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Background: This non-randomized study aimed to compare the efficacy of two pharmacological treatments, "around-the-clock" analgesic treatment (ACAT) and "on-demand" analgesic treatment (ODAT), for managing postoperative pain following hemorrhoidectomy. Material and Methods: The study, conducted from July 2016 to December 2020, included 5335 hemorrhoidectomy patients. Participants were divided into ACAT (3767) and ODAT (1568) groups. The study was registered at clinicaltrials.gov (NCT04953182). Results: Patients had a mean age of 47.47 years, with 59.98% males. Postoperatively, 14.13% reported severe pain, 36.49% moderate, 34.28% mild, and 15.09% no pain. ACAT group's maximum pain was 3.04 (VAS), ODAT 4.95 (p; average pain was 0.79 (ACAT) and 1.45 (ODAT). Discharge pain was 0.42 (ACAT) and 0.63 (ODAT) VAS. The ACAT group consistently reported lower levels of pain across all measured instances. Higher BMI and younger age were pain risk factors (p=.049, p .001 respectively). ACAT administration resulted in reduced opioid usage, with meperidine showing a 68.38% decrease, morphine 43.57% less, tramadol 46.82% less, oxycodone reduced by 38.74%, and codeine by 53.40%. Additionally, the use of non-opioid analgesics was notably lower in the ACAT group, ranging from 16% to 59% less compared to the ODAT group. Conclusion: Hemorrhoidectomy induces moderate postoperative pain, with only 14% experiencing severe pain. A fixed schedule multimodal pain regimen, regardless of procedure and anesthesia type, reduces pain from moderate to mild post-hemorrhoidectomy. This approach also decreases opioid and non-opioid analgesic requirements. Higher BMI and younger age are identified as risk factors for elevated postoperative pain., (Celsius.)

Objective: The aim of this study is to evaluate the effect of erector spinae plane block (ESPB) as a rescue therapy in the recovery room., Materials and Methods: This single-center historical cohort study included patients who received either ESPB or intravenous meperidine for pain management in the recovery room. Patients' numeric rating scale (NRS) scores and opoid consumptions were evaluated., Results: One hundred and eight patients were included in the statistical analysis. Sixty-two (57%) patients received ESPB postoperatively (pESPB) and 46 (43%) patients were managed with IV meperidine boluses only (IV). The cumulative meperidine doses administered were 0 (0-40) and 30 (10-80) mg for the pESPB and IV groups, respectively (p < 0.001). NRS scores of group pESPB were significantly lower than those of Group IV on T30 and T60., Conclusion: ESPB reduces the frequency of opioid administration and the amount of opioids administered in the early post-operative period. When post-operative rescue therapy is required, it should be considered before opioids., (Copyright: © 2024 Permanyer.)

Pain and wound after haemorrhoidectomy constantly bothered the patient's convenience. Recurrently, topical sucralfate is used to treat excoriations and burns. It is considered to enhance epidermal growth and tissue granulation, thus, alleviating patients' problems. This study evaluated topical sucralfate's feasibility, safety, and superiority after haemorrhoidectomy. We searched randomised controlled trial (RCT) studies in PubMed, Google Scholar, Europe PMC, and ClinicalTrials.gov until March 29th, 2022. We investigated the influence of topical sucralfate on pain score postoperatively (24 hours, 7 days, and 14 days), pethidine usage, diclofenac usage, and wound healing rate compared to placebo. This study was conducted following the PRISMA guidelines. This study sorted the final six studies with 439 patients underwent haemorrhoidectomy. Topical sucralfate demonstrated significant outcomes on VAS 24 hours post-operative [Std. Mean Difference -1.00 (95% CI -1.70, -0.31), P = .005], VAS 7 days post-operative [Std. Mean Difference -2.29 (95% CI -3.34, -1.25), P < .0001], VAS 14 days post-operative [Std. Mean Difference -1.88 (95% CI -2.74, -1.01), P < .0001], pethidine usage within 24 hours post-operative [Std. Mean Difference -0.62 (95% CI -0.96, -0.27), P = .0004], diclofenac usage 7 days post-operative [Std. Mean Difference -1.76 (95% CI -2.61, -0.92), P < .0001], diclofenac usage 14 days post-operative [Std. Mean Difference -1.64 (95% CI -2.38, -0.91), P < .0001], and wound healing rate at 28-day post-operative [RR 1.45 (95% CI 1.25-1.68), P < .00001]. Topical sucralfate alleviated pain, improved wound healing, and minimised the usage of pethidine and diclofenac compared to placebo., (© 2022 The Authors. International Wound Journal published by Medicalhelplines.com Inc (3M) and John Wiley & Sons Ltd.)

Introduction: Pain management after open inguinal hernia repair has become an issue that physicians deal with on a daily basis., Aim: The purpose of this study was to investigate the analgesic effect of three different regimens of analgesics administered to patients undergoing open inguinal hernia repair., Methods: A total of 259 patients undergoing open inguinal hernia repair were enrolled. Patients were randomly allocated to one of three groups on admission, which would determine the prescribed post-operative analgesic regimen. Patients allocated to group A receiving a combination of 1gr/8hours intravenous (IV) acetaminophen and 50mg/6hours intramuscular (IM) pethidine, patients in group B receiving a combination of 1gr/8hours IV acetaminophen and 40mg/12hours IV parecoxib, while patients of group C received 1gr/8hours IV acetaminophen monotherapy. All patients remained overnight at the hospital and discharged the day after. Analgesic therapy was administered at regular intervals. Pain was evaluated utilizing the numeric rating scale (NRS) at 5 time points: the first assessment was done at 45 minutes, the second at 2 hours, the third at 6 hours, the fourth at 12 hours and the fifth at 24 hours post-administration. The postoperative pain intensities measured by NRS within groups and between groups at each time were analyzed using one-way repeat measured ANOVA and Post Hoc Test-Bonferroni Correlation., Results: The analgesic regimens of groups A and B (combination regimens consisting of IV acetaminophen and intramuscular pethidine and IV acetaminophen and IV parecoxib, respectively) were found to be of equivalent efficacy (P-value=1.000). In contrast, patients in group C (acetaminophen monotherapy) had higher NRS scores, compared to both patients in groups A (P-value<0.0001) and B (P-value<0.0001)., Conclusion: The combinations of IV acetaminophen with either intramuscular pethidine or IV parecoxib are superior to IV acetaminophen monotherapy in achieving pain control in patients undergoing open inguinal hernia repair., Competing Interests: None declared., (© 2020 Francesk Mulita, Nikolaos Parchas, Konstantina Solou, Levan Tchabashvili, Foteini Gatomati, Fotios Iliopoulos, Ioannis Maroulis.)

This study aimed to compare the efficacy and safety of very early preemptive meloxicam, early preemptive meloxicam, and postoperative meloxicam administration for postoperative pain relief in patients undergoing arthroscopic knee surgery (AKS). Three hundred and six patients about to receive AKS were consecutively enrolled in this randomized, controlled study and randomly allocated into three groups: very early analgesia (VEA) group, early analgesia (EA) group, and postoperative analgesia (PA) group. Pain visual analog scale (VAS) score at rest and at flexion, patient global assessment (PGA) score, consumption of rescue pethidine, and adverse events (AEs) were assessed. Pain VAS score and severity at rest/flexion were all decreased in the VEA group compared with EA group and PA group at 4 h post-operation and were also reduced in the VEA and EA groups compared with the PA group at 8 h and 12 h post-operation. PGA score was lower in the VEA group compared with the EA group and PA group at 4 h post-operation, and was attenuated in the VEA group and the EA group compared with the PA group at 8 h, 12 h, and 24 h post-operation as well. Consumption of rescue pethidine was less in the VEA group than that in the PA group. In addition, no difference in the incidence of AEs was found among the VEA, EA, and PA groups. In conclusion, preemptive meloxicam is more effective in postoperative pain control and equally tolerated compared with postoperative meloxicam in patients receiving AKS.

