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OBJECTIVE Opioid-minimizing or nonopioid therapy using nonsteroidal antiinflammatory drugs (NSAIDs) or tramadol has been encouraged for pain management. This study aimed to examine the noninferiority of NSAIDs to tramadol for pain management following transsphenoidal surgery for pituitary adenomas in terms of analgesic efficacy, adverse events, and rescue opioid use. METHODS This was a randomized, single-center, double-blind noninferiority trial. Patients 18–70 years old with planned transsphenoidal surgery for pituitary adenomas were randomly assigned (in a 1-to-1 ratio) to receive NSAIDs (parecoxib injection and subsequent loxoprofen tablets) or tramadol (tramadol injection and subsequent tramadol tablets). The primary outcome was pain score assessed by a visual analog scale (VAS) for 24 hours following surgery; the secondary outcomes were VAS scores for 48 and 72 hours. Other prespecified outcomes included nausea, vomiting, dizziness, upset stomach, skin rash, peptic ulcer, gastrointestinal bleeding, and pethidine use to control breakthrough pain. Noninferiority of NSAIDs to tramadol was established if the upper limit of the 95% confidence interval (CI) of the VAS score difference was < 1 point and the rate difference of adverse events and pethidine use < 5%. The superiority of NSAIDs was assessed when noninferiority was verified. All analyses were performed on an intention-to-treat basis. RESULTS Two hundred two patients were enrolled between November 1, 2020, and May 31, 2021 (101 in the NSAIDs group, 101 in the tramadol group). Baseline characteristics between groups were well balanced. Mean VAS scores for 24 hours following transsphenoidal surgery were 2.6 ± 1.8 in the NSAIDs group and 3.5 ± 2.1 in the tramadol group (−0.9 difference, 95% CI −1.5 to −0.4; p value for noninferiority < 0.001, p value for superiority < 0.001). Noninferiority and superiority were also achieved for both secondary outcomes. VAS scores improved over time in both groups. Incidences of nausea (39.6% vs 61.4%, p = 0.002), vomiting (3.0% vs 42.6%, p < 0.001), and dizziness (12.9% vs 47.5%, p < 0.001) were significantly lower, while incidence of upset stomach (9.9% vs 2.0%, p = 0.017) was slightly higher in the NSAIDs group compared with the tramadol group. The percentage of opioid use was 4.0% in the NSAIDs group and 15.8% in the tramadol group (−11.8% difference, 95% CI −19.9% to −3.7%; p value for noninferiority < 0.001, p value for superiority = 0.005). CONCLUSIONS NSAIDs significantly reduced acute pain following transsphenoidal surgery, caused few adverse events, and limited opioid use compared with tramadol.

Background: Visceral and shoulder painare among the most frequent reported pain after laparoscopic cholecystectomy (LC). Objectives: To investigate the effectiveness and clinical value of rectal indomecthacin and intraperitoneal lidocaine for treating pain after laparoscopic cholecystectomy. Patients and methods: In Qena university hospital, this prospective randomized comparative study was conducted, 80 patients were scheduled to elective laparoscopic cholecystectomy. Group intraperitoneal"IP" lidocaine (40 patients) received 200 ml saline containing 200 mg 2%lidocaine immediately after pneumoperitoneum, the total solution was sprayed on the upper surface of the liver, right subdiaphragmatic space and around the cholecystectomy site. Group indomethacin (40 patients) received two 100 mg indomethacin rectal suppositories 2 hours prior to surgery. Results: VAS score was significantly lower in indomethacine group ( p value =0.03)over the 24 hours postoperative . The postoperative pethidine requirements were significant lower in group indomethacin mean (34±11.4 mg). Postoperative nausea and vomiting were less in group indomethacin with no statistically significant difference. Conclusion: preoperative rectal indomethacin suppositories decrease postoperative pain scores and analgesics requirements without producing side effects comparing to IP lidocaine in LC. Clinical trail .gov . ID:NCT04964180

