Postoperative analgesic efficacy of nefopam after anorectal surgery: a retrospective observational study

Objective: To examine the effectiveness of nefopam on postoperative pain control after anorectal surgeries. Methods: We retrospectively reviewed the electronic medical records of patients who underwent anorectal surgeries from January 2019 to March 2022 at two medical centers. The data were divided into nefopam and conventional groups. The primary outcome was the number of patients who requested additional opioids in the 24-h postoperative period. The secondary outcomes were numeric rating pain scores (NRPS) within a 24-h postoperative period and analgesic drugs-related side effects. Results: Eighty-seven patients in the conventional group and 60 in the nefopam group were recruited. The nefopam group reported less additional opioid consumption than the conventional group in all dimensions of analysis, including overall, adjusted to anesthetic techniques and types of surgery. However, these did not reach statistical significance (P = 0.093). Only patients in the nefopam group who underwent hemorrhoidectomy under TIVA or spinal anesthesia significantly required fewer additional opioids (P = 0.016, 60% mean difference). Similarly, the 24-h postoperative morphine consumption was lower in the nefopam group (mean difference = -3.4, 95%CI: 0.72,6.08). Furthermore, significantly lower NRPS were reported in the nefopam group during the 12-18 h postoperative period (P = 0.009). On the other hand, analgesic drugs related side effects were similar in both groups. Conclusions: The administration of nefopam after major anorectal surgery is beneficially evident in reducing postoperative opioid requirements. (AU)

Profile of Crohn's disease patients who underwent anorectal examination under anesthesia

Introduction: Crohn's disease (CD) is an inflammatory bowel disease, and in ~ 30% of cases it is associated with perianalmanifestations. To identify the extent of the damage and to implement an appropriate treatment, anorectal examination under anesthesia (EUA) is fundamental. Objective: To describe the profile of patients who underwent anorectal EUA in university and private hospitals in the state of Bahia, Brazil. Methodology: A retrospective, descriptive study with 46 patients who underwent anorectal EUA between March, 2016 and November, 2019. Results: A total of 62 anorectal EUAs were performed in 46 patients. With an average age of 36.8 years, the female gender was predominant (52.2%) among these patients. Anal fistulas were the most frequent findings (83.8%), and in most cases they were treated with a seton placement (69.4%). The main recommended surgical indication was a proper evaluation and identification of perianal disease, followed by drainage of the abscess and therefore immunobiological therapy (59.6%). Conclusion: In the present study, the profile of CD patients was similar to those found in the literature, with a high rate of complex anal fistulas. Additional studies are still necessary to further comprehend and treat this particular and debilitating manifestation of the disease. (AU)

Anorectal application of 5% lidocaine cream reduces pain prior to periprostatic nerve block during transrectal ultrasound guided prostate biopsy: Randomized, prospective controlled study.

OBJECTIVES: Trans rectal ultrasound guided prostate biopsy with periprostatic nerve block (PPNB) is performed following probe insertion and manipulation leaving these initial maneuvers uncovered in terms of pain control. We evaluated whether topical analgesia reduces pain during early stages of the procedure. PATIENTS AND METHODS: Seven group prospective, randomized controlled study: groups 1-3: nerve block with 5 ml 1% lidocaine bilaterally plus perianal topical application of 10 ml 5% lidocaine cream. Groups 4-6 as in 1-3 plus digital application of 10 ml 5% lidocaine cream internally on rectal walls. For each approach exposure times were 5 (groups 1 and 4), 10 (groups 2 and 5) and 20 (groups 3 and 6) min, respectively. The control group (7) received PPNB only. Patients filled a 0-10 visual analogue scale (VAS) at five points: after probe insertion, during probe manipulation, following PPNB, after prostate biopsies and a global pain estimation. RESULTS: Two hundred and fifty-two patients were enrolled. Significant differences in VAS between all study groups and controls were observed at the pre-biopsy stages of the procedure. In multivariate analysis adjusted for prostate specific antigen, diabetes mellitus status, spinal disease, abnormal digital rectal examination and non- benign prostate hyperplasia histology, significance remained for probe insertion and intra-rectal manipulation. For each exposure time no significant differences were observed between topical application and topical + intra-rectal application. After PPNB, differences between study and control groups disappeared. CONCLUSION: Topical anesthesia significantly reduces pain during early stages of prostate biopsy. Perianal application sufficed whereas intra-rectal application of local anesthetics does not add to pain control. Perianal application for 10 min seems to be optimal.

Intrarectal ice application prior to transrectal prostate biopsy: a prospective randomised trial accessing pain and collateral effects.