Background: Protocols for effective postoperative pain control in patients undergoing spinal surgery are not standardized. In our study, we compared the effects of hemostatic absorbable gelatin sponge impregnated with ropivacaine versus normal saline when applied to the transverse process of the operated vertebrae on the postoperative pain following instrumentation spine surgery., Methods: A prospective double-blind randomized study was conducted on 30 patients undergoing spine surgery. At the end of surgery, the hemostatic gelatin sponge was applied by the surgeon on the transverse process of the operated vertebra containing either ropivacaine 0.5% or normal saline NaCl 0.9. Pain was assessed using the visual analog scale (VAS) every 4 hours for 48 hours postoperatively in the 2 groups (ropivacaine vs. normal saline). The total amount of postoperative opioid use was also recorded., Results: The VAS score was significantly lower in patients receiving hemostatic gelatin sponge impregnated with local anesthetics as compared with patients receiving gelatin sponge impregnated with normal saline 48 hours postoperatively; the mean total dose of meperidine given in the first 48 hours postoperatively was significantly lower (53.5 ± 51.0 mg) in patients receiving gelatin sponge impregnated with local anesthetics as compared with patients receiving hemostatic gelatin sponge impregnated with normal saline (140.5 ± 102 mg)., Conclusions: Use of intraoperative hemostatic gelatin sponge impregnated with ropivacaine applied on the transverse process of the operated vertebrae intraoperatively resulted in decreasing the postoperative pain in patients undergoing lumbar instrumentation surgery as manifested by the decrease in the VAS score and the total dose of opioids., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Hernia repair is associated with considerable postoperative pain. We studied the analgesic efficacy of bilateral ultrasound-guided erector spinae plane block in patients undergoing open midline epigastric hernia repair (T6-T9)., Methods: Sixty patients 18-65 years of age were randomly allocated into 2 groups. Patients in the erector spinae plane block group received bilateral ultrasound-guided erector spinae plane block at the level of T7 transverse process using 20 mL of bupivacaine 0.25% on each side, while the control group received bilateral sham erector spinae plane block using 1 mL of normal saline. All patients underwent general anesthesia for surgery. Pain severity (visual analog scale), consumption of intraoperative fentanyl, time to first request of rescue analgesia, and postoperative pethidine consumption were recorded over the first 24 hours postoperatively., Results: At 2 hours postoperatively, the visual analog scale pain score was significantly lower in the erector spinae plane block group compared to the control group (estimated main effect of 2.53; P < .001; 95% CI, 1.8-3.2) and remained lower until 12 hours postoperatively (P < .001 from postanesthesia care unit admission to 4 hours postoperatively, .001 at 6 hours, .025 at 8 hours, and .043 at 12 hours). At 18 and 24 hours, visual analog scale pain scores were not significantly different between both groups (P = .634 and .432, respectively). Four patients in the erector spinae plane block group required intraoperative fentanyl compared to 27 patients in control group. The median (quartiles) of intraoperative fentanyl consumption in the erector spinae plane block group was significantly lower (0 µg [0-0 µg]) compared to that of the control group (94 µg [74-130 µg]). Ten patients in the erector spinae plane block group required postoperative rescue pethidine compared to 25 patients in control group. The median [quartiles] of postoperative rescue pethidine consumption was significantly lower in the erector spinae plane block group (0 mg [0-33 mg]) compared to that of the control group (83 mg [64-109 mg]). Time to first rescue analgesic request was significantly prolonged in the erector spinae plane block group compared to control group (P < .001)., Conclusions: Ultrasound-guided bilateral erector spinae plane block provided lower postoperative visual analog scale pain scores and decreased consumption of both intraoperative fentanyl and postoperative rescue analgesia for patients undergoing open epigastric hernia repair.

Background: Adequate pain control is a major concern in the immediate postoperative period. In multiple strategies for postoperative pain management, topical analgesics have significant advantages of minimizing severe side effects caused by oral and parenteral administration and drug-drug interactions. Therefore, we studied the effect of lidocaine patch on postoperative pain control in laparoscopic appendectomy., Patients and Methods: This randomized double-blind prospective controlled study enrolled 40 acute appendicitis cases that were treated by laparoscopic appendectomy and randomly divided into two groups. Lidocaine patches containing lidocaine 175 mg was applied to the umbilical trocar site of each patient, and pain intensity was assessed with the visual analog scale every 6 hours up to 48 hours after laparoscopic appendectomy., Results: There was no significant difference in age, gender, body mass index, the American society of anesthesiologists score, comorbidity, or underlying disease between the lidocaine patch and control groups. The postoperative pain scores were lower in the lidocaine patch group than in the control group, but statistical significance was not noted at the trocar site or the right lower quadrant of the abdomen (P = .320 and P = .903, respectively). The mean amounts of pethidine used after surgery were significantly smaller in the lidocaine patch group than in the control group (0.10 ± 0.31 mg versus 0.25 ± 0.79 mg, P < .001)., Conclusions: The results of this study suggest that lidocaine patch application to the trocar site after laparoscopic appendectomy may have a positive effect on the management of postoperative pain and can eliminate the need to inject additional analgesics for further postoperative pain control.

Objectives: To study the effect of local wound infiltration with and without adrenaline on pain perception after thyroidectomy using the visual analog score (VAS).  Methods: A prospective randomized controlled double-blinded study was conducted between May 2015 and June 2016 at The University of Jordan Hospital, Amman, Jordan. Eighty-nine patients undergoing planned thyroidectomy were included in the study. Patients were divided randomly into 3 groups: Group A, local wound infiltration with bupivacaine 0.5% was administered; Group B, bupivacaine 0.5% with adrenaline was administered; Group C (control), no infiltration was performed. Standardized thyroidectomies were performed in the 3 groups. Pain perception was measured using VAS at 2, 4, 6, 12, and 24 hours after surgery. A comparison between the 3 groups was carried out. Results: No significant differences among the 3 groups were observed at all time points (p=0.246). Visual analog scores were significantly lower at 12 and 24 hours after operations.  Conclusion: Local wound infiltration with bupivacaine 0.5% does not decrease pain perception after thyroidectomy performed under general anesthesia, and adding adrenaline does not enhance its effect.

Background: Few studies have investigated the use of dexmedetomidine in patient-controlled intravenous analgesia (PCIA) after thoracic surgery. This study to evaluate the effect of dexmedetomidine combined with sufentanil for PCIA after thoracotomy under general anaesthesia., Methods: Ninety-seven adults patients scheduled for thoracotomy surgery. All two groups received PCIA with either sufentanil alone (control group) or combining dexmedetomidine with sufentanil (dexmedetomidine group). Hemodynamic measurements, visual analog scale (VAS) scores at rest and at coughing, Ramsay sedation score (RSS), analgesic consumption, and postoperative nausea and vomiting (PONV) as well as drug-related adverse effects were compared at 2, 6, 12, 24, 36 and 48 h postoperatively., Results: In the patients of the dexmedetomidine group, compared to the control group, the pain scores at rest or at coughing during 48 h postoperatively were lower (P < 0.001), the sedation scores were lower, the consumption of sufentanil and rescue meperidine were lower, and the number of episode of moderate PONV was three times lower. No signs of toxicity or local complications were observed. There was a non-significant trend for a lower HR and BP in the dexmedetomidine group vs., Conclusion: The combining dexmedetomidine with sufentanil for post-thoracotomy PCIA can improve pain control together with the decrease in sufentanil requirements, and improve postoperative patient's satisfaction compared with sufentanil alone in PCIA., Trial Registration: This trial was retrospectively registered on 27 April 2016 at the Chinese Clinical Trial Register (number: ChiCTR-ONC-16008376 ).

Objective: To compare the pain control efficiency of continuous adductor canal block (ACB) and femoral nerve block (FNB) in total knee arthroplasty., Methods: From April to September 2016, patients with severe knee osteoarthritis undergoing primary unilateral total knee arthroplasty (TKA) were prospectively observed, and all the patients were randomized received ultrasound-guided continuous ACB or FNB after surgery. Numeric pain rating scales(NPRS)pain scores in rest and activity 2, 6, 12, 24 and 48 h after surgery were collected, and the preoperative and postoperative quadriceps strength at 24 and 48 h were analyzed. Opioids consumption and anesthesia related adverse effects were also recorded., Results: In the study, 40 patients were enrolled, with 20 patients in each group, male:female=7:33, the age: (63.8±10.1) years, and the body mass index (BMI): (28.5±3.5) kg/m(2).The general conditions were comparable between the two groups. Though the rest pain 2 h after surgery [ACB=0.0(0,6), FNB=3.0(0,5), P=0.004] and activity pain 12 h post operation [ACB=3.0(3,0), FNB=5.5(0,10), P=0.004] were lower in ACB group compared with FNB group, there was no statistical difference in the other pain checking points between the two groups. The quadriceps strength 24 h and 48 h after surgery were(85.3±27.6) N and (80.0±30.1) N in ACB group, (69.0±29.4) N and (64.4±32.0) N in FNB group, both of them were declined by time. The exact data were higher in ACB group, however, there was no statistical difference between the two group by repeated measurements variance analysis(F=2.703, P=0.108).Four patients in ACB group and five in FNB acquired additional use of dolantin once (100 mg/per time) within 24 h. And among them, three patients acquired once dolantin in ACB, two in FNB, from 24 to 48 h postoperation. There were five patients who suffered nausea postoperation in ACB group, and one who reported xerostomia. Four patients in FNB had nausea with vomiting, and three experienced xerostomia. Deep vein thrombosis appeared in 2 patients in FNB group, but no one in ACB group., Conclusion: Continuous ACB is not superior in pain control after TKA compared with FNB, and the quadriceps strength could be reserved more by this method, which performed early benefits in fast rehabilitation.