Background: Abdominoplasty is a popular aesthetic procedure. Both patients and doctors are concerned about post-operative pain and discomfort. erector spinae plane block (ESP) with ultrasound guidance (UG) was an excellent analgesic technique in bariatric surgery. Objectives; to evaluate the intensity and duration of analgesia (ESP) technique to that provided by the transversus abdominis plane (TAP) technique were done bilaterally with (UG) post abdominoplasty. Study Design; A single-blinded, clinical, prospective, randomized study. Patients and Methods; 51 patients received bilateral (UG) block: (ESP) group (n = 25), and (TAP) group (n = 26), Using the same dosage and volume of local anesthetics. Pain intensity using VAS score at first 30 minutes, and then at 2, 4, 6, 8, 12, 16, 20, and 24 hours postoperatively, IV boluses of pethidine (rescue analgesic) were administrated if VAS ≥ 4, The primary outcome considered as the duration of effective analgesia for each block. While the Secondary outcome measured the over-all pethidine usage, patient satisfaction and the incidence of harmful effects from the techniques. RESULTS; VAS score in the ESP group was significantly lower at 8hrs and 12hrs. There was significant prolonged time to the first analgesic dose in ESP group (9.16±1.07 hours) than TAP group (7.65±0.75 hours). Also, a significant reduction in to the overall pethidine intake in 24 hours (110.40±12.74mg.) in the ESP group. Conclusion: Especially in comparison to the TAP block, the ESP block enables more reliable alleviation of pain, longer analgesic period, extends the time to initial analgesic requirements, reduces pethidine usage.

Background: Hypotension is a very common consequence of the sympathetic vasomotor block caused by spinal anesthesia for caesarean section. Maternal symptoms such as nausea, vomiting and dyspnea frequently accompany severe hypotension, and adverse effects on the fetus, including depressed Apgar scores and umbilical acidosis, have been correlated with severity and duration of hypotension. Aim: To investigate the effect of Ondansetron use on the prevention of hypotension and the amount of vasopressor needed to control the hypotension after spinal anesthesia. Methods: This is a prospective double blind, randomized trial carried out in Obstetric Operation room of Baghdad Teaching Hospital, Medical city, Iraq from November, 2018 to August, 2019. Total number of 128 women assessed for eligibility and only 87 were included and allocated into 2 groups. The Ondansetron group (45 women) received 6 mg Ondansetron IV e min before induction of spinal anesthesia. The Placebo group received 3 ml normal saline as placebo before induction. The number of rescue drugs (vasopressors, antiemetic, anti-shivering), vital signs and side effects were recorded each 3 minutes from baseline to 45th minute. Results: The incidence of hypotension, nausea, vomiting and the need for vasopressors and metoclopramide were significantly lower in Ondansetron group than placebo group (p = 0.001, 0.02, 0.003, < 0.001, and 0.001, respectively). Shivering and the need of pethidine for treating this side effect was non significantly lower in ondansetron group than placebo group. Conclusions: The preoperative administration of Ondansetron in cesarean section reduces the risk of spinal anesthesia-induced hypotension, prevents the nausea and vomiting attacks and decreases the need to vasopressors and metoclopramide. Keywords: Spinal anesthesia, caesarian section, ondansetron, hypotension

Introduction Transversus abdominis plane (TAP) block is a simple and effective technique of providing analgesia for lower abdominal surgeries with easily identifiable landmarks. This study investigated the postoperative analgesic efficacy of bilateral ultrasound-guided transversus abdominis plane blocks, in patients undergoing caesarean delivery at Paropakar Maternity and Women's Hospital, Kathmandu, Nepal. Methods Seventy-four patients undergoing caesarean section under spinal anesthesia were randomized to receive TAP block with bupivacaine (n =37) versus no TAP group (n =37), in addition to analgesia with intravenous paracetamol 1gram 6 hourly. At the end of the surgery, an ultrasound-guided TAP block was given bilaterally using 0.25% bupivacaine or no TAP block. Each patient was assessed postoperatively at regular intervals up to 24 hours for numerical pain rating scale and requirement of pethidine. SPSS version 20.0 software was used. Demographic data were analyzed using Student’s t-test and Mann–Whitney U-test. Results The TAP block with bupivacaine compared with no TAP group reduced the postoperative numerical pain rating scale. The time to first analgesic demand time was shorter in the control group (79.05±26.99) minutes compared to the bupivacaine group (416.75±87.29) minutes (P

