The role of duloxetine in reducing opioid consumption after thoracotomy: a prospective, randomized, double-blinded, placebo-controlled pilot trial.

BACKGROUND: Exploration of the thoracic cavity through a thoracotomy incision for thoracic malignancies is accompanied by severe, excruciating acute postoperative pain. The objective of this study is to evaluate the efficacy of perioperative duloxetine when given as part of a multimodal analgesia in reducing the dose of opioids needed to treat acute postoperative pain after thoracotomy. METHODS: Sixty patients scheduled for thoracotomy were randomly assigned to one of two treatment groups. The duloxetine group (D) received duloxetine 60 mg orally two hours before the surgical procedure and 24 hours after surgery, and the placebo group (P) received oral equivalent placebo capsules during the same time schedule. The primary outcome was the postoperative consumption of narcotics. Secondary outcome measures were assessment of postoperative pain scores (VAS) during rest, walking and coughing, hemodynamic variables and development of any side effects. RESULTS: Total dose of morphine needed to treat postoperative pain in first 48 hours, intraoperative isoflurane concentrations, intra- and postoperative epidural infusion rates all were significantly lower in group D (P<0.001). Postoperative pain at rest (VAS-R) was significantly less frequent in group D compared to group P at all-time intervals so as during walking (VAS-W) (P<0.001). While during cough (VAS-C), it was comparable at all time point except at 12 hours which was significantly low in group D (P<0.001). The intra-, postoperative mean blood pressure and development of side effects were comparable between the two groups. CONCLUSIONS: Oral duloxetine used perioperatively during thoracic surgery may play an important role as multimodal analgesia for acute postoperative pain without any added side effects.

The Role of Double Modality Ultrasonographic and Fluoroscopic Guided Superior Hypogastric Plexus Neurolysis in Treating Intractable Pelvic Cancer Pain: A Comparative Study.

BACKGROUND: Superior hypogastric neurolytic block is performed to block visceral pelvic pain. This could be performed through the anterior approach guided by CT or ultrasound and through a posterior approach, guided by fluoroscopy or CT. METHODS: Sixty adult patients with severe visceral pelvic pain (VAS>70 mm) were randomly divided into two groups. Group S: SHP block was done ultrasound guided using the anterior approach and confirmed by fluoroscopy. Group F: SHP block was done fluoroscopic guided using the posterior oblique approach. The VAS (visual analog scale), duration of the technique, time of X-ray exposure, patient satisfaction score, patient global impression of change (PGIC), quality of life score, and daily morphine consumption (mg/day) were measured pre-procedure and at the 1st, 4th, 8th, and 12th week after the procedure. In addition, any side effects of the procedure were recorded. RESULTS: There was a significant difference in VAS between the two groups (P<0.01) (better in group S). The quality of life score was improved from the pre-procedure in both groups (P<0.05), and morphine consumption was significantly lower in group S than in group F (P<0.05) at the 1st, 4th, and 8th week and not significant at the 12th week. The two groups show a statistically significant difference as regards the duration of the procedure and X-ray exposure (P<0.01). There was a statistically significant difference in the satisfactory score between the two groups at the 1st, 4th, 8th, and 12th week (P<0.01). As regards the PGIC score, there was no statistically significant difference between the two groups (P>0.05). In group S, no back pain was reported, while 11 patients of group F complained from post-procedure back pain (P<0.001). CONCLUSION: The anterior ultrasound guided SHPB aided by fluoroscopy is suggested to be more superior to the standard fluoroscopic guided technique in relieving pelvic cancer pain and decreasing morphine consumption.