Analgesic Effects of Different κ-Receptor Agonists Used in Daytime Laparoscopic Cholecystectomy

Background. Comparing the effect of two different κ-receptor agonists, nalbuphine and oxycodone, and regular morphine in patients for prophylactic analgesia of acute pain after daytime laparoscopic cholecystectomy. Methods. One hundred and twenty-four patients undergoing laparoscopic cholecystectomy were randomly allocated to receive nalbuphine (group N), oxycodone (group O), and morphine (group M). The three groups were all given intravenous injection (iv.) of 0.15 mg/kg injection before incision and 0.05 mg/kg injection at the end of pneumoperitoneum. The Visual Analogue Scale (VAS) scores (incision, visceral, and shoulder) and Ramsay sedation scores at 1, 2, 4, 8, 12, 16, 20, and 24 hours after surgery, the time of extubation, the incidence of postoperative adverse events, the satisfaction of pain treatment, and the duration of stay after surgery were all recorded. Results. Compared with group M, the VAS scores of visceral pain at rest decreased in group N and group O at 1-8 h after surgery ( P < 0.05 ). The VAS scores of visceral pain at movement in group N decreased longer than those in group O ( P < 0.05 ). Compared with that of group M, the postoperative time in Ramsay sedation score of group O increased longer than that of group N ( P < 0.05 ). Compared with group N, patients had worse sleep quality in group O, longer length of stay in group M, and lower satisfaction in both groups. Conclusion. Compared with morphine, prophylactic use of the κ-receptor agonists, nalbuphine and oxycodone, during laparoscopic cholecystectomy can reduce postoperative visceral pain. Furthermore, the nalbuphine group had fewer adverse reactions, better analgesia, and better satisfaction.

Continuous fentanyl infusion reduces intra-abdominal pressure, postoperative pain and normalizes lungs’ mechanical changes in newborn with viscera-abdominal disproportion in early post-operative period

We aimed to study the influence of prolonged administration of fentanyl on postoperative pain, intra­ab­dominal pressure and mechanical lungs’ changes that may happen in neonates in early post­operative period. 30 newborns (in the period from January 2017 to May 2021) with gastroschisis were divided into two groups ac­cordingly to the method of analgesia (14 – morphine hydrochloride; 16 – prolonged infusion of fentanyl). Lungs’ mechanical characteristics, effectiveness of post­operative analgesia, abdominal wall relaxation was studied by monitoring of dynamic compliance (Cdyn), pressure and flow­volume loops, capnography. Apprising analgesia sta­tus, we measured hemodynamic, SаO2, blood level of cortizol, C­reactive protein (CRP), glucose, analyzed post­operative pain syndrome using visual analogue scales (VAS). Intra­abdominal pressure (IAP) was controlled by Cron. For statistic analysis we used Student’s t­test. In the group with morphine, thete was the increase of IAP by 11–12 cm H2O, being stable during some period of time, and also variable levels of pain according to VAS, the in­creasing of CRP from 0.8 ± 0.25 mg/dl by 5 mg/dl, cortisol by 674.4 nmol/l, and blood glucosae rate – 7.4 mmol/l. Periods with high traumatic effects and poor analgesia (morphine group) reasoned the increasing IAP, step by step dynamic compliance decreasing in 3.4 times, resistance increasing in 2.42 times and PIP rising till 22 cm H2O. Di­rect correlation between IAP increase and lungs’ mechanical changes took place. The study has demonstrated that prolonged administration of fentanyl prevented high increase of IAP, CRP, levels of glucose and cortizol and changes of VAS data, lungs’ mechanical characteristics.

Influence of Catheter–Incision Congruency in Epidural Analgesia on Postcesarean Pain Management: A Single-Blinded Randomized Controlled Trial

