Effect of preemptive multimodal analgesia for arthroscopic knee ligament repair.

BACKGROUND AND OBJECTIVES: Administration of analgesic medication before surgery, rather than at the completion of the procedure, may reduce postoperative pain. Similarly, administration of multiple analgesics, with different mechanisms of action, may provide improved postoperative pain control and functional recovery. The purpose of our study was to compare pain scores and intravenous opioid consumption after outpatient anterior cruciate ligament (ACL) reconstruction in patients who received a multimodal drug combination (intravenous [IV] ketorolac, intra-articular morphine/ropivacaine/epinephrine, and femoral nerve block with ropivacaine) either before surgery or immediately at the completion of the surgical procedure. METHODS: Forty patients presenting for same-day arthroscopic ACL repair using a semitendinosis tendon graft were included in this study. The patients were randomized to receive the following drugs either 15 minutes before skin incision or immediately after skin closure: (1) Ketorolac 30 mg IV. (2) Intra-articular injection of 20 mL ropivacaine 0.25% + morphine 2 mg and epinephrine 1:200,000. (3) Femoral nerve block with 20 mL ropivacaine 0.25%. Verbal pain scores were obtained in the postanesthesia care unit (PACU) and on postoperative days 1, 3, and 7. IV patient controlled analgesia (PCA) morphine consumption in the PACU was also recorded. RESULTS: Verbal pain rating scores were lower in group I (preemptive) for 2.0 hours after arrival in the PACU. There was no difference between groups in pain scores on postoperative days 1, 3, and 7. Mean IV PCA morphine consumption in the PACU was lower in group I (6.4 mg) versus group II (12.3 mg), P <.05. CONCLUSION: Preemptive, multimodal administration of our 3-component analgesic drug combination resulted in lower pain scores during the initial stay in the PACU unit and lower consumption of IV PCA morphine in the PACU. However, pain scores were similar in both groups on postoperative days 1, 3, and 7; thus, there was no measurable long-term advantage associated with preemptive multimodal drug administration.

Tourniquet inflation during arthroscopic knee ligament surgery does not increase postoperative pain.

PURPOSE: A double-blind clinical trial was conducted to determine the effect of inflation of a thigh tourniquet during anterior cruciate ligament repair on arthroscopic visibility, duration of procedure, postoperative pain and opioid consumption. METHODS: Thirty patients were randomly allocated into two groups; Group I had the thigh tourniquet inflated during surgery whereas the tourniquet was not inflated in Group II patients. All patients received standardized general anesthesia and postoperative pain management. Supplemental analgesia was provided with i.v. morphine via a patient-controlled analgesia (PCA) apparatus. Verbal pain rating scores (0-10) were obtained after surgery. RESULTS: Arthroscopic visibility was impaired in Group II patients (P < 0.0001), but this was ameliorated by increased irrigation flow or addition of epinephrine. Duration of surgery was similar in both groups. There was no difference between groups in postoperative morphine consumption (9.8 +/- 7.1 mg in Group I vs 11.4 +/- 10.2 mg in Group II) or in postoperative pain scores between groups. CONCLUSION: Inflation of a thigh tourniquet did not result in increased pain or opioid consumption after arthroscopic ACL surgery. Arthroscopic visibility was somewhat impaired in some patients without the use of tourniquet. Finally, the duration of the surgical procedure was not increased in patients where the tourniquet was not inflated during the ACL repair.

Pre-incision infiltration with lidocaine reduces pain and opioid consumption after reduction mammoplasty.

BACKGROUND AND OBJECTIVES: To determine the analgesic efficacy of preoperative tumescent infiltration with lidocaine for reduction mammoplasty. METHODS: Women with mammary hypertrophy were randomly allocated to one of two study groups in a double-blind clinical trial. Patients in group 1 received preincision infiltration with 5 mL/kg of 0.35% lidocaine with 1:1,000,000 epinephrine into each breast after induction of general anesthesia. Group 2 patients received similar injections of 5 mL/kg of saline with 1:1,000,000 epinephrine. Intravenous patient-controlled analgesia (PCA) morphine (1.0 mg bolus with 5-minute lockout) was available for 9.5 hours in the postoperative period. Visual analog pain scores were recorded during the postoperative period, and hourly morphine consumption data were retrieved from the PCA apparatus. Fitness for discharge was evaluated by the postanesthesia care unit nurse using standardized discharge criteria. RESULTS: Visual analog pain scores were higher in group 2 patients until 3.5 hours after surgery. Patients in the saline group had higher intravenous morphine consumption during all 1-hour postoperative intervals, although the differences between groups were statistically significant only until 4.5 hours after the operation. Total intravenous morphine consumption during the first 9.5 hours after surgery in group 1 was 16.9+/-11.9 mg versus 31.1+/-18.0 mg in group 2 (P < .05). Postoperative nausea and vomiting occurred with equal frequency (87%) in both study groups, and there was no difference between groups in time to achieve fitness for discharge, i.e., a postanesthesia discharge score of > or = 9. CONCLUSION: Preoperative tumescent infiltration with lidocaine results in reduced pain and lower postoperative opioid requirements in the initial hours after reduction mammoplasty.