Aims: Postoperative shivering is unpleasant and annoying for the patient, occurring in up to 65% of cases undergoing general anesthesia. Various mechanisms were suggested for postoperative shivering. Shivering after anesthesia can cause complications, such as cardiovascular conditions, bleeding, and infection. This study compared the effects of dexamethasone, pethidine, and ketamine on the prevention of shivering after general anesthesia. Methods & Materials: In total, 164 patients with ASA classes one and two in the age range of 20-60 years under general anesthesia with orthopedic surgery, urology, and general surgery were included in the study. This study was a double-blind, randomized, placebo-controlled study. The study patients were divided into 4 groups of 41 subjects. After the induction of anesthesia and before surgery, in the first group, dexamethasone 0.15 mg/kg body weight, in the second group, ketamine 0.5 mg/kg, in the third group, pethidine 0.5 mg/kg, and in the fourth group, normal saline 0.9% were all given in 2 cc volume. After surgery, the examined patients were monitored for visible shivering by the researcher. The obtained data were analyzed using SPSS. Findings: The frequency and severity of shivering were lower in the dexamethasone (P=0.009), pethidine (P=0.004), and the ketamine (P=0.000) groups, compared to the control group. Besides, there was a significant difference between each of these 3 groups and the controls. The frequency and severity of shivering in the dexamethasone group were not significantly different from those of the pethidine group (P=0.565). The frequency and severity of shivering in the dexamethasone and ketamine groups were not statistically significant (P=0.071). The frequency and severity of shivering in the pethidine group with ketamine were not statistically significant (P=0.063). Conclusion: The obtained results indicated that dexamethasone, pethidine, and ketamine were effective in preventing postoperative shivering. There was no difference between these medications in the prevention of postoperative shivering.

Background: Cesarean delivery is a frequently obstetric operation in Egypt with a recently reported over all cesarean section rate of 54% and it causes moderate to severe postoperative discomfort. Infiltration of the wound site is a method to improve postoperative analgesia. The aim of the work: To compare the pain relief effects of ketamine versus dexmedetomidine combined to bupivacaine in local wound infiltration in patients underwent cesarean section and to estimate side effects of medications. Patients and Methods: This randomized, controlled study including 90 women were subjected for elective cesarean delivery under general anesthesia and were divided at random into 3 equal groups to receive 40 ml bupivacaine (0.25%) + either 2 mg/kg ketamine in (group A), 2 μg/kg dexmedetomidine in (group B) or 2 ml saline in (group C) via local wound infiltration. The primary outcome was time of the first analgesia requested. The secondary outcomes were total dose of analgesia per 24 hours, Visual analogue scale, time of starting movement, breast-feeding, passing flatus or stool, start of eating and adverse effects of medications. Results: A significant increase in time of the first analgesic request in group A (8.4 ±1.91) h. and group B (7.5±1.81) h. than group C (4.3±1.24) h. A significant decrease in pethidine consumption in group A (59 ± 28.93 mg) than group B (72 ± 23.1 mg) and group C (102 ±16 mg). The visual analogue scale (VAS) was significantly lower (p

Background: Pain caused by propofol injection is a common occurrence. Aims and Objectives: The aim of this study was to compare and evaluate the efficacy of three drugs, lignocaine, pethidine and ketamine for prevention of pain during propofol injection. Materials and Methods: This double blind, placebo-controlled, parallel multi-arm study was done after written informed consent and ethics clearance. Hundred patients of ASA I and II, 18-65 years of age, and with body mass index 18-30 kg/m2 were included. Exclusion criteria were significant cardiovascular or hepatic diseases, renal insufficiency, and a history of allergy to the study drugs. Group A (Normal Saline), Group B (Ketamine 25 mg), Group C (Lignocaine 20 mg) and Group D (Pethidine 25 mg) were pre-treated with 2 ml of the study agents before propofol injection. The primary outcome was the incidence of pain with propofol injection and the secondary outcomes were the induction time, pain scores at various time intervals, the incidence of recall of pain after surgery, haemodynamic changes and adverse effects. Results: There were highly significant differences (p