Patient-controlled epidural analgesia (PCEA) or epidural morphine may alleviate postcesarean pain; however, conventional lumbar epidural insertion is catheter–incision incongruent for cesarean delivery. Methods: In total, 189 women who underwent cesarean delivery were randomly divided into four groups (low thoracic PCEA, lumbar PCEA, low thoracic morphine, and lumbar morphine groups) for postcesarean pain management. Pain intensities, including static pain, dynamic pain, and uterine cramp, were measured using a 100 mm visual analog scale (VAS). The proportion of participants who experienced dynamic wound pain with a VAS score of >33 mm was evaluated as the primary outcome. Adverse effects, including lower extremity blockade, pruritus, postoperative nausea and vomiting, sedation, and time of first passage of flatulence, were evaluated. Results: The low thoracic PCEA group had the lowest proportion of participants reporting dynamic pain at 6 h after spinal anesthesia (low thoracic PCEA, 28.8%; lumbar PCEA, 69.4%; low thoracic morphine, 67.3%; lumbar morphine group, 73.9%; p < 0.001). The aforementioned group also reported the most favorable VAS scores for static, dynamic, and uterine cramp pain during the first 24 h after surgery. Adverse effect profiles were similar among the four groups, but a higher proportion of participants in the lumbar PCEA group (approximately 20% more than in the other three groups) reported prolonged postoperative lower extremity motor blockade (p = 0.005). In addition, the first passage of flatulence after surgery reported by the low thoracic PCEA group was approximately 8 h earlier than that of the two morphine groups (p < 0.001). Conclusions: Epidural congruency is essential to PCEA for postcesarean pain. Low thoracic PCEA achieves favorable analgesic effects and may promote postoperative gastrointestinal recovery without additional adverse effects.

Comparison between Morphine and Hyaluronidase Added to Local Anesthetic in Sonar Guided Supraclavicular Brachial Plexus Block; Randomized Double Blinded Controlled Study

Background: Huge volumes of local anaesthetics used in conventional blocks may be associated with complications. Hyaluronidase is an enzyme that hydrolyses hyaluronic acid in the tissue. It has been shown to aid the spread of local anaesthetics (LA) through tissue. The aim of this study was to compare between the addition of morphine or hyaluronidase to local anaesthetic in sonar guided supraclavicular brachial plexus block regarding the onset and duration of the block, postoperative analgesia and the total analgesic requirements in the first 24 hours. Patient and methods: Seventy-five patients of American Society of Anaesthesiologists (ASA) physical status I & II, aged 18-60 years, scheduled to acute or elective elbow, forearm or hand surgery under sonar guided supraclavicular brachial plexus block at Tanta University Hospital were randomly allocated into three equal groups; Group I (Control group) received 20 ml containing 9 ml bupivacaine 0.5% and 9 ml lidocaine 2% plus 2 ml normal saline, group II (Morphine group) received 20 ml containing 9 ml bupivacaine 0.5% and 9 ml lidocaine 2% plus 5 mg morphine in 2 ml normal saline and group III (Hyaluronidase group) received 20 ml containing 9 ml bupivacaine 0.5% and 9 ml lidocaine 2% plus 1500 units of hyaluronidase in 2 ml normal saline. The onset of sensory and motor block, duration of sensory and motor block, postoperative VAS, time to first rescue analgesia, total morphine consumption and possible side effects were recorded. Results: Onset of the sensory block and motor block was significantly shorter in the hyaluronidase group than control group and morphine group. Duration of the sensory block and motor block was significantly prolonged in morphine group than hyaluronidase group & control group. VAS started to increase at 6 hours in the control group, at 10 hours in morphine group and at 8 hours in hyaluronidase group. Time to first rescue analgesia was significantly prolonged in morphine group than control group and hyaluronidase group. Total analgesic consumption of morphine was significantly lower in morphine group than control group and hyaluronidase group. Conclusion: Morphine was superior to hyaluronidase as regarding to improving the post-operative pain. The incidence of complications was nil and self-limited in the three groups.

Oxycodone versus morphine for analgesia after laparoscopic endometriosis resection

Background The objective of this study was to compare the analgesic potency of oxycodone versus morphine after laparoscopic deep infiltrating endometriosis resection. Methods Fifty patients undergoing laparoscopic deep infiltrating endometriosis resection were randomized to receive oxycodone or morphine intravenous-PCA after surgery. The primary outcome was opioid consumption during the 24 h after surgery. Secondary outcomes included time to first request for analgesia, the number of bolus, pain, sedation, nausea, vomiting, respiratory depression, and bradycardia. The prominent pain that caused patients to press the analgesic device was also recorded. Results Oxycodone consumption (14.42 ± 2.83) was less than morphine consumption (20.14 ± 3.83). Compared with the morphine group, the total number of bolus (78 vs 123) was less and the average time to first request for analgesia (97.27 ± 59.79 vs 142.17 ± 51) was longer in the oxycodone group. The incidence of nausea was higher in the morphine group than in the oxycodone group at 0–2 h (45.45% vs 17.19%), 2–4 h (50% vs 17.19%),12–24 h (40.91% vs 13.04%) and 0–24 h (39.17% vs 19.13%). The overall incidence of vomiting was higher in the morphine group (27.27% vs 13.92%). There was no difference in visual analogue scale score, the incidence of respiratory depression, and bradycardia between groups. Of the three types of pain that prompted patients to request analgesia, the incidence of visceral pain was highest (59.9%, P < 0.01). Conclusion Oxycodone was more potent than morphine for analgesia after laparoscopic endometriosis resection, and oxycodone has fewer side effects than morphine. Name of the registry: Chinese Clinical Trial Registry Trial registration number: ChiCTR1900021870 URL of trial registry record:http://www.chictr.org.cn/edit.aspx?pid=35799&htm=4 Date of registration: 2019/3/13 0:00:00