Background: Postoperative pain is a common problem in hospitals. Adults undergoing uvulopalatopharyngoplasty (UPPP) with tonsillectomy experience an unacceptable level of intense postoperative pain, especially during the first 24 h after surgery. This study investigated the analgesic effects of vitamin C in patients undergoing UPPP and tonsillectomy., Method: This study was done on forty patients that were evaluated in a randomised double-blinded clinical trial. Patients included in the study were within the age range of 25-50 years with BMI<35, physical status I,II according to the American Society of Anesthesia (ASA) and who underwent uvulopalatopharyngoplasty and tonsillectomy. Patients with epilepsy, BMI>35, any neuropsychiatric disorders, a history of chronic pain, liver and/or renal disease, drug allergy, and drug abuse were excluded from the study. All patients underwent the same method of anaesthesia and surgical procedure. During the first 30 min after the beginning of the surgery, group C (vitamin C) received infusion of 3 g vitamin C in 500 mL of Ringer and group P received 6 mL normal saline in 500 mL of Ringer. Measurements of systolic blood pressure, diastolic blood pressure, mean arterial blood pressure and heart rate were recorded before and during anaesthesia and at intervals of 0,15,30 and 60 min after extubation. Pain severity was recorded according to VAS score at intervals of 0 (recovery room), 6, 12 and 24 h after the procedure, request for analgesic drugs (iv paracetamol or pethedine) according to total number of times of analgesic request and time of the first dose of analgesic use and dose of pethidine were also recorded by questionnaire., Results: There was a significant difference in evaluations for mean pain severity between the two groups at recovery room, 6, 12 and 24 h after surgery (P-value = 0.001). There was a significant difference in mean times that patient requested an analgesic, time of first dose of analgesic and pethidine dose between the two groups (P-value< 0.05). There was no significant differences in measurements of systolic blood pressure, diastolic blood pressure, mean arterial blood pressure and heart rate in different times between the two groups (P-value> 0.05). Blood loss was similar in the two groups (P-value> 0.05)., Conclusion: According to this study, administration of vitamin C 3 g IV intraoperative reduced postoperative pain without increased side-effects in patients undergoing UPPP and tonsillectomy., (© 2016 John Wiley & Sons Ltd.)

Background: Atorvastatin is a 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase inhibitor widely used in treatment of hypercholesterolemia and prevention of coronary heart disease and has various pleiotropic effects. In this study, the efficacy of atorvastatin emulgel (2 %) in reducing postoperative pain at rest, pain during defecation and analgesic requirement after open hemorrhoidectomy was investigated., Methods: A total of 66 patients with third- and fourth-degree hemorrhoids undergoing open hemorrhoidectomy were included in this prospective, double-blind, randomized controlled trial. The patients were randomly assigned to either atorvastatin emulgel or placebo immediately after surgery and then every 12 h for 14 days. The primary outcomes were intensity of pain at rest and during defecation, measured with a visual analog scale, and the analgesic requirement, measured by amount of pethidine and acetaminophen consumption, and percent of wound healing., Results: There was no significant difference in the average postoperative pain scores in the first 48 h (P 12h  = 1, P 24h  = 0.128 and P 48h  = 0.079) after the surgery between the two groups, but at the week 1 the pain scores during defecation were considerably lower in the atorvastatin group than in placebo group (P = 0.004), which also was the same at the week 2 (P = 0.03). There was no significant difference in the average pethidine and acetaminophen (mg) administration at 12 h and 24 h between the two groups after surgery. Regarding the data about wound healing, at the week two the healing was much better in the treatment group than it was in control group and the difference was statistically significant (P = 0.04)., Conclusions: Compared with placebo, atorvastatin emulgel reduced postoperative pain at rest and on defecation and could improve the healing process after open hemorrhoidectomy., Trial Registration Number: IRCT201404013014N8.

Aim: The aim of this study was to determine the efficacy of a single 40-mg intravenous (i.v.) dose of parecoxib as an adjunctive analgesia to intrathecal morphine after elective cesarean delivery (CD)., Methods: A total of 82 low-risk term pregnant women who were scheduled for elective CD during the June 2014-June 2015 study period were enrolled. Two hours after surgery, subjects were randomly assigned to receive either i.v. injection of 2 mL (40 mg) parecoxib (study group; n = 41) or 2 mL normal saline solution (control group; n = 41). Patient randomization into groups was determined by the hospital's central computer system. Outcome measurements included total postoperative supplemental meperidine consumption, recorded pain score by numeric pain rating scale at 6, 12, 18, and 24 h, postoperatively, and patient satisfaction., Results: Patient characteristics and pregnancy outcomes were comparable between groups. Total postoperative meperidine consumption was not significantly different between groups (12.7 ± 18.8 mg vs 8.3 ± 16.7 mg; P > 0.05). Compared with control, the study group was significantly less likely to experience moderate to severe postoperative pain (score ≥ 4) at 6 h (0% vs 21.9%; P = 0.002). Study group patients reported higher satisfaction than control group patients (median score: 8 vs 6; P < 0.01). No patients in either group reported adverse effects from their assigned intervention., Conclusion: Parecoxib did not demonstrate effectiveness in reducing patient requirement for supplementary meperidine after CD. However, administration of a single 40-mg dose of i.v. parecoxib after elective CD demonstrated effectiveness in reducing pain scores, with a resulting increase in patient satisfaction., (© 2016 Japan Society of Obstetrics and Gynecology.)

Background: Abdominal pain is a common complaint following endoscopic resection (ER)., Aims: To investigate the predictive factors for abdominal pain after ER., Methods: Patients who were scheduled to undergo endoscopic mucosal resection or endoscopic submucosal dissection for the treatment of gastric adenoma or cancer were prospectively enrolled. Pain scores were checked every 6 h after ER and whenever patients complained of pain by using a 0-10 pain scale. If the pain score exceeded 5, 25 mg of intravenous (IV) pethidine was administered., Results: Among 156 patients who underwent ER, 66 (42.3 %) received IV pethidine due to moderate/severe abdominal pain. Both the number of patients complaining of abdominal pain and the pain scores decreased with time following the procedure, with only a few patients complaining of mild abdominal pain 2 days after ER. Multivariate analysis showed that female sex [odds ratio (OR) 2.88; confidence interval (CI) 1.31-6.33], tumor location in the lower third of the stomach (OR 5.46; CI 2.31-12.92), and procedures time more than 60 min (OR 2.96; CI 1.26-6.98) were significant predictive factors for developing pain after ER., Conclusions: Female sex, tumor location in the lower third of the stomach, and longer procedure time were significantly associated with pain after ER. Close monitoring and active management of pain is recommended for patients who have these risk factors. With these efforts, the majority of patients could experience pain relief within 2 days after the procedure.

Objective: To study postoperative pain relief in major gynaecological surgery by perioperative parecoxib administration in Thammasat University Hospital., Material and Method: This double-blind randomized controlled clinical trial was conducted in Thammasat University Hospital, Pathumthani, Thailand from October 2013 to May 2014. One hundred and twenty patients who underwent elective gynaecological surgery were randomized assigned to study and control groups. Study group (n = 60) received 40 mg parecoxib and control group (n = 60) received placebo at 1 hour before surgery. The postoperative visual analog scale (VAS) at 3, 6, 12 and 24 hours, frequency of meperidine consumption in 24 hours and side effects of parecoxib were recorded., Results: VAS of study group after operation at 3, 6, 12 and 24 hours was significantly lower than control group. Meperidine consumption in placebo group was significantly higher than study group (27.50 ± 19.36 and 48.75 ± 28.15 mg, respectively; p < 0.001). There was no side effect from parecoxib in this study., Conclusion: Intravenous postoperativeparecoxib injection could relief pain and reduced meperidine consumption. Parecoxib could be safely used in gynaecological surgery for postoperative pain relief

Background/aims: Minimally invasive laparoscopy provides faster recovery, less pain, fewer complications, and better cosmesis than laparotomy. We aimed to evaluate outcomes of postoperative local anesthesia infiltration at the single-incision laparoscopic surgery (SILS) wound., Methodology: This prospective, non-randomized controlled study evaluated outcomes of 58 colorectal cancer cases receiving SILS from May 2010 to December 2010. Twenty-nine patients received postoperative infiltration of local anesthesia at the wound site; another 29 patients did not. Demographic, intra- and postoperative data were compared. Postoperative pain was assessed by visual analogue scale and analgesic usage., Results: Local anesthesia group included 16 males, 13 females (mean age, 62.0 ± 15.1 years); no local anesthesia group included 14 males, 15 females (mean age, 58.1 ± 12.7 years). There were no significant differences between groups at baseline (i.e., age, gender, disease stage, tumor location or size) except BMI (25.2 ± 2.8 vs. 23.5 ± 3.4, p = 0.041) was significantly higher. Postoperative pain scores were significantly lower in local anesthesia group than in no local anesthesia group (median VAS score 2.0, IQR 2.0-3.0 vs. VAS score 3.0, IQR 3.0-4.0, respectively, P = 0.024)., Conclusions: Our results provide further evidence of SILS safety. Local anesthesia infiltration at SILS wounds decreases postoperative wound pain and analgesic usage.