OBJECTIVES: To analyze the efficacy of intrarectal ice application as an anesthetic method prior to transrectal ultrasound (TRUS) guided prostate biopsy. MATERIALS AND METHODS: A total of 120 consecutive men were included into the study prospectively. Patients were equally randomized as group 1 and 2 with 60 patients each. Ice was applied as an anesthetic method 5 minutes before procedure to the patients in group 1. Patients in group 2 were applied 10 mL of 2% lidocaine gel 10 minutes before procedure. Twelve core biopsy procedure was performed for all patients. The pain level was evaluated using a visual analogue scale (VAS). RESULTS: Median pain score was 3.5 (1-8) in group 1 and 5 (1-8) in group 2. There is significantly difference between groups regarding the mean sense of pain level during the procedure. (p=0.007) There was also no difference in complications between two groups about presence and duration of macroscopic hematuria and rectal bleeding. CONCLUSIONS: Intrarectal ice application prior to TRUS prostate biopsy has an effect on reducing pain. Development of new techniques about cold effect or ice can make this method more useful and decrease complication rates.

Does rectus sheath infusion of bupivacaine reduce postoperative opioid requirement?

INTRODUCTION: The aim of this work was to assess the effect of intermittent bupivacaine infusion into rectus sheath space on postoperative opioid requirement, postoperative pain score and peak expiratory flow rate. PATIENTS AND METHODS: A prospective, randomised study involving patients undergoing midline laparotomy. Patients were randomised to receive either intermittent infusion of bupivacaine 0.25% or normal saline via catheters placed in the rectus sheath for 48 h after operation. All patients received intravenous morphine infusion on demand with a patient-controlled analgesic device (PCAD). RESULTS: Forty ASA I-III patients were studied. Nineteen were randomised to receive bupivacaine and 21 patients received normal saline. Patient characteristics and surgical variables were comparable in the two groups. The mean wound lengths were similar. There was no statistically significant difference in postoperative opioid requirement, postoperative pain score and peak expiratory flow rate between the two groups. CONCLUSIONS: Intermittent bupivacaine infusion into the rectus sheath space after midline laparotomy does not reduce postoperative opioid requirement nor does it affect postoperative pain score or peak expiratory flow rate.

[Complications of transrectal biopsy of the prostate].

The aim of the study was to assess frequency of various complications of transrectal multifocal biopsy of the prostate (TMBP), to specify prophylactic measures against such complications. Primary TMBP under US guidance was made in 612 patients (mean age 65.8 years, mean level of PSA 12.6 ng/ml). TMBP complications include: hematuria (220 patients, 35.9%), hemospermia (166 patients, 27.1%), pain in the perineum and the rectum (189, 30.9%), acute prostatitis (21 patients, 3.4%), acute orchiepididymitis (7 patients, 1.1%), acute urine retention (9 patients, 1.5%), long-term rectal hemorrhage (13 patients, 2.1%), loss of consciousness during the biopsy (7 patients, 1.1%). The analysis of TMBP complications leads to the conclusion that adequate preparation of the patients and accurate conduction of the prostatic biopsy technique under US guidance make this invasive manipulation diagnostically effective and safe.

Quantification of mitral regurgitation using proximal isovelocity surface area method in dogs.

The present study was performed to determine the accuracy and reproducibility of calculating the mitral regurgitant orifice area with the proximal isovelocity surface area (PISA) method in dogs with experimental mitral regurgitation and in canine patients with chronic mitral insufficiency and to evaluate the effect of general anesthesia on mitral regurgitation. Eight adult, Beagle dogs for experimental mitral regurgitation and 11 small breed dogs with spontaneous mitral regurgitation were used. In 8 Beagle dogs, mild mitral regurgitation was created by disrupting mitral chordae or leaflets. Effective regurgitant orifice (ERO) area was measured by the PISA method and compared with the measurements simultaneously obtained by quantitative Doppler echocardiography 4 weeks after creation of mitral regurgitation. The same procedure was performed in 11 patients with isolated mitral regurgitation and in 8 Beagle dogs under two different protocols of general anesthesia. ERO and regurgitant stroke volume (RSV) by the PISA method correlated well with values by the quantitative Doppler technique with a small error in experimental dogs (r = 0.914 and r = 0.839) and 11 patients (r = 0.990 and r = 0.996). The isoflurane anesthetic echocardiography demonstrated a significant decrease of RSV, and there was no significant change in fractional shortening (FS), ERO area, LV end-diastolic and LV end-systolic volume. ERO area showed increasing tendency after ketamine-xylazine administration, but not statistically significant. RSV, LV end-systolic and LV end-diastolic volume increased significantly (p < 0.01), whereas FS significantly decreased (p < 0.01). The PISA method is accurate and reproducible in experimental mitral regurgitation model and in a clinical setting. ERO area is considered and preferred as a hemodynamic-nondependent factor than other traditional measurements.