Oxytocin injection after caesarean delivery: intravenous or intramyometrial?

PURPOSE: To determine, after Caesarean delivery, uterine contractility and blood pressure following intravenous (i.v.) and intramyometrial (imy) injection of oxytocin. METHODS: In a double-blind clinical trial 40 parturients scheduled for elective Caesarean section with spinal anaesthesia were randomized into two equal groups. One litre Ringer's lactate was administered i.v. before intrathecal injection of 1.7 ml bupivacaine 0.75% and 0.3 mg morphine. All patients received simultaneous i.v. and imy injections after removal of the placenta. Patients in Group 1 received 5 IU (10 IU.ml-1) oxytocin i.v. and 2 ml saline imy: Group 2 patients received 0.5 ml saline i.v. and 20 IU oxytocin into the myometrium. Baseline systolic blood pressure (SBP) and heart rate were measured before delivery and at one minute intervals for 15 min after injection of study solutions. Uterine contractility was assessed at 1, 2, 4, 6, 8, 10 and 15 min after oxytocin injection. Haemoglobin concentration before surgery and on first post-operative day was also recorded. RESULTS: Mean decrease in systolic blood pressure (SBP) one minute after oxytocin was 8.4 mmHg in Group vs 14.6 mmHg in Group 2 (P < 0.001). Systolic blood pressure returned to baseline two minutes after oxytocin in Group 1 and after three minutes in Group 2. Uterine contractility and change in haemoglobin concentration were similar in both groups. CONCLUSION: Intramyometrial administration of 20 IU oxytocin after Caesarean delivery is associated with more severe hypotension than is i.v. injection of 5 IU oxytocin. Route of oxytocin injection did not affect uterine tone.

Peri-operative multimodal pain therapy for caesarean section: analgesia and fitness for discharge.

PURPOSE: To compare, the efficacy of a multi-modal analgesic regimen and single drug therapy with iv PCA morphine alter Caesarean delivery with spinal anaesthesia. METHODS: Forty ASA 1-2 parturients presenting for elective Caesarean section were randomized to receive multimodal pain treatment with intrathecal morphine, incisional bupivacaine and ibuprofen+acetaminophen po until hospital discharge (Group 1) or conventional therapy with iv PCA morphine weaned to acetaminophen+codeine po (Group 2). Both groups received spinal anaesthesia with 1.7 ml hyperbaric bupivacaine 0.75%. Visual analog pain scores at rest (RVAPS) and with movement (DVAPS) were recorded q 2 hr during the first 24 hr, then q 4 hr until discharge. Time to first walking, eating solid food, flatus, bowel movement, voiding and hospital discharge were recorded. RESULTS: Pain scores were lower in Group 1 patients during the first 24 hr after spinal injection RVAPS 0.6 +/- 0.1 in Group 1 vs 2.1 +/- 0.1 in Group 2 (mean +/- SEM), DVAPS 1.9 +/- 0.1 in Group 1 vs 4.1 +/- 0.1 in Group 2 (P < 0.0001). Times to first flatus, 36.1 hr +/- 2.9 vs 20.5 +/- 1.8 (P < 0.05) and to first bowel movement, 74.8 hr +/- 5.6 vs 57.4 +/- 4.7 (P < 0.0001) were longer in Group 2 patients. There was no difference between groups in time to eating solid food, walking or hospital discharge. CONCLUSION: Multi-modal pain therapy resulted in improved early post-operative analgesia during the first 24 hr after Caesarean delivery. Patients receiving iv PCA morphine followed by acetaminophen+codeine po were more likely to develop decreased bowel mobility. All patients, with one exception, achieved discharge criteria (eating solid food, absence of nausea, normal lochia, dry incision and DVAPS < 4) at 48 hr after spinal injection.