The analgesic effect of nefopam combined with low dose remifentanil in patients undergoing middle ear surgery under desflurane anesthesia: a randomized controlled trial.

BACKGROUND: We investigated the effects of the combined administration of nefopam, a N-methyl-D-aspartate receptor antagonist and low dose remifentanil, on early postoperative pain and analgesic requirement. METHODS: Fifty patients scheduled to undergo mastoidectomy and tympanoplasty were randomized to be given either nefopam 40 mg mixed with normal saline 100 ml (Group N) or an equal amount of normal saline (Group C) before anesthesia induction. Anesthesia was maintained with 5-6 vol% desflurane and remifentanil 0.05-0.15 µg/kg/min during the surgery. Postoperative pain was controlled by titration of ketorolac in the postanesthesia care unit (PACU) and ward. We evaluated the intraoperative remifentanil dose, recovery profiles, ketorolac demand in the PACU and ward, numeric rating scale (NRS) for pain at time intervals of every 10 min for 1 h in the PACU, 6, 12, 18 and 24 h in a ward, as well as the time to first analgesic requirement in the PACU and ward. RESULTS: Ketorolac demand and NRS in the PACU were significantly lower in Group N than Group C (P = 0.002, P = 0.005, respectively). The time to first analgesic requirement in the PACU in Group N were significantly longer than Group C (P = 0.046). There were no significant differences in intraoperative remifentanil dose, ketorolac demand, NRS, and the time to first analgesic requirement in the ward between the groups. CONCLUSIONS: Nefopam administration combined with low dose remifentanil infusion reduces pain and analgesic consumption during the immediate postoperative period in patients undergoing middle ear surgery under desflurane anesthesia.

Sufentanil infusion before extubation suppresses coughing on emergence without delaying extubation time and reduces postoperative analgesic requirement without increasing nausea and vomiting after desflurane anesthesia.

BACKGROUND: Coughing, hypertension, tachycardia, and even laryngospasm can occur due to airway irritation during emergence from anesthesia. We investigated the effect of maintaining a sufentanil infusion during emergence from anesthesia by evaluating the incidence of cough and recovery profiles at extubation. METHODS: In total, eighty-four patients undergoing an elective laparoscopic hysterectomy were randomly divided into two sufentanil groups and a control group. During emergence, sufentanil was administered in the sufentanil groups at a rate of 0.2 µg/kg/hr (Group S1) or 0.3 µg/kg/hr (Group S2), and saline was administered to the control group. Cough score, hemodynamic changes, and recovery profiles, such as duration from skin closure to a bispectral index of 80, to eye opening at verbal command, to tracheal extubation and the total duration of study solution infusion, were recorded. The pain score, the total volume of administered patient-controlled analgesia (PCA), and the postoperative nausea and vomiting (PONV) score were evaluated 1, 6, and 24 hours after surgery. RESULTS: Groups S1 and S2 showed significantly lower cough scores and smaller hemodynamic changes on extubation compared to Group C. Recovery profiles showed no significant differences among the three groups. Pain score, PONV at 1 hour postoperatively, and the total volume of PCA administered at all evaluation times were significantly lower in Groups S1 and S2 than in the control group. However, pain score, and PONV at 6 hours and 24 hours postoperatively showed no significant differences. CONCLUSIONS: A sufentanil infusion (0.2-0.3 µg/kg/hr) during emergence from desflurane anesthesia may suppress coughing on extubation in patients with body mass indexes (BMI) of 21-26 without delaying extubation time. It may also reduce the postoperative analgesic requirement without increasing PONV.

The neurological safety of intrathecal acyclovir in rats.

BACKGROUND: Effective early antiviral treatments reduce both acute zoster pain and the risk of postherpetic neuralgia. The authors hypothesized that the direct neuraxial administration of acyclovir could provide superior drug application to the spinal neural structures with a higher viral burden and have various advantages over the other routes of drug administration in terms of required doses, side effects, and efficacy. OBJECTIVE: To know whether intrathecal acyclovir injection is neurologically and histopathologically safe or not. STUDY DESIGN: Randomized, experimental trial in rats. SETTING: Associated experiment center. METHODS: A total of 40 rats weighing between 250-300g were used. The rats were randomly divided into 2 groups of 20 each using a random number table: normal saline group (Group N) and acyclovir group (Group A). Rats in Group N were administered 20 µl of normal saline and Group A were administered the same volume of 700 µg/mL acyclovir into the intrathecal space via an intrathecal catheter. Saline or acyclovir was administered daily for 5 consecutive days. The changes in behavior and sensory-motor function were checked and histopathological findings of the spinal cords were observed by light and electron microscopy. RESULTS: No rats in Group N or Group A showed any behavioral change or sensory-motor dysfunction during the 5-day observation period. Furthermore, no histopathological abnormalities of the spinal cord were observed in the 6th day after the last intrathecal administration of the drug. LIMITATIONS: There is a need to perform studies to evaluate long-term safety by observing cumulative neurotoxic effects with continual injection during a long-term period. CONCLUSIONS: There was no evidence of neurological and histopathological abnormalities following intrathecal acyclovir injection.