Background: According to current recommendations a multimodal approach is believed to be the gold standard for postoperative pain treatment in children. However, several surveys in the last few years demonstrated that postoperative pain in children is still a serious problem, mainly because opioids are avoided. One of the reasons for this is the fear of severe adverse events following opioid administration. Tramadol is a weak mu-opioid agonist and inhibits reuptake of noradrenaline and serotonin (5HT). Because of a relatively wide therapeutic window and a ceiling effect with a lower risk for severe adverse events (for example respiratory depression) tramadol is a widely used opioid in children. However, the exact efficacy and occurrence of adverse events following tramadol (in comparison with placebo or other opioids) for postoperative pain treatment in children and adolescents are currently not clear., Objectives: To assess the effectiveness and side effect profile of tramadol for postoperative pain relief in children and adolescents undergoing different surgical procedures., Search Methods: We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 6), MEDLINE via PubMed (January 1966 to July 2014) and EMBASE via Ovid (January 1947 to July 2014). There were no restrictions regarding language or date of publication. The reference lists of all included trials were checked for additional studies., Selection Criteria: All randomised controlled clinical trials investigating the perioperative administration of tramadol compared to placebo or other opioids for postoperative pain treatment in children and adolescents were included., Data Collection and Analysis: Three review authors independently assessed the study eligibility, performed the data extraction and assessed the risk of bias of included trials., Main Results: Twenty randomised controlled trials involving 1170 patients were included in this systematic review. The overall risk of bias in included trials was assessed as unclear, because concealment of allocation processes and blinding of outcome assessors were poorly described. Due to inconsistent outcome reporting, data from 17 included trials could be pooled for some endpoints only. Eight trials compared tramadol administration with placebo and five trials found that the need for rescue analgesia in the postoperative care unit (PACU) was reduced in children receiving tramadol (RR 0.40; 95% CI 0.20 to 0.78; low quality evidence). Only one trial investigated the number of patients with moderate to severe pain, but a non-validated pain scale was used (very low quality evidence). Four trials compared morphine with tramadol administration. There was no clear evidence of difference in the need for rescue analgesia in the PACU (RR 1.25; 95% CI 0.83 to 1.89; low quality evidence) with tramadol compared with morphine. No trials could be pooled for the outcome 'number of patients with moderate to severe pain'. Three trials were included for the comparison of tramadol with nalbuphine. There was no clear evidence for the need for rescue analgesia in the PACU (RR 0,63; 95% CI 0.16 to 2.45; low quality evidence). Only one trial reported the number of patients with moderate to severe pain, but used a non-validated pain scale (very low quality evidence). Two out of six included trials, which compared pethidine with tramadol, reported the number of children with a need for rescue analgesia within the PACU and showed no clear evidence (RR 0.93; 95% CI 0.43 to 2.02; very low quality evidence). Two trials reported the number of patients with moderate to severe pain and showed a lower RR in patients treated with tramadol (RR 0.64; 95% CI 0.36 to 1.16; low quality evidence). Only one trial was included, which compared tramadol with fentanyl, reporting the number of patients with the need for rescue analgesia (very low quality evidence). Generally, adverse events were poorly reported. Most data could be pooled for the comparison with placebo focusing on the RR for postoperative nausea and vomiting (PONV) in the postoperative care unit and 24 h postoperation. Children treated with tramadol, compared to placebo, did not show clear evidence of benefit for PONV in the postoperative care unit (RR 0.84; 95% CI 0.28 to 2.52; moderate quality evidence) and 24 h postoperation (RR 0.78; 95% CI 0.54 to 1.12; moderate quality evidence)., Authors' Conclusions: The overall evidence regarding tramadol for postoperative pain in children is currently low or very low and should be interpreted with caution due to small studies and methodological problems (different validated and non-validated pain scales with different pain triggers, missing sample size calculations and missing intention-to-treat analysis). Nevertheless, we demonstrated that tramadol administration might provide appropriate analgesia when compared to placebo; this is based on results showing reduced rescue analgesia in children treated with tramadol compared to placebo. In contrast, the evidence regarding the comparison with other opioids (for example morphine) was uncertain. Adverse events were only poorly reported, so an accurate risk-benefit analysis was not possible.

Purpose: To confirm the validity of postoperative creatine kinase (CK) values as an indicator of muscle lesion, assess the relationship of CK with variables indicating surgical invasiveness and investigate an association between CK values and excessive postoperative pain., Material and Methods: The study included 96 patients (mean age 62.8 years) who underwent instrumented spine fusion for degenerative lumbosacral disease. Serum CK concentration was determined on the first postoperative day. All patients received intravenous paracetamol and metamizole, and in cases of intense pain, rescue analgesia with iv meperidine. Patients were categorized according to whether or not they required rescue analgesia. Data on the number of levels fused, the duration of surgery, and operative bleeding were recorded in each patient., Results: CK values were higher in men and in younger patients. Significant correlations were found between CK and the number of fused levels and duration of surgery. Only 17.7% of patients required rescue analgesia. CK levels did not significantly differ between patients who did not need rescue analgesia (1135 IU/L) and those who did (1421.5 IU/L)., Conclusions: Serum CK concentration is a valid marker of surgical muscle injury and is affected by the age and sex. Factors such as the magnitude and duration of surgery show a relationship with postoperative CK values. The incidence of severe postoperative pain is not significantly related to CK level.

Objectives: To evaluate the efficacy and tolerability of pregabalin in postoperative pain management after laparoscopic cholecystectomy (LC)., Patients and Methods: A prospective, randomized, placebo, controlled, double-blinded study was conducted at Anesthesia Department, Laparoscopy Surgery Unit, Ain Shams University Hospital. Ninety patients with ASA physical status I-II scheduled for elective LC under general anesthesia were included. Patients were randomly assigned to the following groups (n=30 each): pregabalin group (P), received 150 mg pregabalin capsules 2 hours preoperatively, 12 hours postoperatively, and twice daily for 2 days; gabapentin group (G), received 1200 mg gabapentin capsules (400 mg, ×3) 2 hours preoperatively, 12 hours postoperatively, and 400 mg three times daily for 2 days; and control group (C), received placebo capsules. Postoperative pain scores were recorded on a visual analogue scale. The following data were recorded: total daily pethidine and diclofenac consumption, numeric sedation score, and the postoperative nausea, vomiting, and dizziness scores., Results: The 24-hour pethidine consumption was significantly lower (P<0.001) in both pregabalin and gabapentin groups versus control. Both groups had significantly less (P<0.001) patients with postoperative nausea, vomiting, sedation, and dizziness versus control. Overall patient satisfaction with pain management was significantly higher (P<0.001) in pregabalin group versus gabapentin or control groups., Conclusions: Gabapentin 1200 mg and pregabalin 150 mg are effective and safe analgesics for reducing postoperative pain in LC. The perioperative oral administration of pregabalin 150 mg in patients undergoing LC is an effective and safe method of analgesia with a low incidence of adverse effects and reduces postoperative pethidine consumption.

Background and Purpose: Pain at the surgery site is a common complaint in patients who experience percutaneous nephrolithotomy (PCNL). The aim of this double-blind, randomized clinical trial is evaluation of the effect of scheduled infusion of bupivacaine on postsurgical pain and narcotic consumption after tubeless PCNL under spinal anesthesia., Patients and Methods: Forty patients were randomly divided into two groups. A small caliber fenestrated feeding tube was placed into the nephrostomy tract under direct vision in a manner in which its tip lied close to the renal capsule. The study group received infusion of diluted bupivacaine while physiologic saline was injected in the control group. Each patient was given the same dose every 6 hours until 24 hours after the surgical procedure., Results: Mean pethidine injection was significantly lower in the group who underwent bupivacaine instillation (20.5±14.5 vs 3.97±2.4 mg: P=0.009). There was no significant difference between mean visual analogue scale (VAS) score in these two groups after 6 and 12 hours while it was significantly lower after 18 and 24 hours in the patients who had received bupivacaine. Mean time to the first analgesic request was significantly longer in the study group (11.35 vs 6.44 hours: P=0.001)., Conclusion: Intermittent perirenal instillation of bupivacaine via the nephrostomy tract after PCNL decreases the need for more systemic narcotics and provides acceptable analgesia in the postoperative period.

