Analgesic efficacy of pre-operative etoricoxib for termination of pregnancy in an ambulatory centre.

INTRODUCTION: Etoricoxib is a second generation cyclooxygenase-2 inhibitor with a rapid-onset time and a long duration of action. It is ideal for providing pre-emptive analgesia for ambulatory surgeries. We hypothesised that pre-operative etoricoxib can decrease the use of fentanyl post-operatively, when compared with placebo in patients undergoing termination of pregnancy. We also compared their pain scores, time to discharge, side effects and satisfaction with analgesia post-operatively. METHODS: After approval by the hospital research ethics committee and receipt of informed written consent, we recruited 40 American Society of Anesthesiologists Physical Status Classification I and II patients scheduled for elective first trimester termination of pregnancy. Patients were randomly allocated to receive either oral etoricoxib 120 mg (Group E, n=20) or placebo tablet (Group P, n=20) pre-operatively. A blinded observer evaluated the post-operative pain scores, need for supplementary analgesia, side effects and satisfaction scores. Sample size was calculated (power of 0.8 and alpha=0.05) to detect a 20 percent difference in fentanyl usage. Amount of fentanyl used, pain scores and satisfaction scores were analysed using non-parametric tests. The incidence of side effects was analysed using chi-squared test. RESULTS: Etoricoxib 120 mg significantly decreased the amount of fentanyl required after termination of pregnancy compared to placebo (0 microg/patient, interquartile range [IQR] 0-25 versus 50 microg/patient, IQR 0-50, p-value is less than 0.05). Patients who received etoricoxib 120 mg also had significantly lower pain scores than the placebo group at time of discharge (8 +/- 11 versus 1 +/- 3, p-value is less than 0.05) and at six hours post operation (8 +/- 12 versus 0 +/- 0, p-value is less than 0.01). There was no difference in their side effects, and time to discharge and overall satisfaction were similar in both groups. CONCLUSION: Pre-operative administration of oral etoricoxib 120 mg decreased the use of fentanyl and pain scores after minor gynaecological surgery without significant side effects.

Recombinant factor VIIa after amniotic fluid embolism and disseminated intravascular coagulopathy.

This case report illustrates the successful use of activated recombinant factor VIIa in the management of severe postpartum hemorrhage secondary to amniotic fluid embolism.

[Comparison of preemptive analgesia efficacy between etoricoxib and rofecoxib in ambulatory gynecological surgery].

OBJECTIVE: To compare the preemptive analgesia efficacy between two cycloxygenase-2 inhibitors, rofecoxib and etoricoxib in the ambulatory uterine evacuation patients. METHODS: In this randomized, double-blinded, placebo-controlled trial 60 patients were randomly divided into three groups and received a single dose of placebo, rofecoxib 50 mg, or etoricoxib 120 mg, respectively, before operation. Patient's visual analogue score (VAS) was rated postoperatively at 15 min, 30 min, 60 min, time-to-discharge, 6 h and 24 h. Fentanyl (in post-anesthesia care unit) and paracetamol (at home) were supplementary analgesics and the dosage was also recorded. Patient's satisfaction score was rated at 24 h postoperatively. RESULTS: Etoricoxib 120 mg and rofecoxib 50 mg were significantly superior to placebo at 6 h postoperatively (P < 0.05) while there was no significant differences of VAS at other time points. The amounts of Fentanyl used in post-anesthesia care unit were similar in three groups, but paracetamol taken at home was much less in rofecoxib group and etoricoxib group than in placebo group (P < 0.01). Compared to rofecoxib, etoricoxib provided better pain relief after discharge (P < 0.05). The overall pain management satisfaction score was significantly higher in etoricoxib group (96 +/- 7) than in other groups (P < 0.01). CONCLUSION: Preemptive rofecoxib 50 mg and etoricoxib 120 mg may significantly decrease VAS at 6 h postoperatively, and reduce the usage of analgesics in ambulatory uterine evacuation patients. Etoricoxib 120 mg offeres better pain relief at home compared with rofecoxib 50 mg.

Pulse dye densitometry: a novel bedside monitor of circulating blood volume.

