The effect of dextromethorphan, alone or in combination with ibuprofen, on postoperative pain after minor gynaecological surgery.

BACKGROUND: Experimental studies have demonstrated that peripheral tissue injury may lead to hyperexcitability of nociceptive neurones in the dorsal horn, in part mediated by N-methyl-D-aspartate (NMDA)-receptor mechanisms. Sensitisation of dorsal horn neurones may be an important contributor to postoperative pain. The aim of the present study was to investigate the effect of the NMDA-receptor antagonist dextromethorphan on pain after minor gynaecological surgery, and to evaluate a potential additive effect with ibuprofen. METHODS: In a double-blind, placebo-controlled study, 100 patients scheduled for elective termination of pregnancy were randomised to receive placebo, oral ibuprofen 400 mg, oral dextromethorphan 120 mg, or a combination of ibuprofen 400 mg and dextromethorphan 120 mg, 1 h before surgery. Pain and analgesic requirements were assessed 0.5, 1 and 2 h after operation. RESULTS: We observed no effect of dextromethorphan on visual analogue scale (VAS) pain scores or analgesic consumption, and no additive or synergistic analgesic effects between ibuprofen and dextromethorphan. Ibuprofen reduced pain scores compared with placebo, and analgesic consumption compared with both placebo and dextromethorphan. The combination of ibuprofen and dextromethorphan increased preoperative nausea compared with both placebo and ibuprofen, whereas no statistically significant side effects were observed with dextromethorphan alone. CONCLUSION: No analgesic effects of oral dextromethorphan 120 mg on pain after surgical termination of labour, and no additive analgesic effects when combined with ibuprofen 400 mg, were observed. Ibuprofen reduced both VAS pain scores and analgesic consumption compared with placebo.

Effect of preoperative oral dextromethorphan on immediate and late postoperative pain and hyperalgesia after total abdominal hysterectomy.

Dextromethorphan is a noncompetitive N-methyl-D-aspartate (NMDA) receptor antagonist known to inhibit wind-up and NMDA-mediated nociceptive responses of dorsal horn neurons. Experimental and clinical studies indicate that NMDA-receptor antagonists may potentiate the effect of analgesics such as morphine, local anesthetics and NSAIDs. Results from previous clinical studies of dextromethorphan in postoperative pain are conflicting, possibly related to administration of insufficient doses of the drug. Fifty patients scheduled for non-malignant elective abdominal hysterectomy in general anesthesia were randomized to receive oral dextromethorphan 150 mg, or placebo 1 h before surgery. The patients received patient-controlled analgesia with morphine for 24 h postoperatively as the only analgesic. Patient-controlled analgesia (PCA) morphine consumption was reduced with 30% from 0-4 h after operation in patients receiving dextromethorphan compared with placebo (P=0.02); no differences were observed from 5-24 h postoperatively. There were no significant differences between groups for visual analogue scale scores at rest, during cough, or during mobilization, pressure pain detection thresholds, von Frey hair pain detection thresholds, or peak flow. At 24 h after operation, hyperalgesia to von Frey hair stimulation proximal to the surgical wound was easily detected in 23 of 25 patients receiving dextromethorphan, and in 22 of 25 patients receiving placebo, with no significant difference between groups. Pooled data from both groups showed a weak but significant correlation between the extent of hyperalgesia at 24 h after operation, and total 24 h postoperative PCA morphine consumption (Rs=0.28, P=0.05). Three months postoperatively, hyperalgesia was still detectable in 18 of 22 examined patients in the dextromethorphan group, and in 16 of 23 patients in the placebo group, without statistical differences between groups. There were no significant differences in side-effects (nausea, vomiting, sedation). In conclusion, oral dextromethorphan 150 mg reduced PCA morphine consumption immediately (0-4 h) after hysterectomy, without prolonged effects on pain or wound hyperalgesia. A positive correlation between the magnitude of wound hyperalgesia at 24 h after operation, and total 24 h postoperative PCA morphine consumption was demonstrated.

Warm or cold saline for volume preload before spinal anaesthesia for caesarean section?

In this study, we compared the effect of prophylactic administration of warm and cold saline against spinal anaesthesia induced hypotension in parturients undergoing elective caesarean section. One hundred and thirteen parturients with singleton pregnancies received an i.v. infusion of isotonic saline 20 mL x kg(- 1)during the 15 min before spinal injection followed by 10 mL x kg(- 1)during the 20 min after spinal injection. Fifty-seven patients were allocated to the warm saline group (37 degrees C) and 56 to the cold saline group (21 degrees C). Discomfort in the infusion arm was less in the warm saline group (P<0.01), whereas the incidence of shivering was similar in the two groups. Following induction of spinal anaesthesia, blood pressures were significantly higher in the cold saline infusion group compared to the warm saline group (P<0.05). However, the group mean difference in mean arterial pressure was only about 5 mmHg, and the amount of ephedrine administered and the incidence of clinical significant hypotension did not differ between groups. In conclusion, the temperature of the fluid used for i.v. preload and maintenance at caesarean section under spinal anaesthesia is not clinically important.