Background: Several surveys over the past few years have demonstrated that postoperative pain in children is not treated appropriately. One pharmacological treatment option in a multimodal approach for postoperative pain treatment is the systemic administration of opioids. However, opioids are rarely used for postoperative pain treatment in children due to fear of adverse events. One long-standing opioid for systemic use is nalbuphine, a kappa-receptor agonist and µ-receptor antagonist. The efficacy of nalbuphine is believed to be similar to morphine. Increased dosing might result in a ceiling effect, and thus less analgesia than expected. In addition, there might be a lower risk for opioid-induced side effects (nausea, vomiting) and severe adverse events (respiratory depression) due to the antagonistic effect of the µ-receptor. Nalbuphine may be an useful opioid for postoperative use in children, but exact efficacy (e.g. compared to other commonly used opioids) has not been determined yet., Objectives: To assess the efficacy and adverse events of nalbuphine for acute postoperative pain treatment in children undergoing surgery., Search Methods: We systematically searched the following databases: The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 7), MEDLINE via Pubmed (January 1966 to July 2013) and EMBASE via Ovid (January 1947 to July 2013). We did not impose any restrictions regarding language or publication date. We checked all reference lists of retrieved articles for additional references., Selection Criteria: All randomised controlled trials (RCTs) investigating nalbuphine compared with placebo or other opioids were included., Data Collection and Analysis: Two review authors independently scanned the retrieved articles and made a decision regarding inclusion or exclusion of studies for this review. The same authors also performed the data extraction and the assessment of risk of bias., Main Results: Ten RCTs including 658 patients were finally included in this systematic review. Five trials compared nalbuphine with placebo. Data from one out of five studies for the outcome moderate/severe pain following nalbuphine compared to placebo gave a risk ratio (RR) 1 hour postoperatively (postop) of 0.1 (95% confidence interval (CI) 0.01 to 0.71; low quality evidence) and a RR 2 hours postop of 0.14 (95% CI 0.02 to 1.06; low quality evidence). The estimated RR based on data from a single study indicated that nalbuphine reduced the requirement for analgesia two hours postop (RR 0.47; 95% CI 0.27 to 0.84; low quality evidence). Two included trials compared nalbuphine with morphine and showed a nonsignificant lower or comparable RR for moderate/severe pain at 1 hour postop (RR 0.84; 95% CI 0.12 to 5.74; low quality evidence), and 2 hours postop (RR 1.09; 95% CI 0.59 to 2.01; low quality evidence) for nalbuphine versus morphine. Four trials compared nalbuphine with tramadol for postoperative pain; data from one trial (per outcome) revealed a lower but nonsignificant RR for the need of additional rescue analgesics in children receiving nalbuphine (RR 2 hours postop 0.75; 95% CI 0.39 to 1.43; low quality evidence) (RR 12 hours postop 0.33; 95% CI 0.04 to 2.77; low quality evidence). One out of three trials comparing nalbuphine with pethidine demonstrated that the RR was not significantly lower following nalbuphine administration compared to pethidine (RR 2 hours postop 1.07; 95% CI 0.52 to 2.23; low quality evidence) (RR 24 hours postop 1.13; 95% CI 0.52 to 2.44; very low quality evidence). The most common adverse event was postoperative nausea and vomiting (PONV). Only one included trial reported that the RR for PONV in the postoperative care unit (PACU) was not significantly higher following nalbuphine compared to placebo (RR 1.00; 95% CI 0.16 to 6.42; low quality evidence) nor to morphine (RR 1.33; 95% CI 0.64 to 2.77; low quality evidence)., Authors' Conclusions: Because the overall quality of available evidence was low, this systematic review could not definitively show that the analgesic efficacy of nalbuphine is superior compared to placebo. Furthermore, due to the lack of significant results the comparison with other common opioids is also unclear. The same holds true for the evidence focusing on adverse events following nalbuphine compared to placebo or other opioid administration. The evidence is limited, because studies did not report conclusively all important postoperative pain outcomes (e.g. number of patients with the need for rescue analgesia, postoperative pain scores). Thus, a quantitative analysis was not possible for many major aspects (e.g. rescue analgesia, pain scores) and heterogeneity could not be further explored.

Purpose: To evaluate meperidine-sparing effect of intravenous (IV) paracetamol in patients undergoing percutaneous nephrolithotomy (PCNL)., Patients and Methods: One hundred patients who underwent PCNL were randomized to paracetamol (n=50) and placebo (n=50) groups. Patients received 100 mL of physiologic saline with or without 1 g IV paracetamol every 8 hours after PCNL up to 24 hours in the paracetamol and placebo groups, respectively. Patients in both groups received intramuscular meperidine in case of unrelieved pain. The visual analog scale (VAS) was used to evaluate pain intensity scores in the postoperative period. Total meperidine consumption, mean VAS score in the first 6 and 24 hours, demographic variables, operative variables, and side effects were recorded., Results: The mean VAS pain intensity scores at 6 and 24 hours were 50.22 and 41.32 mm in the paracetamol and 75.29 or 65.5 mm in the placebo group (P<0.001). The mean consumed meperidine dose was 54.40 mg and 77.60 mg in the paracetamol and placebo groups, respectively (P<0.001)., Conclusion: In this study, IV paracetamol significantly reduced total meperidine consumption and pain intensity scores compared with placebo. IV paracetamol can be an effective and safe part of multimodal analgesia regimes for postoperative pain management after PCNL.

Objective: To assess the analgesic efficacy of bupivacaine infiltrations into the nephrostomy tract in tubeless and standard percutaneous nephrolithotomy (PCNL)., Methods: This prospective, randomized controlled study enrolled 121 patients. Patients were randomized to receive a 20-mL infiltration of 0.25% bupivacaine into the nephrostomy tract after PCNL. Patients were divided into 2 groups. The group 1 patients received bupivacaine infiltrations, whereas group 2 did not. Patients' visual analog scale (VAS) pain scores were evaluated at 6, 12, and 24 hours postoperatively. Pain in the postoperative period was managed with intramuscular diclofenac sodium (75 mg) or meperidine (pethidine) hydrochloride (50 mg), as requested by the patients., Results: The patients were a mean age of 43.2 ± 12.7 years (range, 18-74 years). The VAS pain scores at 6, 12, and 24 hours postoperatively and the amount of diclofenac sodium needed were significantly less in the group with bupivacaine infiltration than in those that did not receive the infiltration (P <.05). The VAS pain scores in patients with tubeless PCNL were significantly lower than those in patients with standard PCNL (P <.05)., Conclusion: The pain after tubeless and standard PCNL may be decreased by bupivacaine infiltration into the nephrostomy tract. The findings of the present study reveal that a tubeless procedure and local analgesic infiltration into the nephrostomy tract after the PCNL is the more comfortable procedure for the patients., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Anecdotal reports suggest that cannabis users require increased postoperative analgesia but there is insufficient supporting data., Methods: A prospective randomized study was carried out in 73 patients undergoing elective operations. Postoperatively, all patients were assessed by a blinded investigator, who recorded pain intensity, sedation levels, mood, and hourly analgesia requirements. We calculated the mean pain intensity difference at the first postoperative hour (MPID1) and the sum of pain intensity differences (SPID1). The following end points were compared between cannabis users and non-users using SPSS 16: MPIDI; SPID; patient mood; supplemental analgesia requirements and global assessment scores., Results: There were 42 cannabis users and 31 non-users. Cannabis users had significantly higher supplemental pethidine requirements (82.7 mg, SD = 3.4 vs. 51.6 mg, SD = 42.7, p = 0.003) and significantly greater MPID1 scores (1.88, SD = 1.09 vs. 1.35, SD = 1.12, p = 0.001) compared to non-users. Female cannabis users required significantly more analgesia than males (93.3 mg, SD = 45.8 vs. 78.3 mg, SD = 44.3, p = 0.025)., Conclusion: Cannabis users require significantly more opioid rescue analgesia in the immediate postoperative period. Further research is needed to elucidate the precise mechanism by which this occurs.

Objective: To compare the results of 0.2 mg and 0.3 mg of spinal morphine in patients with post-thoracotomy pain., Design: A prospective, randomized, double-blind study., Setting: A university hospital and a tertiary referral center., Participants: Forty patients undergoing thoracotomy for lung resection., Interventions: Spinal morphine: 0.2 mg or 0.3 mg., Methods and Main Results: Patients were randomly allocated to receive either 0.2 mg or 0.3 mg of spinal morphine for post-thoracotomy pain prior to general anesthesia. Cumulative 24- and 48-hour intravenous patient-controlled analgesia meperidine consumption and numeric rating scale score for pain were recorded. The severity score (4-point scale) of sedation, nausea, vomiting, and pruritus was assessed for interval during the postoperative period. The times to first drinking/eating/sitting/walking were recorded. There was no statistically significant difference in 24-hour postoperative meperidine usages between the 2 groups, which were 110 (interquartile range 90-180) and 95 (interquartile range 57.5-175) mg, respectively. The median pain free times, time to first drinking, eating, sitting, and walking showed no differences between the 2 groups. The numeric rating scale score for pain and incidences of side effects were not different between the 2 groups. One patient who received 0.3 mg of spinal morphine developed respiratory acidosis with a respiratory rate of 10 per minute at 44 minutes after extubation., Conclusions: In patients who underwent elective thoracotomy, 0.2 mg of spinal morphine was as effective as 0.3 mg. Increasing the dosage of spinal morphine does not decrease postoperative meperidine consumption, but may lead to respiratory depression in rare cases., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: Epigastric pain management following endoscopic submucosal dissection is an important consideration. This study aimed to investigate the utility and safety of fentanyl patches for pain relief after the procedure., Methods: Patients who were scheduled to undergo endoscopic submucosal dissection were prospectively randomised to either a transdermal fentanyl patch group or a placebo control group. An additional pethidine was intravenously administered when pain developed and a numerical rating scale was used to evaluate both pre- and post-procedural pain., Results: One hundred and ten patients were randomly assigned to receive either a 12 mcg/h fentanyl patch or a control patch on the night before the procedure. The fentanyl patch group had significantly lower pain scores immediately following the procedure (mean, 5.17 vs. 4.26, p=0.030). Maximal pain scores during the first 24 h (5.43 vs. 4.46, p=0.038) and pain scores on the day after the procedure (2.98 vs. 1.20, p<0.001) were also lower in the fentanyl patch group. In addition, the fentanyl patch group required a significantly lower dose of pethidine for pain management (24.54 vs. 11.25, p=0.004)., Conclusions: The application of a transdermal fentanyl patch is an effective, convenient, and safe method to control epigastric pain after endoscopic submucosal dissection., (Copyright © 2012 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: Wound infiltration with local anesthetics may improve postoperative analgesia. Tramadol has been shown to have effects similar to those of local anesthetics. The purpose of this study was to investigate the effects of wound infiltration with levobupivacaine and tramadol on postoperative analgesia for lumbar discectomies., Methods: Eighty adult patients who were scheduled to undergo elective lumbar discectomy operations were included in the study. Patients were randomly allocated to 4 groups: wound infiltration with 100 mg levobupivacaine (group L), 2 mg/kg tramadol (group T), 2 mg/kg tramadol plus 100 mg levobupivacaine (group LT), and saline (group C). Pain scores with the visual analog scale, patient-controlled analgesic consumption (pethidine), time to first analgesic treatment, and side effects were assessed during the postoperative period., Results: The time to first analgesia was earliest in group C (11.3±2.2 min), followed by group L (163.0±216.3 min) and group T (803.2±268.4 min) (P<0.001). None of the patients in group LT required postoperative analgesic supplementation, and the visual analog scale scores were <3 at all measurement times (P<0.05). Postoperative opioid consumption was 196.0±71.6 mg in group C, 129.0±78.3 mg in group L, and 37.0±35.4 mg in group T (P<0.001). The incidence of side effects was lower in group LT than in the other groups., Conclusions: Wound infiltration with combined levobupivacaine and tramadol resulted in elimination of postoperative analgesic demand and reduction in the incidence of side effects. We conclude that infiltration of the wound site with combined levobupivacaine and tramadol provides significantly better analgesia compared with levobupivacaine or tramadol alone.