Biopsia prostática guiada por ecosonograma transrectal: tolerancia con instilación de lidocaína / Biopsy prostática guided by ecosonograma transrectal: tolerance with lidocaína instilación

Evaluar si hay mejoría del grado de dolor provocado por la biopsia prostática (BP) guiada mediante ecosonogranma transrectal utilizando lidocaína instilada transrectal. Estudio prospectivo, randomizado (randomización 2 a 1), doble ciego y controlado, donde se instiló 40 cc de lidocaína viscosa al 2 por ciento o gel lubricante previo a la BP en pacientes con sospecha de cáncer por tacto rectal anormal o PSA por encima de 2,5 ng/ml. Se utilizó la escala visual análoga del dolor (EVAD) de 11 puntos y se interrogó al paciente si se sometería nuevamente al procedimiento sin anestesia o con ella. Ciento sesenta pacientes aptos para el análisis: ciento seis con lidocaína y 54 con gel. El promedio de biopsias realizadas por paciente fue de 13,61. Los grupos no diferían en cuanto a la edad, IPSS previo, volumen prostático, PSA ni número de biopsias realizadas. Los que recibieron lidocaína tuvieron valores promedio de EVAD de 4,44 ± 2,61 mientras que en los que recibieron placebo fue de 5,35 ± 2,54 (p<0,05). Los pacientes menores de 60 años presentaron más dolor; igual que los que tenían síntomas prostáticos moderados y severos. El aumento en el número de punciones no afectó adversamente el grado de dolor. El 79 por ciento de los pacientes (en ambos grupos) aceptaría repetirse la BP del mismo modo en que se le practicó, y un 11 por ciento adicional (también en ambos grupos) permitiría realizarla nuevamente con algún anestésico. La instatalción transrectal de lidocaína viscosa disminuye el dolor producido por la BP guiada por ecosonograma transrectal. Los pacientes menores de 60 años y aquellos con índices de IPSS de 8 o más son más propensos a tener valores de EVAD por la BP más elevados, sugiriendo que en estos pacientes se deben utilizar medidas adicionales (analgesia oral, parenteral o sedación)

Diazepam submicron emulsions containing soya-bean oil and intended for oral or rectal delivery.

Physically stable diazepam submicron emulsions were prepared using soya-bean oil. Diazepam concentration 4 mg/ml, suitable for rectal or oral delivery, was achieved in 20% emulsions. Mixture of egg lecithin (1.2%) and poloxamer (2.0%) has been chosen as the most suitable emulsifying agent. Composition of the emulsion may be supplemented with alpha-tocopherol and parabens. However, the system was not stable when either phenylethanol or chlorhexidine gluconate was added. Taste masking agents commonly used as food additives decreased stability of the preparation and were not efficient in elimination of a bitter taste of the drug-loaded emulsions.

Baixas doses de morfina e fentanil por via subaracnóidea associadas a diclofenaco por via retal para controle da dor pós-operatória em cesarianas / Low doses of subarachnoid morphine and fentanyl combined with rectal diclofenac for postoperative pain control after cesarean delivery

Justificativa e objetivos: este estudo avaliou a eficácia e os efeitos colaterais da combinaçäo de baixas doses de morfina subaracnóidea (10 e 25µg) e diclofenato retal e também as vantagens e desvantagens da adiçäo de 10µg de fentanil subaracnóideo à técnica. Método: cem pacientes submetidas à raquianestesia para cesariana foram alocadas em quatro grupos de 25, os quais receberam, junto com 12,5mg de bupivacaína 0,5 por cento hiperbárica, os seguintes tratamentos: grupo M25, 25µg e morfina; grupo M10, 10µg de morfina; grupo M25+F10, 25µg de morfina e 10µg de fentanil; grupo M10+F10 10µg de morfina e 10µg de fentanil. Todos os grupos receberam 50mg de diclofenaco via retal a cada 6 horas no primeiro dia pós-operatório, iniciando-se sua administraçäo no final da cirurgia. Níveis de dor e efeitos colaterais foram avaliados de hora em hora nas primeiras 6 horas e posteriormente a cada 3 horas nas primeiras 24 horas. Resultados: o número de pacientes que referiram ausência de dor foi maior no grupo M25 quando comparado com os grupos M10 e M10+F10. O número de pacientes que solicitaram analgésico suplementar foi maior no grupo M10, quando comparado com os grupos M25 e M10+F10. A incidência de prurido leve, näo tratado, foi menor no grupo M10, quando comparado com os grupos M25 e M10+F10. Prurido tratado foi mais frequente no grupo M25, quando comparado com os grupos M10 e M10+F10. Conclusöes: a dose de 25µg de morfina subaracnóidea é mais eletiva que a dose de 10µg no controle da dor pós-operatória em cesarianas, quando combinada com diclofenaco por via retal. A adiçäo de fentanil a ambas as doses de morfina näo oferece vantagens clínicas

