Pre-emptive versus post-surgical administration of ketorolac for hysterectomy.

Seventy-seven women who underwent routine vaginal or abdominal hysterectomy were randomly allocated to receive intravenous ketorolac 30 mg either 30 min before surgical incision (pre-emptive group, n = 37), or at the end of the surgical procedure (post-surgical group, n = 40). The patients received routine post-operative care, which included morphine by patient-controlled analgesia, 1 mg per demand with a lockout of 6 min and a background infusion of 1 mg h-1. In addition, pain was assessed at 12 and 24 h using a 100 mm visual analogue scale (VAS), both at rest and on coughing. At 24 h, the median VAS at rest was 24 mm (range 0-80) in the pre-emptive group and 28 mm (range 0-100) in the post-surgical group. The average morphine consumption rate over the first 24 h was 1.9 mg h-1 (SD +/- 0.6) in the pre-emptive group, and 2.2 mg hr-1 (SD +/- 1.1) in the post-surgical group. There were no significant differences on univariate testing. Subsidiary stepwise multiple regression modelling identified age, weight, type of hysterectomy, and the timing of ketorolac administration as significant explanators of post-operative morphine consumption. A statistically significant pre-emptive analgesic effect was therefore identifiable, but the clinical significance is uncertain in relation to the other influences on post-operative analgesic requirements.

Ketorolac for early postoperative analgesia.

STUDY OBJECTIVE: To determine the efficacy and speed of onset of analgesia of a single dose of intravenous (IV) or intramuscular (IM) ketorolac tromethamine following major orthopedic surgery. STUDY DESIGN: Double-blind, randomized, placebo-controlled trial. SETTING: A district general hospital in England. PATIENTS: 112 patients aged 18 to 80 years suffering moderate or severe pain following orthopedic surgery. INTERVENTIONS: Patients were randomized to receive 30 mg ketorolac IV, 30 mg ketorolac IM, or placebo following surgery. MEASUREMENTS AND MAIN RESULTS: Verbal pain intensity scores were performed prior to admission to the study, then frequently for the first 45 minutes following administration of study medication, and subsequently at hourly intervals. Times to request for further analgesia were noted. Patient assessment of overall acceptability and pain relief of the study medication was recorded. There was no statistical difference in speed of onset of analgesia between the ketorolac groups and placebo. Median (range) times to first analgesic following study drugs were: ketorolac IV 45 minutes (9 to 1440 minutes), ketorolac IM 34 minutes (10 to 1440 minutes), placebo 24 minutes (10 to 615 minutes). There was a statistically significant difference between the ketorolac groups and placebo (ketorolac IV vs. placebo, p < 0.01; ketorolac IM vs. placebo, p = 0.03). Patient assessment of overall acceptability and pain relief was significantly better for IV ketorolac compared with placebo (p < 0.01). By 6 hours, 78% of the IV ketorolac group and 95% of the IM ketorolac and placebo groups required further analgesia. CONCLUSIONS: Despite high patient acceptability compared with placebo, the use of ketorolac as the sole analgesic failed to control postoperative pain following major orthopedic surgery. IV administration of ketorolac conferred no advantages over the IM route with regard to efficacy or speed of onset.

Effect of intraoperative inspired gas mixtures on postoperative nocturnal oxygen saturation.

Continuous postoperative nocturnal pulse oximetry was performed in 20 patients undergoing elective cholecystectomy to examine if the composition of anaesthetic gas mixtures affects postoperative gas exchange. The patients were allocated randomly to receive either nitrogen or nitrous oxide during anaesthesia, and oximetry was performed on the night before operation and the first and third nights after operation. Considerable oxygen desaturation was seen in both groups. During the first night after operation the proportion of the night during which oxygen saturation was less than 85% was greater in the nitrogen group than in the nitrous oxide group, but there was no significant difference between the mean overnight saturation values of the two groups.

Profound hypotension following intravenous codeine phosphate. Three case reports and some recommendations.

Three adults are described who developed life-threatening hypotension following intravenous codeine phosphate. It is recommended that codeine phosphate should not be given intravenously to adults.

Metabolic acidosis and fatal myocardial failure after propofol infusion in children: five case reports.

OBJECTIVE: To examine the possible contribution of sedation with propofol in the deaths of children who were intubated and required intensive care. DESIGN: Case note review. SETTING: Three intensive care units. SUBJECTS: Five children with upper respiratory tract infections aged between 4 weeks and 6 years. RESULTS: Four patients had laryngotracheo-bronchitis and one had bronchiolitis. All were sedated with propofol. The clinical course in all five cases was remarkably similar: an increasing metabolic acidosis was associated with brady-arrhythmia and progressive myocardial failure, which did not respond to resuscitative measures. All children developed lipaemic serum after starting propofol. These features are not usually associated with respiratory tract infections. No evidence was found of viral myocarditis, which was considered as a possible cause of death. CONCLUSION: Although the exact cause of death in these children could not be defined, propofol may have been a contributing factor.