Background: Laparoscopic sleeve gastrectomy is the gold standard option for the management of morbid obesity, it is a less invasive procedure with better cosmetic results and shorter operative time and hospital stay. Moreover, the current body of evidence shows that laparoscopic interventions are generally associated with less post-operative pain and analgesic requirements. Aim of Study: To compare the efficacy and safety of intraperitoneal levobupivacaine, and/or magnesium sulphate in different combinations for post-operative pain relief in patients undergoing laparoscopic sleeve gastrectomy. Methods: This is double blind prospective randomized clinical trial set at Ain Shams University Hospitals over a period of 7 months from February to September 2020 on 60 patients who were scheduled to undergo laparoscopic sleeve gastrectomy at Ain Shams University Hospitals. 60 patients were divided into three groups: Group A included patients received intraperitoneal instillation of 30ml of 0.25% Lev-obupivacaine alone, group B included patients received intra-peritoneal instillation of 30ml Magnesium Sulphate 10% alone and Group C included patients received intraperitoneal instil-lation of 15ml Magnesium Sulfate 10% plus 15ml of 0.25% Levobupivacaine to a total volume of 30ml. Results: The average Time to 1st dose of post-operative analgesia demand was also the longest in LevMg group compared to Mg group and Lev group (8.75±4.51 hours compared to 1.40±0.50 hours and 4.95±1.76 hours respectively) which was also highly significant. When total analgesia consumption in 24 hours was analysed, LevMg group had 35.00±26.66mg, Mg group had 136.50±19.27mg and Lev group 87.00±33.73 mg of Pethidine consumption which was highly significant Bupivacaine group had mild tomoderate pain and most of the patients in bupivacaineplus magnesium sulphate group had mild pain in first 24 hours of surgery. Conclusion: Intraperitoneal combination of levobuivacaine and maghnesium sulphate is more effective than levobupiavacaine or maghnesium sulphae alone for post-operative pain after laparscopic sleeve gastrectomy.

Spinal anaesthesia is a safe and efficient procedure for regional anaesthesia, Shivering is a prevalent side effect of spinal anaesthesia. Ondansetron, a 5-HT3 receptor blocker, should be used to treat and avoid shivering after spinal anaesthesia. The aim of this study was to decide if a weight-adjusted dose of ondansetron is superior to a fixed-dose in preventing shivering following spinal anaesthesia for caesarean delivery. While secondary objectives included determining the prevalence of ondansetron and pethidine adverse reactions. Patients and methods; This was a prospective, randomised, double-blinded, controlled clinical trial involving 129 people, Three equal groups of women were randomly assigned. 1st. received a fixed dose of ondansetron (4mg), 2nd. received ondansetron at a weight controlled dose of 0.1mg/kg, and 3rd. received 0.5 mg/kg pethidine after spinal anaesthesia. the incidence and severity of shivering were measured, as well as the incidence of headache, pruritus, nausea, and vomiting perioperatively were studied. Results; Shivering was observed in 13 patients (30.2 %) in the first group (FDO), 11 patients (25.6 %) in the second group (WAO), and 11 patients (25.6 %) in the third group (PC), but no significant difference between the groups was observed (p-value˃ 0.05). Shivering was more severe (grade II) in the first group (FDO) 5 patients (11.6 %) than in the second group (WAO) 3 patients (6.9 %). Conclusions: A weight-adjusted dosage of 0.1 mg/kg significantly decreased the rate and severity of postspinal shivering while causing less adverse effects and improving hemodynamic stability.