INTRODUCTION: Monitoring of circulating blood volume is important in the management of critically ill patients. Current methods of circulating blood volume measurements such as indicator dilution using radioisotopes or Evans blue dye are unsuitable for clinical application as these tests do not allow for frequent repeated measurements to be done. A direct bedside measurement of circulating blood volume using the principle of pulse dye densitometry was recently introduced. This is essentially an indicator dilution technique using indocyanine green combined with the principle of pulse spectrophotometry. METHODS: This paper aims to review this method of circulating blood volume measurement and provide a summary of the published clinical trials that compared its accuracy with the other conventional methods of circulating blood volume measurement, based on a Medline search, spanning the period 1966 to August 2000. RESULTS: Published studies show that pulse dye densitometry gives comparable results when compared to other conventional methods of blood volume measurement. Its ability to measure circulating blood volume accurately and repeatedly, as frequently as every 20 min makes it suitable for clinical application. CONCLUSION: Pulse dye densitometry provides for a rapid, semi-noninvasive and convenient bedside assessment of circulating blood volume that is applicable clinically. Further studies are needed to ascertain the impact of the use of pulse dye densitometry on the mortality and morbidity of the critically ill.

Neurological complications in obstetric regional anaesthesia.

Neurological complications after obstetric central neural blocks are rare events. Although central neural blockade does cause neurological complications, there must be awareness that neurological deficits may either develop spontaneously (e.g. epidural abscess/haematoma) or as a result of the labour and delivery process (maternal obstetric palsies). We have attempted to review as completely as possible the published survey and case reports in the English literature on neurological complications of obstetric regional blockade obtained from Medline spanning the period 1966 to November 1998. We also performed cross-checking of our references to find important missing articles, e.g. papers published in journals not included in Index Medicus at the time of publication, such as the International Journal of Obstetric Anesthesia. We wish to provide some insight to the incidences, pathophysiology, clinical features, investigations, treatment and prognosis of these complications. Maternal obstetric palsies and case reports of spontaneous epidural abscess/haematoma are also discussed. It is often difficult, if not impossible, to determine the exact aetiology, but unfortunately for the anaesthetists, regional blockade is usually incriminated till proven otherwise. Although we cannot eliminate the occurrence of neurological complications completely, preventive measures can still be taken to decrease their incidence (e.g. aseptic technique). There must also be regular monitoring after neural blockade for the development of neurological complications. Early diagnosis and prompt appropriate treatment will usually lead to complete resolution of the neurological deficit even in cases of epidural haematoma/abscess.

Cauda equina syndrome after spinal anaesthesia with hyperbaric 5% lignocaine: a review of six cases of cauda equina syndrome reported to the Swedish Pharmaceutical Insurance 1993-1997.

Six cases of cauda equina syndrome with varying severity were reported to the Swedish Pharmaceutical Insurance during the period 1993-1997. All were associated with spinal anaesthesia using hyperbaric 5% lignocaine. Five cases had single-shot spinal anaesthesia and one had a repeat spinal anaesthetic due to inadequate block. The dose of hyperbaric 5% lignocaine administered ranged from 60 to 120 mg. Three of the cases were most likely caused by direct neurotoxicity of hyperbaric 5% lignocaine. In the other 3 cases, direct neurotoxicity was also probable, but unfortunately radiological investigations were not done to definitely exclude a compressive aetiology. All cases sustained permanent neurological deficits. We recommend that hyperbaric lignocaine should be administered in concentrations not greater than 2% and at a total dose preferably not exceeding 60 mg.

Sedation for the conduct of lumbar epidural anaesthesia: a study using subanaesthetic dose of ketamine in combination with midazolam.