Objective: To compare post-operative outcomes between tubeless and conventional large-bore nephrostomy tube drainage following percutaneous nephrolithotomy in children., Methods: The study comprised 54 patients under 14 years of age who were undergoing percutaneous nephrolithotomy at 60 renal units and met the inclusion criteria. They were randomised to placement of a 16F nephrostomy tube (Group A, 30 renal units) or tubeless drainage (Group B, 30 renal units) at the end of the procedure. Patient age, number and position of stones, operating time, change in haemoglobin, post-operative analgesia requirement, length of hospital stay and post-operative complications were compared between the two groups, using SPSS version 17 and t test., Results: Group A had 28 patients, while Group B had 26. The mean age in Group A was 7.2 +/- 3.2 years, and in Group B it was 6.3 +/- 3.6 years (age range 3-13 years and 1-13 years respectively). The mean size of stone was 28.6 +/- 16.7mm and 20.4 +/- 9.3mm; mean change in Hb was 0.78 +/- 0.69mg/dl and 0.63 +/- 0.54mg/dl; and the mean operating time was 54 +/- 20.7 minutes versus 66.9 +/- 22.9 minutes in the two groups respectively. There was significantly less requirement for post-operative pethidine in Group B versus Group A (p=0.01). The postoperative clearance and complications were comparable between the two groups, while the duration of hospital stay was significantly shorter in Group B compared to Group A (p=0.007)., Conclusion: Tubeless percutaneous nephrolithotomy in children is safe and effective. Post-operative analgesia requirement is less and hospital stay is shortened compared to the conventional nephrostomy placement after percutaneous nephrolithotomy.

Objective: To compare postoperative pain perception and analgesia requirements in patients undergoing cesarean section (CS) using general versus spinal anesthesia., Study Design: A prospective, observational study of patients undergoing elective CS during 2009 under either general or spinal anesthesia. Postoperative pain intensity and analgesia requirements were evaluated for up to 48 h after surgery., Results: A total of 153 women were enrolled; 77 received general and 76 received regional anesthesia. Postoperative meperidine requirements in the first 24 h were significantly higher in the general anesthesia group. Pain scores were mostly comparable between the groups. Nevertheless, lower pain scores were graded after 8 h in the general versus the spinal anesthesia and this reversed at 48 h., Conclusion: Spinal anesthesia is comparable to general anesthesia in terms of post-operative pain control. In choosing the type of anesthesia in CS, other factors such as the urgency and potential maternal and fetal hazards should be taken into account.

Purpose: Gabapentin has demonstrated analgesic effects in some studies. This double blind randomized clinical trial (RCT) was conducted to evaluate whether the pre-emptive use of gabapentin 600 mg could reduce postoperative pain, nausea and vomiting, and meperidine consumption in patients after hysterectomy., Methods: Between 2009 and 2010, a total of 170 patients who were candidates for abdominal hysterectomy were assessed for eligibility to enter the study. Thirty patients were excluded for different reasons; and 140 included patients were randomly assigned to one of two groups according to the method of treatment, gabapentin or placebo, in a double-blind manner before hysterectomy. Postoperatively, the pain was assessed on a visual analogue scale (VAS) at 1, 4, 8, 12 and 24 h at rest. Meperidine intramuscularly was used to treat postoperative pain on VAS score and patients demand. Total meperidine and anti emetic drug consumption in the first 24 h after surgery was also recorded. The trial is registered at irct.ir, number IRCT201106186829N1., Results: Patients in the gabapentin group had significantly lower VAS scores at all time intervals, than those in the placebo group. The total meperidine consumed in the gabapentin group was significantly less than in the placebo group. Postoperative nausea and vomiting (PONV) and anti emetic drug consumption were significantly decreased in gabapentin group., Conclusion: Pre-emptive use of gabapentin 600 mg orally, significantly decreases postoperative pain and PONV, and also rescues analgesic and anti emetic drug requirements in patients who undergo abdominal hysterectomy.

Objective: To determine the effectiveness of preoperative parecoxib sodium injection for pain relief after laparoscopic gynecologic surgery., Material and Method: A prospective double-blind, randomized study was conducted in 268 patients who underwent laparoscopic gynecologic surgery at Vajira Hospital between November 1, 2010 and March 31, 2011. The patients were randomly allocated into two groups to receive either single intravenous 40 mg parecoxib (treatment group; n = 133) or normal saline (control group; n = 135) 30 min before surgery. The degree of postoperative pain was assessed every 2 h in the first 8 h postoperation, then every 4 h until completion of 24 h by using a verbal rating scale. Total consumption of meperidine over a 24-h period and the adverse events relevant to parecoxib sodium were also recorded., Results: Mean pain scores at all measured times in the treatment group were insignificantly lower than those in the control group (p = 0.106). The mean 24-h postoperative meperidine consumption in the treatment group was significantly lower compared to that in the control group (26.3 +/- 28.1 mg and 39.1 +/- 34.6 mg, respectively, p = 0.001). The proportion of patients requiring meperidine in the treatment group was significantly lower than that in the control group (58.6% and 70.3%, respectively, p = 0. 045). No serious adverse events were observed in both groups., Conclusion: Preoperative parecoxib sodium significantly reduced postoperative meperidine requirement and consumption, while insignificantly declined the pain scores. Serious adverse events were not encountered

To determine the effect of adding ketamine to pethidine in reducing post-operative pain in patients undergoing major abdominal operations, in a double blind randomized controlled trial, 100 patients aged 15-60 years who were candidate for elective major abdominal surgery allocated into two groups of pethidine + ketamine group (5 mg pethidine and 0.25 mg kg(-1) ketamine) or pethidine and placebo group (10 mg pethidine and NS) according to the regimen prescribed in postanesthesia care unit. Severity of pain (using visual analogue scale), prescribed dose of pethidine and side effects were recorded until 24 h after operation. Regarding post-operative pain, pethidine + ketamine group showed significant lower scores in all the times except 0 min, 2, 6 and 16 h. Nausea was significantly less frequent amongst pethidine + placebo group at times of 0, 15, 30 and 45 min (p < 0.05). Comparison of two groups did not show significant differences in prescribed pethedine dose in 0, 9, 12, 16, 20 and 24 h (p > 0.05). Yet, the mean dose of administered pethidine as rescue analgesic was significant lower in pethidine + ketamine group compared to pethidine + placebo group (112 +/- 31.5 mg vs. 133.5 +/- 24.5 mg, p < 0.001). In conclusion, our results showed that co-administration of ketamine and pethidine in postanesthesia care unit will improve postoperative pain and reduce narcotic consumption. It may, however, increase rate of postoperative nausea in the first hour after operation.

Introduction: Tonsillectomy is frequently associated with postoperative pain of considerable duration, which is usually accompanied by the substantial consumption of both opioid and non-opioid analgesic such as NSAIDs and local anaesthetics., Objective: The aim of this study was to evaluate the efficacy between 2% viscous lignocaine and sodium diclofenac based upon the visual analogue scores (VASs), consumption of pethidine 0.5mgkg(-1) as the rescue drug postoperatively and time taken to resume feeding., Methods: 130 patients aged between 5 and 12 years old were randomly allocated into 2 groups to be given either 2% viscous lignocaine 4mgkg(-1) body weight topically post-tonsillectomy or sodium diclofenac 1mgkg(-1) per-rectal post-induction of anaesthesia. Postoperatively visual analogues score was done for 24h, the amount of pethidine given and time when the patient start taking oral feeding of clear fluid, soft diet and normal diet were documented., Results: There was no significant difference in the visual analogue scores in both groups, however the requirement of pethidine as the rescue drug postoperatively was significant 2h post-tonsillectomy (p=0.023) in viscous lignocaine group compared to sodium diclofenac. The time taken to resume oral feeding and soft diet was also significant in viscous lignocaine group (p=0.016 and p=0.007) whereas there was no significant in taking normal diet., Conclusion: We concluded that 2% viscous lignocaine applied topically post-tonsillectomy is comparable to sodium diclofenac per-rectal in providing analgesia and faster oral feeding.