Behavioural changes and children's memories after intravenous, inhalation and rectal induction of anaesthesia.

Ninety two-to-seven-year-old children admitted for routine day case ENT operations were randomly allocated to have either intravenous thiopentone (group I), halothane inhalation (group II) or rectal methohexitone (group III) for anaesthesia induction. Using a postoperative questionnaire, the parents evaluated the changes in the child's behaviour one day, one week and one month after the operation. Problematic changes were detected in 17 (59%) children in group I, 14 (50%) in group II and 17 (58%) in group III (NS). Although the children in group II behaved most calmly during the induction they had significantly more negative memories of the induction of anaesthesia (six children in group II vs two in group I and one in group III) and of the hospital in general (17 in group II vs 11 in group I and eight in group III) than children in the other groups. Judging from memories of young children, intravenous and rectal inductions are less distressing to them than inhalational induction.

[Rectal administration of anesthetic agents]. / La somministrazione di farmaci anestetici per via rettale.

OBJECTIVES: To collect data in the current literature dealing with the diffusion, the reliability and the effectiveness of the rectal administration of anaesthetic drugs. To evaluate differences with parenteral administration. DATA SOURCES: Pharmacokinetics and clinical studies published in recent years in indexed journals. STUDY SELECTION: Based on the study methodology, drugs employed and pharmacokinetic parameters evaluated. DATA EXTRACTION: Factors involved in absorption of drugs from the rectal mucosa, clinical effect and pharmacokinetic data of the following drugs: diazepam, flunitrazepam, midazolam, ketamin and methohexital, then a brief evaluation of other drugs: thiopental, etomidate, morphine and chloral hydrate. DATA SYNTHESIS: The most widely used drugs are benzodiazepines: they are safe, easy to manage and highly effective; among them midazolam has the best kinetic and dynamic pattern. Ketamin is useful during painful diagnostic procedures; with the use of barbiturates there is a greater risk of respiratory depression and more caution must be employed. CONCLUSIONS: Wide intervariability of rate of absorption, achievement of plasma levels and clinical effect is a relevant drawback of this technique, such to make it not preferable to the parenteral route, when both are feasible. It deserves, anyway, more consideration, and maintains its validity for the preparation of the paediatric patient to general anaesthesia.

Conscious sedation by rectal administration of midazolam or midazolam plus ketamine as alternatives to general anesthesia for dental treatment of uncooperative children.

The trial included 24 children (aged 2-7 yr) referred for dental treatment under general anesthesia, since conventional behavioral management methods had failed to achieve treatment acceptance. As an alternative, they received, on two separate occasions with "identical" dental treatment, conscious sedation by rectal administration of either midazolam (0.3 mg/kg body weight (bwt)) or midazolam (0.3 mg/kg bwt) plus ketamine (1.0 mg/kg bwt). This allowed a double-blind, crossover design. The aims were to assess conscious sedation, combined with local anesthesia, as an alternative to general anesthesia, and further to evaluate the effects obtained by addition of a low dose of ketamine to rectally administered midazolam. The feasibility of dental treatment was rated as excellent or good for 16 of the 24 children when premedicated with midazolam, and for 18 of the 24 children when ketamine was added to midazolam. At least some treatment could be given to all children. Verbal contact was maintained with all children throughout both treatment sessions. The children were significantly less anxious when they arrived for the second session. Amnesia and drowsiness were significantly increased when ketamine was added to midazolam. The combination also tended to be more efficient in relief of anxiety and prevention of pain, but there were large variations in the children's responses to the drugs. Midazolam significantly reduced the blood oxygen level, but not with ketamine added. For most children, both regimens proved to be appropriate as alternatives to general anesthesia.(ABSTRACT TRUNCATED AT 250 WORDS)

Anaesthesia without tears.