Continuous end-tidal carbon dioxide monitoring during normofrequent jet-ventilation.

BACKGROUND: Continuous end-tidal carbon dioxide (ETCO2) monitoring during normofrequent jet-ventilation (NFJV) has not previously been successful and no correspondence between ETCO2 and arterial carbon dioxide (PaCO2) demonstrated. METHODS: During NFJV jet-ventilation in 19 healthy volunteers, continuous ETCO2 was measured and compared to PaCO2 values. The original ETCO2 sampling line from our Datex CO2 measuring equipment was placed longitudinally against a suction catheter and both were wrapped with aluminium foil. They were placed 4-5 cm above the carina and the position was verified with a fiberoptic bronchoscope. RESULTS: The correlation between methods gave a Pearson's product moment correlation (r value) of 0.836, significant at the P < 0.001 level, indicating a close correlation between methods. A difference against mean scatter diagram confirmed that ETCO2 and PaCO2 measurements are of equal value in monitoring healthy patients during NFJV. CONCLUSION: A valuable method of continuous ETCO2 monitoring during NFJV is presented.

Myocardial ischaemia and spinal analgesia in patients with angina pectoris.

We have studied prospectively myocardial ischaemic events by Holter monitoring of ST-segment depression in patients with angina pectoris given spinal analgesia for minor surgery compared with a reference day of normal daily activities. Monitoring was undertaken continuously for 24 h on both days, starting just before anaesthesia on the day of surgery. On the reference day, seven of 14 patients had 27 ischaemic events with mean max ST-depression of 0.15 mV and total duration of 143 min, compared with 10 of 14 patients with 70 ischaemic events with mean max ST-depression of 0.22 mV and total duration of 1078 min (P < 0.01 for all). On the day of surgery, the first ischaemic event occurred a mean 338 min (range 75-480 min) after spinal analgesia, and the duration of all first events was 480 min. On this day, the first ischaemic event was associated with increased heart rate (103 beat min-1 (range 66-131 beat min-1) compared with 92 (60-122) beat min-1 during all events (P = 0.011)). In patients with angina pectoris, myocardial ischaemia did not occur immediately after the onset of spinal analgesia, but several hours later, corresponding to the cessation of block. This could be explained by increased cardiac pre- and afterload, probably further aggravated by the volume load.

[Ketamine. A controversial anesthetic agent]. / Ketamin. Et kontroversielt anaestesimiddel.

On the basis of a review of the literature, a survey is presented concerning the controversial anaesthetic agent ketamine, its pharmacology, mechanism of action and employment. Particular emphasis is placed on the cerebral, cardiovascular and pulmonary effects and the clinical employment. Similarly, the side effects and their prophylaxis are described. It is concluded that ketamine is considered to be a valuable preparation which can be employed both in and outside hospital.

[Peptic ulcer in children]. / Ulcus pepticum hos børn.

Peptic ulceration in children is a rare condition. Primary ulcers, representing 70% of ulcers in children greater than 6 years are predominantly duodenal in location. A positive family history for peptic ulcers is common. Immunosuppressive therapy, severe infections and intracranial lesions are important etiologic factors associated with secondary ulcers. The mortality is approximately 80%. The clinical characteristics of both groups are described. Treatment of children's ulcers and associated complications are described with emphasis on reserving surgical treatment for ulcers not responding to medical therapy and complicated ulcers. We recommend increased attention to this notoriously difficult diagnosis and increasing use of upper gastrointestinal fiberoptic endoscopy.

[Fatal acute stomach ulcer perforation in a 4-year-old child]. / Akut ventrikelulcus med perforation og letal udgang hos 4-årigt barn.

A fatal case of perforation of a gastric ulcer in a 4 1/2-year-old child is presented and discussed.

[Recurrent secondary stomach ulcer in a boy 3 months of age with osteogenesis imperfecta]. / Recidiverende sekundaert ulcus ventriculi hos en tre måneder gammel dreng med osteogenesis imperfecta.

A case is described where a 3-month-old boy who had osteogenesis imperfecta with multiple fractures presented with vomiting and bleeding. A gastric ulcer was diagnosed by endoscopy but could not be visualized by repeated radiography. In spite of adequate treatment with H2-antagonists and antacids the bleeding recurred three months later. Development of hypertrophic pyloric stenosis was diagnosed and pyloromyotomy was performed after which the patient recovered without further recurrences. This case suggests that multiple ulcerogenic factors should considered and treated in pediatric patients with recurrent secondary ulcers in spite of appropriate treatment.