Effects of Preoperative Low-Dose Gabapentin on Postoperative Pain and Sedation of Patients Undergoing General Anesthesia

Objective: To study the drug interaction between gabapentin and morphine in surgical patients under general anesthesia. Materials and Methods: Two hundred sixty patients undergoing surgery under general anesthesia were randomized into two groups, A with 130 patients receiving gabapentin 2.0 to 3.5 mg/kg orally for premedication add-on, and B with 130 patients getting morphine 0.1 to 0.2 mg/kg intravenously. After surgery, a co-researcher assessed patients using Ramsay sedation scale (RSS) and pain numeric rating scale (NRS) at 2, 4, 8, 12, 16, and 24-hour intervals. Results: Two hundred thirty-two patients were included the present study without procedural adverse events. There were 120 and 112 patients in gabapentin and morphine group, respectively. The administration dosage of gabapentin and morphine between the two groups showed statistically significant differences (p=0.031). During the emergence, the RSS on the sedation, agitation, drowsiness, and pain scores of gabapentin (1.8±0.4) and morphine (1.7±0.5) appeared statistically significant differences (p=0.032); however, the RSS on that in the post-anesthetic care unit (PACU) were 2.0±0.1and 2.0±0.2, respectively, which showed insignificant differences (p-value 0.283). Conclusion: A small, single oral dose of gabapentin as premedication showed a synergistic effect on intraoperative morphine administration. However, this additive effect was not long lasting through the PACU and might not be suitable for an extended surgery. Keywords: Drug interaction; Gabapentin; Morphine; Anesthesia

Differential Aspects of Natural and Morphine Reward-Related Behaviors in Conditioned Place Preference Paradigm

Natural rewards are essential for animal survival. On the other hand, drug-seeking behaviours can be maladaptive and endanger survival. The present study was conducted to enhance our understanding of how animals respond to food and morphine as natural and drug rewards, respectively, in a conditioned place preference (CPP) paradigm. We designed a protocol to induce food-CPP and compare it as a natural reward with morphine-CPP in rats. The protocol for reward induction in all groups (foods and morphine) consisted of three phases: pre-test, conditioning, and post-test. In morphine groups, we injected morphine as a reward (5 mg/kg, s.c.), and for inducing natural-reward, we used two different protocols, by one of the rats were deprived of food for 24h. In the other method, rats were restricted for food for 14 days. During the conditioning period, animals received daily chow, biscuit, or popcorn as a reward inducer. Results revealed that CPP did not induce in food-deprived rats. A combination of food restriction (as a facilitator) and a biscuit or popcorn induced reward using CPP. In contrast, food deprivation did not facilitate food-CPP in response to regular food. Interestingly the CPP score of the group which received biscuit during a 7-day conditioning period was more than that of the morphine group. In conclusion, food restriction could be a better protocol than food deprivation to facilitate food reward.

Intraoperative Intravenous Methadone and Ketamine Combination versus Intravenous Morphine and Ketamine Combination for Post-Operative Analgesia in Patients Undergoing Lower Extremity Fracture Surgery

Background: Pain management for lower extremity fracture surgeries can be challenging. The purpose of this study is to determine whether the use of ketamine and methadone are more effective than ketamine and morphine to reduce postoperative pain and morphine requirements in patients undergoing lower extremity fracture surgery. Materials and Methods: Seventy-five patients 18-65 years of age, ASA class I-III, were enrolled in this study, which scheduled for elective lower extremity orthopedic surgery involving fracture of femur or tibia were recruited for the study. Thirty-eight randomized to the Methadone group and 37 randomized into the Morphine group. Participants were randomized to either one of the two groups: methadone (2ug/kg fentanyl, 0.2 mg/kg ketamine and 0.2 mg/kg methadone IV) versus control (2 ug/kg fentanyl, 0.2mg/kg ketamine and 0.2 mg/kg morphine IV). The primary outcome was total morphine equivalent (MEQ) during the first 24 and 48 hours after surgery. Secondary outcomes included postoperative pain scores in PACU, at 24 and 48 hours, as well as postoperative nausea and vomiting (PONV). Results: There was no difference in intraoperative consumption of fentanyl between the Methadone group 360mcg and Morphine group 344mcg. In the first 24 hours postoperatively, the Methadone group consumed less MEQ compared with the Morphine group (36.1 mg vs 54.8 mg, p=0.0072), showed lower pain scores than the Morphine group (p=0.0146), and experienced more nausea and vomiting than the Morphine group. There were no differences in sedation in both groups. Conclusion: The intraoperative use of intravenous methadone significantly reduced post-operative opioid requirement in patients undergoing lower extremity fracture surgery. The results also demonstrated the methadone group had a higher rate of PONV.

