolism with decreased end-tidal carbon dioxide levels and/or hemodynamic changes) were 8.0% (n = 4) in Group 1 and 50.0% (n = 24) in Group 2 (p < 0.0001). There was no association between the rate and severity of venous air embolism with patient demographics (p > 0.05). An association was found, however, between the rate of venous air embolism and the type of surgical pathology (p < 0.001); venous embolism occurred more frequently in patients with a meningioma. There were no major surgical or anesthetic complications related to patient position during the postoperative period. CONCLUSIONS For patients in the semisitting position, an increase in the degree of head elevation is related directly to a higher rate of venous air embolism. With a 30° head elevation and our standardized technique of positioning, the semisitting position can be used safely in neurosurgical practice.

The frequency and severity of metabolic acidosis related to topiramate.

Objective We planned a cross-sectional analysis to determine the frequency and severity of metabolic acidosis in patients taking topiramate while awaiting craniotomy. Methods Eighty patients (18 - 65 years) taking topiramate to control seizures while awaiting elective craniotomy were enrolled. Any signs of metabolic acidosis or topiramate-related side effects were investigated. Blood chemistry levels and arterial blood gases, including lactate, were obtained. The severity of metabolic acidosis was defined according to base excess levels as mild or moderate. Results Blood gas analysis showed that 71% ( n = 57) of patients had metabolic acidosis. The frequency of moderate metabolic acidosis was 56% ( n = 45), while that of mild metabolic acidosis was 15% ( n = 12). A high respiratory rate was reported in only 10% of moderately acidotic patients. Conclusions In patients receiving topiramate, baseline blood gas analysis should be performed preoperatively to determine the presence and severity of metabolic acidosis.

Effects of a fentanyl-propofol mixture on propofol injection pain: a randomized clinical trial.

BACKGROUND: Propofol injection pain is a common problem that can be very distressing for patients. We compared the effects of injection with saline followed by injection with a fentanyl-propofol mixture, injection with fentanyl followed by a propofol injection, and injection with saline followed by propofol alone on propofol injection pain. METHODS: The patients were assigned randomly to one of three groups. A rubber tourniquet was placed on the forearm to produce venous occlusion for 1 min. Before anesthesia induction, group C (control, n = 50) and group M (fentanylpropofol mixture, n = 50) received 5 ml of isotonic saline, while group F (fentanyl, n = 50) received 2 µg/kg of fentanyl. After the tourniquet was released, groups C and F received 5 ml of propofol and group M received 5 ml of a mixture containing 20 ml of propofol and 4 ml of fentanyl. At 10 s after the study drugs were given, a standard question about the comfort of the injection was asked of the patient. We used a verbal rating scale to evaluate propofol injection pain. Statistical analyses were performed with Student's t-tests and Fisher's exact tests; P < 0.05 was considered to indicate statistical significance. RESULTS: The demographic data were similar among the groups. In group M, the number of patients reporting propofol injection pain was significantly lower than in groups F and C (both P < 0.001). No patient in group F or M experienced severe pain, whereas 24 patients (48%) had severe pain in group C (both P < 0.001). CONCLUSIONS: This study shows that a fentanyl-propofol mixture was more effective than fentanyl pretreatment or a placebo in preventing propofol injection pain.

The Effect of Flurbiprofen on Postoperative Sore Throat and Hoarseness After LMA-ProSeal Insertion: A Randomised, Clinical Trial.

OBJECTIVE: We hypothesized that flurbiprofen lozenges reduce the ProSeal laryngeal mask airway (LMA) related symptoms of Post Operative Sore Throat (POST), hoarseness and dysphagia compared to placebo lozenges. METHODS: Eighty American Society of Anesthesiologists (ASA) I-II patients undergoing general anaesthesia with LMA were included in this prospective, randomized, placebo-controlled clinical and single centre (university hospital) study. Group F received an 8.75 mg flurbiprofen lozenge (Strefen(®)) and Group P received a placebo lozenge 45 minutes before the induction of anaesthesia. Postoperative sore throat, hoarseness and dysphagia were evaluated 30 minutes after removal of the LMA in the recovery room and then at 4, 12 and 24 h after surgery using a 4-point scale. Data were analysed using Student's t test, and Fisher's exact and Mann-Whitney U tests. A p value of <0.05 was considered statistically significant. RESULTS: The 8.75 mg flurbiprofen lozenges reduced the severity of early (30 mins) POST and dysphagia. The severity of dysphagia at 4 h and hoarseness at 12 h were also significantly reduced in Group F. There were no significant differences betweeen the groups regarding incidence of sore throat, dysphagia and hoarseness throughout the study period. CONCLUSION: Preoperative flurbiprofen lozenges reduce the severity of early postoperative sore throat and dysphagia.