Rectal induction of anaesthesia is a useful method but is not widely used in South Africa. We studied the onset of action and side-effects of 1% methohexitone administered rectally in a dose of 20 mg/kg to 110 preschool children. Ninety-one per cent were adequately sedated for inhalation induction by mask within 10 minutes, and all by 15 minutes, of drug administration. There was no evidence of significant cardiovascular or respiratory depression and only minor complications such as faecal soiling (11.8%) and hiccough (3.6%) were noted. The technique has been favourably received by parents, surgeons and nursing staff and has now become routine practice.

Cardiovascular effects of rectal methohexital in children.

STUDY OBJECTIVE: To define the cardiovascular effects of rectal methohexital in children with normal cardiac function. DESIGN: Cardiovascular evaluation of each patient was performed before and after medication. Each patient's predrug results were used as control measurements for comparison with measurements made after methohexital administration. SETTING: Inpatient operating room induction area in a privately endowed philanthropic children's hospital. PATIENTS: Forty-seven children age 35 +/- 22 months (mean +/- SD) scheduled for elective orthopedic or plastic surgery, free of cardiac or pulmonary disease, and receiving no medication with central nervous system activity. INTERVENTIONS: Control measurements of heart rate (HR), blood pressure (BP), and echocardiographic evaluations were obtained on the day before scheduled surgery. Repeat measurements were performed after the onset of methohexital-induced sleep. The time span of the measurements was designed to include the period of peak plasma methohexital concentration. In the preoperative holding area, 30 mg/kg of a 10% methohexital solution was administered rectally. If sleep did not occur in 15 minutes, an additional 15 mg/kg was given. MEASUREMENTS AND MAIN RESULTS: HR increased markedly after rectal methohexital [126 +/- 23 beats per minute (bpm) to 144 +/- 21 bpm, p less than 0.001], and stroke volume (SV) decreased (24 +/- 9 ml to 21 +/- 8 ml, p less than 0.01). There were no significant changes in BP or cardiac index. The shortening fraction and ejection fraction remained within the normal range for this age-group. CONCLUSIONS: Rectal methohexital induces sleep in healthy pediatric patients with minimal cardiovascular side effects. The primary effects are increased HR and decreased SV.

Continuous oxygen saturation monitoring following rectal methohexitone induction in paediatric patients.

Rectal methohexitone has been used to induce anaesthesia in paediatric patients for a number of years. This study was conducted in order to confirm the safety of this method of induction for uncomplicated routine paediatric patients. Children between the ages of six months and six years were considered candidates for induction with methohexitone (10%, 25-30 mg.kg-1). Patients were monitored with a continuous oxygen saturation recording. Forty-nine patients participated in this study and anaesthesia was induced successfully in 44. The mean age of the patients was 2.7 +/- 1.6 yr. The mean weight was 13.8 +/- 4.3 kg and the mean dose of methohexitone for successful induction was 27.0 +/- 3.0 mg.kg-1. Continuous oximeter recordings were available in 31 of the 42 patients who allowed oximeter placement prior to administration of methohexitone. No major desaturation events were noted in any patient. Two brief episodes of desaturation occurred. One with a nadir of 90% which lasted for 45 sec and another with a nadir of 86% which lasted for 26 sec. Both children had their heads flexed over their parents' shoulders at the time of the event resulting in partial airway obstruction. Both of these episodes were the result of upper airway obstruction which was clinically diagnosed by the anesthetist and readily corrected by repositioning the head. This study confirms the efficacy and safety of rectal methohexitone for induction of general anaesthesia in children. Mechanical obstruction of the airway following induction seems to be the most likely cause for oxygen desaturation. Monitoring of pulse oximetry does not appear necessary provided the child is carefully observed for adequacy of air exchange.

Rectal ketamine and midazolam for premedication in pediatric dentistry.

Rectally administered midazolam (0.30 mg/kg) and ketamine (5 mg/kg) were compared for preanesthetic medication in children undergoing dental extractions. Sixty patients between the ages 2 and 9 years were randomly allocated to three groups in this double-blind study. In one group of patients who received ketamine rectally, intravenous midazolam (0.05 mg/kg) also was administered immediately after induction of anesthesia. The results from this trial show that 30 minutes after rectal administration of the two drugs, good anxiolysis, sedation, and cooperation were obtained in most patients. Although midazolam appeared to be marginally more efficacious than ketamine in the majority of assessments made and seemed to have less adverse effects, no statistically significant differences could be shown. Ketamine showed a slight decrease and midazolam a slight increase in average blood pressures after premedication. These blood pressure differences were, however, considered to be of little clinical importance.