Objectives: To evaluate respiratory function and pain score in patients undergoing coronary bypass procedures during the first 7 postoperative days., Methods: The study was carried out as a case-control study between April 2008 and April 2009 in the Department of Cardiovascular Surgery, Firat University Faculty of Medicine, Elazig, Turkey. Thirty patients, who had undergone a median sternotomy (MS) for coronary artery bypass graft, were randomized to either the electroacupuncture and pharmacologic analgesia (acupuncture) group, or the pharmacologic analgesia alone (control) group. In each group, severity of pain, analgesic intake, respiratory function, and pulmonary complications were recorded. Pethidine hydrochloride and metamizole sodium were administered., Results: Of the 30 subjects, 15 were in the control group and 15 in the acupuncture group. There were no statistically significant differences between the 2 groups in terms of age and gender. Statistically significant differences in metamizole, pethidine, days 3, 5, 6, and 7 visual analogue scale scores were observed between the acupuncture and control groups. Postoperative complications (atelectasia) were observed in 2 (13.3%) patients, one (6.6%) in each group. The postoperative forced expiratory volume in one second/forced vital capacity value was higher than the preoperative value in the acupuncture group., Conclusions: Electroacupuncture was more effective than control treatments in decreasing pain and limiting opioid and non-opioid medication intake during the first 7 postoperative days following MS.

Objective: To determine the advantages and disadvantages of the use of diclofenac sodium instead of meperidine for postcesarean section pain control., Methods: A total of 130 patients who had undergone cesarean section at the Department of Obstetrics and Gynecology of Gazi University Hospital were prospectively randomised to receive one of two postoperative pain control regimens. The first group of patients received intramuscular diclofenac sodium at a dose of 2 x 75 mg and additional breakthrough meperidine was given intramuscularly at 50 mg dosages each time, if necessary. Patients in the second group received only 6 x 50 mg meperidine., Results: Twenty-seven of the 65 patients in the diclofenac group complained of unrelieved pain within the subsequent 24 h postoperatively. Patients receiving diclofenac alone or a combination of diclofenac + meperidine were less sedated and the time to the first passing of flatus was shorter than that in the patients treated with only meperidine., Conclusions: Diclofenac alone was safe and effective for the majority of the patients and it decreased the opioid requirements in the remaining patients.

Aim: To compare the analgesic properties and efficacy of transnasal butorphanol with intramuscular meperidine after anal surgery., Methods: Sixty patients who underwent fistulectomy were enrolled in the study from January 2006 to December 2007. They were randomly divided into transnasal butorphanol (n = 30) or intramuscular meperidine (n = 30) treatment groups. Assessment of postoperative pain was made using a visual analogue scale (VAS). The VAS score was recorded 6 h after the completion of surgery, before receiving the first dose of analgesic, 60 min after analgesia and the next morning. Any adverse clinical effects such as somnolence, dizziness, nausea or vomiting were recorded. Satisfaction with narcotic efficacy, desire to use the particular analgesic in the future and any complaints were recorded by patients using questionnaires before being discharged., Results: Forty-two men and eighteen women were included in the study. There were no significant differences in VAS scores between the groups within 24 h. Length of hospital stay and the incidence of adverse effects between the groups were similar. In addition, most patients were satisfied with butorphanol nasal spray and wished to receive this analgesic in the future, if needed., Conclusion: Butorphanol nasal spray is effective for the relief of pain after fistulectomy. However, it offered patients more convenient usage and would be suitable for outpatients.

Objectives: We aimed to determine the effects of intraperitoneal administration of levobupivacaine on pain after laparoscopic cholecystectomy in a prospective, randomized, double-blinded, placebo-controlled trial., Methods: In all patients, infiltration of levobupivacaine 0.25% (15 mL) was used prior to skin incisions for trocar insertion. After pneumoperitoneum was achieved, patients were allocated randomly to receive intraperitoneally either 40 mL of 0.25% levobupivacaine (LB group, n=20) or normal saline (NS group, n=20) under direct vision into the hepatodiaphragmatic lodge and above the gallbladder. Data of intraoperative variables, postoperative pain relief, rescue analgesic consumption, side effects, and patient satisfaction were followed in both groups., Results: The postoperative pain scores were significantly lower in the first half-hour period in the LB group than in the NS group (p<0.05). However, the incidence of right shoulder pain was not significantly different between the LB group (10%) and NS group (15%). The mean dose of meperidine consumption and the number of patients needing rescue meperidine were significantly lower in the LB group than in the NS group (p<0.05). Significantly lower vomiting incidence and increased patient satisfaction were determined in the LB group compared to the NS group (p<0.05)., Conclusion: Intraperitoneal administration of 40 mL levobupivacaine 0.25% given immediately after pneumoperitoneum into the hepatodiaphragmatic lodge and above the gallbladder demonstrated useful effects on postoperative pain relief after laparoscopic cholecystectomy, especially in the early postoperative period, and reduced postoperative rescue analgesic requirement, with excellent patient satisfaction. There were no LB-related complications or side effects.

The under-treatment of postoperative pain is prevalent worldwide. This cross-sectional study examined general practitioners' (GPs) knowledge and practices regarding postoperative analgesia in Caesarean deliveries. Postoperative analgesia was said to ensure that patients were pain-free (38.7%), achieved early mobilization (19.4%) and enabled early breast feeding (16%). Pethidine was the opioid of choice; normally prescribed eight hourly (69%) and was combined with non-steroidal anti-inflammatory drugs (NSAID) by 48.6% of doctors and used solely by 51.6%. The prescription of analgesics was mainly influenced by drug availability (45.2%) and potency (19.4%). Most doctors (93.5%) had never attended a pain management course or used pain scores. Doctors at level 1 hospitals were less likely to use pethidine in combination with NSAID (odds ratio: 0.11; confidence interval: 0.02-0.59) compared to those in the specialized hospital. The GPs recognized the importance of postoperative analgesia, but their practices made patients vulnerable to pain after caesarean section.

Objective: In this study, the authors investigated the effect of the addition of remifentanil to tramadol or morphine for patient-controlled analgesia (PCA)., Design: Prospective, randomized, double-blind, controlled study., Setting: University Hospital., Patients, Participants: The authors randomly allocated 133 patients undergoing major abdominal surgery to receive IV PCA with tramadol alone, tramadol plus remifentanil, morphine alone or morphine plus remifentanil., Interventions: Bolus doses of tramadol (0.2 mg/kg), tramadol (0.2 mg/kg) plus remifentanil (0.2 microg/kg), morphine (0.02 mg/kg), or morphine (0.02 mg/kg) plus remifentanil (0.2 microg/kg) were available every 10 minutes without time limit or background infusion., Main Outcome Measure(s): Discomfort, sedation, pain scores, side effects, and total and bolus tramadol and morphine consumption were recorded for up to 24 hours after the start of PCA., Results: Pain scores at rest and movement were greater with tramadol alone than in the other groups at 1, 2, and 6 hours (p < 0.0125). The addition of remifentanil reduced cumulative tramadol consumption at 6, 12, and 24 hours, but not morphine consumption. More patients required supplementary rescue analgesia with meperidine, and with greater dosage, with tramadol alone (p < 0.001), and the incidence of nausea was greater with tramadol alone. The addition of remifentanil not only significantly improved discomfort scores in remifentanil groups, but also increased the degree of sedation in morphine-remifentanil group., Conclusions: After major abdominal surgery, adding remifentanil to PCA tramadol resulted in better pain scores, lower analgesic consumption, and fewer side effects when compared with tramadol alone. However, analgesic outcome with remifentanil was not prominent in MR group as much as in TR group.

Background: The aim of this randomized, double blind, controlled study was to assess the effect of intravenous coadministration of small dose midazolam with ketamine on postoperative pain and spinal block level., Methods: Sixty patients undergoing arthroscopic knee surgery under spinal anesthesia were randomized into three groups: Group I (saline control); group II (ketamine 0.15 mg/kg i.v.); and group III (ketamine 0.15 mg/kg + midazolam 0.01 mg/kg i.v.). Sedation scores, visual analogue scores, time to first postoperative analgesic, total meperidine consumption, patient satisfaction, sensory and motor block levels, and two segments regression times were assessed., Results: Sedation scores were significantly lower in group I when compared with groups II and III at 1, 3, 5, and 10 minutes after administration of the spinal anesthetic (P = 0.001). Sensory block was significantly higher in group III (P = 0.001) in comparison with group II. Two segment regression time was significantly longer in group II than group I, whereas no difference was found between groups II and III. Total meperidine consumption was significantly higher in group I (P = 0.001). Patient satisfaction was significantly higher in group III compared with group I (P = 0.001), but no difference was found between groups II and III (P = 0.3)., Conclusion: Ketamine improved the postoperative pain patient satisfaction, increased the maximal sensory level, and was associated with lower sedation scores in the first 15 minutes after administration. Group I was also associated with decreased total meperidine consumption and delayed the time to first recue analgesic administration. Coadministration of ketamine and midazolam did not provide any further benefit over ketamine alone.

