Comparison of the relative analgesic efficacies of epidural or intramuscular diamorphine following total knee arthroplasty.

BACKGROUND AND OBJECTIVES: Debate has proliferated as to the true site of action of opioids when placed in the epidural space. The aim of this study was to compare the analgesic effects of a bolus of diamorphine given by the epidural or intramuscular route. METHODS: Sixty patients having elective primary total knee replacements were recruited and randomized to receive epidural or intramuscular diamorphine. A lumbar epidural catheter was sited and 10 mL of bupivacaine 0.5% wt vol-1 was injected. Patients subsequently received diamorphine 5 mg into the epidural space or as an intramuscular injection. Patient-controlled analgesia with intravenous morphine was used for postoperative analgesia. The primary outcome measures included time to first patient-controlled analgesia use and total morphine consumption in 24 h. Secondary end-points considered possible treatment complications. RESULTS: All primary end-points showed significant differences in favour of epidural diamorphine. Medians for times to first patient-controlled analgesia use and total 24 h morphine requirements were significantly different (P < 0.001) at 418 vs. 198 min and 11 vs. 39 mg, respectively. There were no significant differences in secondary end-points. CONCLUSIONS: This study has shown the superior analgesic efficacy of epidural diamorphine when compared to intramuscular injection.

Use of W-plasty in stenotic stoma: a new solution for an old problem.

INDICATION: Amongst late complications of stomas, stenosis can be difficult to treat. Repeated dilatations rarely achieve long-term resolution and re-fashioning is not always successful. Application of an existing plastic surgical technique to treat stomal stenosis is described. METHOD: After marking the skin, a W-plasty is made with a number of consecutive small triangular flaps through the skin. The corresponding mucosal margin is then made to interdigitate with this configuration and fixed using a Gillies corner stich with 5/0 Vycril rapide on a compound curved needle. RESULTS: Five patients underwent W-plasty reconstruction for a stenotic stoma. Median follow up was 12.5 months (range 11-15). No patient had stenosis of the stoma on review and the patient satisfaction rate was high. CONCLUSION: The W-plasty technique is a new treatment for stenotic stoma.

A comparison of cyclizine, ondansetron and placebo as prophylaxis against postoperative nausea and vomiting in children.

Nausea and vomiting is a relevant and common problem with unfavourable sequelae in children undergoing some plastic surgery procedures. There is a lack of anti-emetic trials performed in children, with only a few investigating the roles of the older anti-emetic agents such as cyclizine compared with newer ones such as ondansetron. This randomised, controlled, double-blind study examined the effectiveness of a single dose of ondansetron (0.1 mg x kg-1), cyclizine (20 mg) and placebo (normal saline) in the prevention of postoperative nausea and vomiting in 150 children (mean age 3.6 years) undergoing plastic genitourinary procedures. Rates of previous postoperative nausea and vomiting and motion sickness were comparable across the groups. Postoperative vomiting was significantly reduced with ondansetron prophylaxis (p = 0.006) but there was no detectable anti-emetic effect with cyclizine. Furthermore, cyclizine caused pain on injection (p < 0.001).