We gave sedation for the conduct of lumbar epidural analgesia using intravenous ketamine 0.3 mg.kg-1 with intravenous midazolam 2 mg. Forty adult Chinese females undergoing major gynaecological laparotomies had epidural catheter inserted before general anaesthesia, 20 of whom were given ketamine and midazolam (study group) and the other 20 acted as control. During the conduct of the epidural, the pain and anxiety scores in the study group were significantly less than the control group (P < 0.05). Patients were significantly more sedated in the study group (P < 0.05). All the patients in the study group were satisfied and would consent to future epidural versus 75% in the control group (significant at P < 0.05). Ninety per cent of patients in the study group had amnesia but none in the control group. Pain experienced during the epidural was the reason for refusal of future epidural. We did not observe any emergence phenomenon or cardiovascular stimulation. There was a statistically significant decrease in the pulse oximetry oxygen saturation (SpO2) in the study group but none required oxygen supplementation. We concluded that pain caused by the conduct of epidural did decrease the patient's acceptance rate to future epidural, and the combined use of intravenous ketamine 0.3 mg.kg-1 and midazolam 2 mg provided adequate sedation, analgesia, anxiolysis and amnesia to significantly increase the acceptance rate without any significant side effects.

Monoplegia following obstetric epidural anaesthesia.

We describe a case of transitory monoplegia following obstetric epidural anaesthesia which we believe to be either due to direct trauma to the nerve roots or radicular artery spasm resulting in spinal cord ischaemia both secondary to the epidural catheter. An obstetric epidural was performed on a 34-year-old lady with no significant past medical history. Transient radicular pain down her left leg was experienced during the insertion of the catheter. She had unilateral block on her left side which could not be rectified despite injecting local anaesthetics in the right lateral position, resiting the epidural catheter, and administering a total dose of 6 ml of 1.5% plain lignocaine and 19 ml of 0.25% plain bupivacaine. There was no hypotension, and no vasoconstrictor was used epidurally. She still had left-sided numbness and weakness 9 hours after removal of the catheter, but without urinary or bowel dysfunction. A magnetic resonance imaging scan excluded any space occupying lesion. She was managed conservatively and had complete recovery 35 hours after the last dose of local anaesthetics.

Combination of suppository diclofenac and intravenous morphine infusion in post-caesarean section pain relief--a step towards balanced analgesia?

UNLABELLED: Post-Caesarean section analgesia can be achieved by morphine infusion. NSAIDs are frequently administered to relieve uterine cramps. This study is aimed at assessing the efficacy of the combination of suppository diclofenac and morphine infusion in post-Caesarean section pain relief. General anaesthesia was given to 60 patients who were randomly allocated into two groups: group A received 100 mg suppository diclofenac before surgical incision and morphine infusion 1.5 mg per hour postoperatively while group B received only morphine infusion 1.5 mg/H postoperatively. Pain assessment was done by an unbiased observer on arrival of the patients in the recovery room, then 6 hours, 12 hours and 24 hours later. Pain relief was found to be better in group A, with group B requiring more supplemental analgesia. Apart from better analgesic effect for wound pain, group A also had more favourable scores for uterine cramping pain. The incidence of nausea or vomiting was similar in both groups. No respiratory depression was observed in both groups. Two cases of increased bleeding (one from each group) were observed, both receiving conservative treatment. THE CONCLUSION: suppository diclofenac improved the analgesic efficacy of morphine infusion in post-Caesarean analgesia.

A comparison of antiemetic efficacy of droperidol alone and in combination with metoclopramide in day surgery anaesthesia.

We have studied the antiemetic efficacy of droperidol alone, and in combination with metoclopramide in first trimester termination of pregnancy in day surgery. The aim was to determine whether the addition of metoclopramide could further reduce the incidence of postoperative nausea and vomiting (PONV) but avoid excessive sedation. Group I (control, n = 40) received i.v. droperidol 0.625 mg at induction. Group II (study, n = 40) received i.v. droperidol 0.625 mg and i.v. metoclopramide 10 mg at induction. The incidence of nausea at 1 and 2 hours postoperatively was 23% and 10% in group I, and 5% and nil in group II respectively. The difference in the incidence of nausea was significant at p < 0.05 at one hour but not at two hours postoperatively. No patients vomited. There was no difference in the sedation and pain score between them. We did not observe any significant side effects attributable to either drug. All patients were discharged home within 3 hours. We conclude that in the prevention of PONV, the combination of metoclopramide and droperidol is superior to the use of droperidol alone at one hour but not at two hours postoperatively.