Background: Postoperative pain in children is common after adenotonsillectomy. Rectal acetaminophen has been used effectively for postoperative pain management in small children. The aim of this randomized double blind study was to evaluate the prophylactic effect of rectal acetaminophen on postoperative pain management and opioid requirements in children undergoing adenotonsillectomy., Materials and Methods: 104 children, 7 to 15 yr, ASA I or II scheduled for elective adenotonsillectomy were recruited for the study. Patients were randomized to receive either rectal acetaminophen 40 mg/kg or nothing after induction of standard anesthesia. The postoperative pain was assessed using visual analog scale (VAS) every 2 hours for the first 6 hours. The need for rescue analgesic, intravenous pethedine of 0.5 mg/kg, was recorded at 24 hours after surgery., Results: Pain scores were significantly lower in acetaminophen group at different times (p<0.001) and needed less rescue analgesic (p<0.001)., Conclusion: We conclude that prophylactic rectal acetaminophen is effective in reducing pain after adenotonsillectomy and postoperative analgesic requirement.

Background and Objective: Local anaesthetics administered intraabdominally have been found to reduce analgesic requirements postoperatively after hysterectomy. This study was designed to assess the optimal dose of local anaesthetics for best pain relief., Methods: Sixty patients undergoing abdominal hysterectomy were randomly divided into three groups to receive 10 ml h infusion of levobupivacaine intraabdominally postoperatively for 48 h in a double-blind manner: group L, 7.5 mg h; group M, 12.5 mg h and group H, 17.5 mg h. Pain intensity was measured using the numeric rating scale, ketobemidone consumption over 48 h was measured with a patient-controlled analgesia pump, recovery parameters, expiratory muscle strength, time to home readiness, plasma concentration of levobupivacaine and health-related quality of life were all measured at defined time points postoperatively., Results: No differences were found between the active groups in pain intensity, recovery parameters or health-related quality of life. Pain intensity was maximal during 0-4 h and during coughing. Expiratory muscle strength decreased significantly during 0-4 h in all active groups, with no differences between the groups. Plasma concentration of levobupivacaine was below known toxic concentrations in humans, and no patient had symptoms of local anaesthetic toxicity. Health-related quality of life showed improved scores at 3 months after the operation compared with preoperative values, but no differences between the groups were found in any of the parameters., Conclusion: Satisfactory analgesia can be achieved with low doses of levobupivacaine administered intraabdominally, except during the early postoperative period. No advantages were seen in this study when higher doses of levobupivacaine were administered as a continuous infusion for postoperative pain relief.

Background: Recently, the peripheral anesthetic effect of tramadol has been the theme of many studies. The postoperative analgesic effects of subcutaneous wound infiltration with tramadol have not been extensively studied and compared with those of intravenous administration., Objective: To compare the therapeutic effects and complications of intravenous versus local wound infiltration of using tramadol following pyelolithotomy., Methods: This double-blind study was carried out on 60 patients (age 18-60 y) of American Society of Anesthesiologists physical status I-II who were awaiting pyelolithotomy in Sina Hospital, Tehran, Iran, during 2006 and 2007. They were randomly assigned to receive intravenous or subcutaneous wound infiltration with tramadol. Vital signs, the intensity of pain (visual analog scale), and the level of consciousness (Ramsey Sedation Scale [RSS]), as well as the frequency of nausea and vomiting were recorded during 30 minutes to 1 hour after the patient entered the recovery room. Vital signs were also recorded every hour until 6 hours postoperatively and then on the day after the patient was transferred to the ward., Results: The RSS was lower in patients who had received subcutaneous infiltration of tramadol (p < 0.001). A significant difference was noted in the severity of pain between the groups; it was higher in the group that received intravenous tramadol. The average time for the first meperidine requirement was 45.2 +/- 8.4 min (mean +/- SD) in the subcutaneous group and 21.6 +/- 12.4 min in the intravenous group. Total meperidine consumption was lower in patients who had received subcutaneous wound infiltration with tramadol compared with those who had received intravenous tramadol (p < 0.001). Nausea and vomiting were more frequent during the first hour of recovery; the complication, however, was less frequent in the subcutaneous group., Conclusions: Subcutaneous wound infiltration with tramadol reduces postoperative opioid consumption and produces less nausea and vomiting than does intravenous administration.

Background: Intraarticular injection of neostigmine has been reported to create long-lasting analgesia due to the blockade of muscarinic receptors and neuronociceptive transmitters. The aim of the study was to determine if similar effects could be achieved after adding neostigmine to bupivacaine during infiltration of the surgical area before inguinal hernia surgery., Methods: Ninety patients (82 males and 8 females), aged 20-88 (mean 54.8) years, scheduled for Lichtenstein hernia surgery under spinal anaesthesia, were randomly allocated to three groups. The surgical area was infiltrated with 10 mL of 0.5% bupivacaine in group 1, or 10 mL of 0.5% bupivacaine with 0.5 mg neostigmine in group 2. Patients in the control group did not receive local infiltration. Postoperative pain was assessed using a numerical rating scale (NRS), and adjective rating scale (ARS) and the need for rescue analgesia (ketoprofen or pethidine) was recorded., Results: The patients of group 1 required rescue analgesia significantly later, compared to the other two groups. Intense pain occurred less frequently in group 1 and the most frequently in group 3. The need for rescue analgesia was also least in group 1 and greatest in group 3., Conclusions: Neostigmine added to bupivacaine had no effect on analgesia after pre-emptive local wound infiltration.

Preoperative and postoperative psychological factors, postoperative pain, analgesic consumption, treatment satisfaction were compared in patients treated with intravenous patient-controlled analgesia (IV-PCA) or intramuscular analgesics after laparoscopic ovarian cystectomy. Thirty-one women with laparoscopically operated benign ovarian cysts were recruited in Zonguldak Karaelmas University Faculty of Medicine, Department of Obstetrics and Gynecology. Postoperatively sixteen women received morphine delivered by IV-PCA pump system and 15 women were prescribed another opioid (meperidine) intramuscularly. Two weeks before and one day after the surgery, Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) were self-administered. Afterwards, the operation visual analog scale (VAS) and satisfaction with pain control scale were recorded. Preoperative BDI and BAI scores of both groups were comparable. Postoperative BDI (7.9 +/- 7.2 versus 13.8 +/- 6.9, P = 0.03) and BAI (11.4 +/- 9.1 versus 17.4 +/- 6.2, P = 0.045) scores were significantly lower in the IV-PCA group. Morphine usage with PCA resulted in significantly higher pain scores than equivalent doses of meperidine administered intramuscularly (2.94 +/- 1.0 versus 1.67 +/- 0.7, P = 0.001). Although higher pain scores were obtained from IV-PCA group, self-reported satisfaction rates were higher in this group (8.3 +/- 1.1 versus 7.4 +/- 1.1, P = 0.04). Involvement of patients in their pain management might increase the awareness of pain but their satisfaction about the control of postoperative pain was significantly improved.

Study Objectives: To compare the efficacy of injectable lornoxicam with diclofenac, ketoprofen, and dipyrone for acute postoperative pain., Design: Prospective, randomized, placebo-controlled, double-blind study., Setting: University hospital., Patients: 200 ASA physical status I patients who were scheduled for elective septoplasty with general anesthesia., Interventions: Patients were divided into 5 groups according to the intramuscularly administered analgesic drug: lornoxicam 8 mg (twice daily), diclofenac 75 mg (twice daily), ketoprofen 100 mg (twice daily), dipyrone 1 g (three times daily), and placebo (twice daily)., Measurements: Pain intensity was evaluated with a 0 to 100 mm Visual Analog Scale (VAS) at the 2nd, 4th, 6th, 8th, 12th, 16th, 20th, and 24th hour postoperatively. Intramuscular pethidine 1 mg/kg was administered to patients requiring additional analgesia, and treatment-related adverse effects were noted., Main Results: Pethidine requirement was found to be significantly higher in the placebo group (1.8 mg/kg per 24 hours; 95% confidence interval, 1.5-2.2) than in the other groups (P = 0.001). No significant difference in opioid requirement was found among the treated groups (P > 0.05). Postoperative VAS scores were significantly lower at specific hours in the treatment groups when compared with placebo group (P < 0.05). No statistically significant difference in adverse effects was found among the groups studied (P > 0.05)., Conclusions: Efficacy of lornoxicam in the management of acute postoperative pain was not superior to that of other nonopioid analgesics used in this study.

Objective: Perioperative analgesia effects the postoperative course of pain. The purpose of this study was to evaluate its possible relation with the consumption of dolantine and analgesics and the facet-induced pain and postoperative pain score in degenerative disc surgery., Methods: We employed perioperative intra- and perifacet bupivacaine infiltration technique to reduce the postoperative pain after lumbar disc surgery. The study was randomized and observer blinded enrolling 40 American Society of Anesthesiologists physical status class I-II patients scheduled for elective degenerative lumbar disc surgery. The patients were divided into two groups of 20 of which Group 1 underwent injection of bupivacaine into the subcutaneous and muscular layers around the incision site, while Group 2 underwent additional intra- and perifacetal joint infiltration. Postoperatively, the patients were provided with a programmed patient-controlled pump which was only activated on demand to infuse dolantine for the next 24 hours. In the postanesthesia care unit the delay for analgesia and the dose of dolantine used were recorded., Results: There was no statistical significance between these two groups regarding postoperative visual analoque scale scores. The time before the first analgesic request was significantly longer in facet group (p= 0,006). The cumulative dolantine dose was also significantly lower in the facet group (p= 0,001)., Conclusion: The results indicate that facet joint infiltrative analgesia may have an effect on the postoperative analgesic requirement and reduce the dolantine consumption.