The effect and optimal dose of sufentanil in reducing injection pain of microemulsion propofol.

BACKGROUND: Propofol is used as an induction and maintenance agent for general anesthesia but it can cause adverse reactions like hyperlipidemia, growth of microorganisms, and pulmonary embolisms. Microemulsion propofol was developed to avoid these side effects but incidence and severity of pain on injection is higher than with lipid emulsion propofol. We aimed to compare the effects of sufentanil in analgesic doses for reducing the injection pain of microemulsion propofol. METHODS: The candidates included eighty patients, 19-60 years old and ASA I-II. They were randomly classified into four groups and pretreated with normal saline, sufentanil 0.1 µg/kg, 0.2 µg/kg or 0.3 µg/kg before injection of microemulsion propofol. Five minutes after receiving pretreatment drug, 2 mg/kg of microemulsion propofol was injected and VAS was recorded. RESULTS: There were no significant differences in the incidence of injection pain among the groups. Severity of injection pain was significantly lower in the sufentanil 0.3 µg/kg group than normal saline and sufentanil 0.1 µg/kg group. Significant differences in blood pressure and heart rate were observed in sufentanil groups only after endotracheal intubation. One patient each in sufentanil 0.1 µg/kg and 0.3 µg/kg group experienced mild cough, one from sufentanil 0.3 µg/kg group experienced dizziness and another showed signs of hypoxia. One patient each in normal saline and sufentanil 0.1 µg/kg group showed clinical symptoms of phlebitis in the injection area. CONCLUSIONS: Pretreatment with sufentanil 0.3 µg/kg reduced the severity of microemulsion propofol injection pain without increasing arterial blood pressure and heart rate after endotracheal intubation.

Multiple psoas abscess formation after pharmacopuncture -a case report-.

Acupuncture has been widely used in alternative medicine for pain relief but may have many complications due to lack of appropriate cares. Pharmacopuncture is a sort of acupuncture that injects a herbal ingredient through a thin tube for the purpose of combining the effects of the herb and acupuncture and it has many pitfalls. The agents used in pharmacopuncture are not refined for a desired effect and not produced by sterile standard processes under strict medical surveillance. We report a case of a 44-yr-old male patient who had multiple abscesses in the psoas region with fever, right low back and hip pain that began after the pharmacopuncture treatment. This case shows that although pharmacopuncture has been practiced widely, it is important that the appropriate aseptic technique should be used to prevent severe infections and other complications.

No enhancement of sensory and motor blockade by ketamine added to ropivacaine interscalene brachial plexus blockade.

BACKGROUND: Ketamine can enhance anesthetic and analgesic actions of a local anesthetic via a peripheral mechanism. The authors' goal was to determine whether or not ketamine added to ropivacaine in interscalene brachial plexus blockade prolongs postoperative analgesia. In addition, we wanted to determine the incidence of adverse-effects in patients undergoing hand surgery. METHODS: Sixty adults scheduled for forearm or hand surgery under the interscalene brachial plexus block were prospectively randomized to receive one of the solutions of the study. Group P received 0.5% ropivacaine 30 ml, group K received 0.5% ropivacaine 30 ml with 30 mg ketamine, and group C received 0.5% ropivacaine with 30 mg ketamine i.v. Loss of shoulder abduction, elbow flexion, wrist flexion and loss of pinprick in the C4-7 sensory dermatomes were assessed at 1-min intervals. Adverse-effects were assessed every 5 min. The duration of the sensory and motor blocks was assessed after operation. Adverse-effects were also recorded. RESULTS: The onset time of sensory or motor blockade and the duration of sensory or motor blockade were similar in all groups. Adverse-effects occurred in 44% of patients in group K and 94% of group C. CONCLUSION: This study suggests that 30 mg ketamine added to ropivacaine in the brachial plexus block does not improve the onset or duration of sensory block, but it does cause a relatively high incidence of adverse-effects. These two findings do not encourage the use of ketamine with local anesthetics for brachial plexus blockade.