"COMPARATIVE CLINICAL EVALUATION OF INTRATHECAL ISOBARIC LEVOBUPIVACAINE (0.5%) WITH MORPHINE AND ISOBARIC ROPIVACAINE (0.5%) WITH MORPHINE IN INFRAUMBILICAL SURGERIES -A CLINICAL STUDY”

Background: Subarachnoid block is a simple technique that provides a deep and fast surgical block through the injection of small doses of local anaesthetic drug in Subarachnoid space. Various local anesthetic agents have been used in subarachnoid block since their introduction, isobaric drugs along with opioids provide excellent combination of shorter motor and longer sensory block which is useful for short duration infraumbilical surgeries. Methods: The present study is a prospective, comparative and clinical study between age group 18-45 years of either sex belonging to ASA grade I and II undergoing elective infra-umbilical surgeries. 40,40 patients were taken into each group. Mean duration of surgery in each group was around 90 minutes. Perioperative vitals like heart rate, blood pressure, oxygen saturation, ECG were recorded. Motor block was assessed through modied Bromage scale and post operative pain was assessed through VAS visual analogue scale , also need for rescue analgesia was monitored postoperatively. Results: We found that 150 microgram intrathecal morphine added as an adjuvant to 0.5% isobaric ropivacaine provided prolonged duration of analgesia and early recovery as compared to 150 microgram intra thecal morphine added with 0.5% isobaric levobupivacaine in patients undergoing infra-umbilical surgeries without causing signicant hemodynamic variation and adverse effects. Conclusion: In present study, we conclude that time of onset of sensory block was more and duration of sensory and motor block was less in isobaric ropivacaine with morphine as compared to isobaric levobupivacaine with morphine. Which revealed that ropivacaine group provides good postoperative analgesia and shorter motor block, that leads to early recovery and better patient satisfaction So, ropivacaine with morphine seems to be better as compared to levobupivacaine with morphine group.

587 Methadone and Morphine for Outpatient CO2 Laser Pain Management

Introduction Burn reconstruction with CO2 laser is now very popular. Providing adequate analgesia is imperative for large total body surface area (TBSA) resurfacing. CO2 lasers’ cause significant pain during the procedure and pain similar to that of a severe sunburn post-operatively. Thus, adequate analgesia that provides peri-operative and post discharge management without delaying discharge is beneficial. At our institution, we use a multimodal analgesic preoperative and intra-operative approach to deal with this issue. The preoperative intervention utilizes a novel approach of oral methadone for older children and avoids the use of intra-operative morphine as a preemptive measure for pain management. The purpose of this outcomes review was to determine if our peri-operative analgesic practices were effective in controlling peri-operative pain. Methods After corporate IRB review, this project was undertaken as a quality improvement initiative and was not formally supervised by an institutional review board. A chart review of all patients who received CO2 laser treatment (CLT) was conducted. Using a Donabedian model for outcomes measure, postoperative and pre-discharge observational pain scores (scale 1–10), peri-operative analgesics, demographics, percent burn treated, incidents of rescue medication before discharge home, time to discharge and adverse reactions were collected. Results 74 patients were reviewed (47 male, 27 female), ages 4 to 30, average age 17. Average percent body surface area treated was 17.5%. Out of 74 cases, 18 received intra-operative morphine and 56 received oral methadone pre-operatively. All patients received routine intra-operative ketorolac and lidocaine/prilocaine cream, based on weight. In the PACU there were 2 recorded rescue doses of morphine in the morphine group and 0 in the methadone group. There was one post- operative recorded observational pain score of 5 in the methadone group and one each of 3 and 8 in the morphine group, both of which received rescue morphine. There were no differences in mean times to discharge between groups. Observational pain scores were 0 for both groups at discharge. Chi square analysis showed no statistical difference between groups. No adverse outcomes (respiratory arrest or readmission for pain) were recorded in either group. Conclusions Both pre-operative oral methadone and intra-operative morphine are effective in controlling peri-operative pain in our children undergoing laser surgery. Categorical age differences and low group sizes may have contributed to outcomes and should be considered in the next review.