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As pain in the intensive care unit (ICU) is still common despite important progress in pain management, we studied the efficacy of an intravenous bolus of morphine 2.5 vs 7.5 mg for procedural pain relief in patients after cardiothoracic surgery in the ICU. In a prospective double-blind randomised study, 117 ICU patients after cardiothoracic surgery were included. All patients were treated according a pain titration protocol for pain at rest, consisting of continuous morphine infusions and paracetamol, applied during the entire ICU stay. On the first postoperative day, patients were randomised to intravenous morphine 2.5 (n=59) or 7.5 mg (n=58) 30 minutes before a painful intervention (turning of patient and/or chest drain removal). Pain scores using the numeric rating scale (Numeric Rating Scale, range 0 to 10) were rated at rest (baseline) and around the painful procedure. At rest (baseline), overall incidence of unacceptable pain (Numeric Rating Scale ≥4) was low (Numeric Rating Scale >4; 14 vs 17%, P=0.81) for patients allocated to morphine 2.5 and 7.5 mg respectively. For procedure-related pain, there was no difference in incidence of unacceptable pain (28 vs 22%, P=0.53) mean pain scores (2.6 [95% confidence interval 2.0 to 3.2] vs 2.7 [95% confidence interval 2.0 to 3.4]) between patients receiving morphine 2.5 and 7.5 mg respectively. In intensive care patients after cardiothoracic surgery with low pain levels for pain at rest, there was no difference in efficacy between intravenous morphine 2.5 mg or morphine 7.5 mg for pain relief during a painful intervention. [ABSTRACT FROM AUTHOR]

A volunteer study suggested that taking paracetamol 4 g daily could result in elevated alanine aminotransferase plasma levels in a substantial proportion of healthy volunteers. The safety of this dose of paracetamol for acute postoperative pain remains controversial. This study aimed to examine the incidence of alanine aminotransferase elevations after short-term use of paracetamol 4 g daily, as part of the standard pain management protocol, for 93 consecutive patients after cardiothoracic surgery. Alanine aminotransferase levels and other liver function tests were measured preoperatively as baseline and once daily after surgery during the intensive care unit stay. Preoperative alanine aminotransferase levels of more than one time the upper limit of normal (ULN >40 U/l) was observed in 11% (n=10) of the patients but none of these baseline alanine aminotransferase levels exceeded three times the ULN (>3 x ULN). The average daily dose of paracetamol administered was 50 mg/kg (SD=16) after surgery. Postoperative alanine aminotransferase levels of >1 x ULN was observed in 17% (n=16), and 4% (n=4) exceeded >3 x ULN The other liver function tests of the latter four patients, including aspartate aminotransferase (range 173 to 5590 U/l), gamma-glutamyltransferase (range 56 to 103 U/l), lactate dehydrogenase (range 376 to 3518 U/l) and the International Normalised Ratio (range 2.0 to 6.6), were all abnormal. These four patients all had right ventricular failure or cardiogenic shock during the postoperative period which could explain the significant rises in alanine aminotransferase after surgery. In conclusion, the incidence of significant alanine aminotransferase elevations after using daily paracetamol as an analgesic agent for cardiac surgery, at a dose of 4 g per day, was low and mostly due to complications after surgery. Our results, albeit still very limited, provided some reassurance about the safety of paracetamol 4 g daily, as a supplementary analgesic agent for adult patients undergoing cardiac surgery. [ABSTRACT FROM AUTHOR]