Preventive effects of perioperative parecoxib on post-discectomy pain.

BACKGROUND: Cyclooxygenase inhibitor treatment is viewed increasingly critical because of safety considerations, and there are several open questions on their optimal use. METHODS: In a randomized placebo-controlled study in 320 patients undergoing discectomy, we administered parecoxib 40 mg either perioperatively (before operation and after operation), after operation (first dose given in the evening after surgery), or before operation (single parecoxib dose given 45 min before surgery). We measured the main outcome variables: average pain score, morphine consumption, and opioid-related symptom distress at 25, 49, and 73 h after surgery. RESULTS: Perioperative parecoxib significantly (i) improved the pain score compared with both placebo and postoperative parecoxib, (ii) decreased morphine consumption, and (iii) reduced the opioid-related symptom distress score. Neither a single preoperative dose nor postoperative parecoxib (first dose given in the evening after surgery) significantly improved morphine's analgesic effectiveness. CONCLUSIONS: Perioperative parecoxib compared with postoperative parecoxib improves post-discectomy pain and results in a reduction in adverse effects associated with opioid therapy. Postoperative parecoxib, or a single pre-incisional parecoxib dose, does not significantly improve post-discectomy pain or opioid side-effects up to 3 days after surgery.

[Cardiotoxic and neurotoxic effects after accidental intravascular bupivacaine administration. Therapy with lidocaine propofol and lipid emulsion]. / Kardio- und neurotoxische Nebenwirkungen nach akzidenteller intravasaler Bupivacainapplikation. Therapie mit Lidocain, Propofol und Lipidemulsion.

Accidental intravascular administration of bupivacaine can cause severe neurotoxic and cardiotoxic effects. We report a case of suspected bupivacaine intoxication due to intravascular injection via an epidural catheter and treatment with lidocaine, propofol, and a 20% lipid emulsion resulting in fast resolution of cardiotoxic and neurotoxic effects. Possible mechanisms of action of the medications used are discussed.

Does perioperative administration of rofecoxib improve analgesia after spine, breast and orthopaedic surgery?

BACKGROUND AND OBJECTIVE: Data on the effectiveness of cyclooxygenase 2 inhibitors in postoperative pain therapy vary widely. We tested in a prospective, placebo-controlled, randomized, double-blind trial the hypotheses that perioperative (i.e. preoperative and postoperative) administration of the cyclooxygenase 2 inhibitor rofecoxib decreases pain scores and morphine consumption after spine, breast and orthopaedic surgery. METHODS: Five hundred and forty patients scheduled for spine, breast or orthopaedic surgery were randomly assigned to receive in combination with postoperative morphine via patient controlled analgesia pump for 4 days either rofecoxib 50 mg administered perioperatively, rofecoxib 50 mg administered only postoperatively, or placebo. Primary outcome criteria were pain score at rest (numeric rating scale 0-4) and morphine consumption. RESULTS: Perioperative rofecoxib significantly decreased pain score 0 (0-1) vs. 1 (0-2) (median (interquartile range)), and morphine consumption 18 (6-33) vs. 22.5 (12-38) compared with placebo. In contrast, rofecoxib when administered only postoperatively did not significantly improve analgesic effects or side-effects at time of assessment of the main criteria (24 h after skin closure), but during the follow-up period at 48 h and 72 h after skin closure pain scores and morphine consumption were improved compared to placebo. The analgesic effects of rofecoxib were independent from the type of surgery. CONCLUSIONS: Perioperative administration of the cyclooxygenase 2 inhibitor rofecoxib decreases pain scores and morphine consumption after orthopaedic, breast and spine surgery. However, the benefit of preoperative administration of the cyclooxygenase 2 inhibitor seems to be only moderate, suggesting that early postoperative administration may be a useful alternative approach. There is no evidence that the type of surgery influences analgesic effects of cyclooxygenase 2 inhibitors.