Objective: This study is aimed to compare the analgesic effect and safety of preoperative (versus postoperative) meloxicam administration in femoroacetabular impingement (FAI) patients who underwent hip arthroscopy (HA). Methods: Totally, 136 FAI patients who scheduled for HA were recruited, then they were randomly assigned to preoperative administration (PREA) group (orally meloxicam 7.5 mg in 12h, 24h before operation, then orally 7.5 mg/d from 12h to Day 7 after operation; N=68) or postoperative administration (POSA) group (orally meloxicam 7.5 mg/d from 12h to Day 7 after operation; N=68) in 1:1 ratio. Furthermore, pain visual analog scale (VAS) score, patient satisfaction score, Harris hip score (HHS) and adverse events were assessed. Besides, the accumulated pethidine consumption for rescuing analgesia was calculated. Results: Acute pain VAS score at rest (Day1 – Day2) and pain VAS score at motion (Day1 – Day3) were decreased, meanwhile short-term patient satisfaction score (Day1–Day3) was increased in PREA group compared with POSA group; however, these scores in long-term period were of no difference between PREA group and POSA group (Day3–Month3). Furthermore, accumulated pethidine consumption on Day3 and Day7 were attenuated in PREA group compared with POSA group. Additionally, HHS at any assessed time points (Day7–Month3) did not differ between two groups. Besides, no difference in the incidence of adverse events was found between two groups. Conclusions: Preoperative meloxicam administration displays superior efficacy in short-term pain control, patient satisfaction improvement and attenuated consumption of rescue analgesia over postoperative meloxicam administration in FAI patients who underwent HA., Цель: это исследование было направлено на сравнение обезболивающего эффекта и безопасности предоперационного и послеоперационного введения мелоксикама у пациентов с фемороацетабулярным импиджментом (FAI), перенесших операцию артроскопии тазобедренного сустава (HA). Методы: всего было набрано 136 пациентов FAI, которым назначена HA, затем они были случайным образом распределены в группу предоперационного введения (PREA) (мелоксикам перорально 7,5 мг за 12 часов, за 24 часа до операции, затем перорально 7,5 мг/день с 12 часов до 7 дней после операции; N = 68) или группу послеоперационного введения (POSA) (мелоксикам перорально 7,5 мг/сут с 12 часов до 7 дней после операции; N = 68) в соотношении 1: 1. Кроме того, проводилась оценка боли по визуальной аналоговой шкале (ВАШ), оценка удовлетворенности пациентов, оценка тазобедренного сустава Харриса (HHS) и побочные эффекты. Также было рассчитано накопленное потребление петидина для снятия анальгезии. Результаты: оценка острой боли по ВАШ в покое (Day 1 – Day 2) и оценка боли по ВАШ при движении (Day 1 – Day 3) были уменьшены, в то время как краткосрочная оценка удовлетворенности пациентов (Day 1 – Day 3) была увеличена в группе PREA по сравнению с группой POSA; однако эти оценки в отдаленном периоде не различались между группой PREA и группой POSA (Day 3 – Month 3). Кроме того, накопленное потребление петидина на 3-й и 7-й день было снижено в группе PREA по сравнению с группой POSA. Также, HHS в любые оцененные временные точки (Day 7 – Month 3) не различались между двумя группами. Кроме того, не было обнаружено различий в частоте нежелательных явлений между двумя группами. Заключение. Предоперационное введение мелоксикама демонстрирует более высокую эффективность в краткосрочном купировании боли, улучшении удовлетворенности пациентов и меньшем потреблении спасательной анальгезии по сравнению с послеоперационным введением мелоксикама у пациентов с FAI, перенесших HA., Завдання: це дослідження мало на меті порівняти знеболюючий ефект і безпеку передопераційного та післяопераційного введення мелоксикаму у пацієнтів з фемороацетабулярним ураженням (FAI), які перенесли операцію з артроскопії кульшового суглоба (HA). Методи: загалом було набрано 136 хворих на FAI, яким запланували HA, потім їх випадковим чином розподілили до групи передопераційного введення (PREA) (перорально мелоксикам 7,5 мг за 12 годин, 24 години до операції, потім перорально 7,5 мг/добу з 12 годин до дня 7 після операції; N = 68) або групи післяопераційного введення (POSA) (перорально мелоксикам 7,5 мг/добу з 12 год до дня 7 після операції; N = 68) у співвідношенні 1: 1. Крім того, оцінювали оцінку аналогової шкали болю (VAS), оцінку задоволеності пацієнтів, оцінки кульшовго суглоба Харріса (HHS) та побічні ефекти. Також було розраховано накопичене споживання петидину для менеджменту знеболення. Результати: оцінка гострого болю VAS у стані спокою (Day 1 – Day 2) та оцінка VAS болю при русі (Day 1 – Day 3) була зменшена, тимчасом оцінка короткочасного задоволення пацієнтів (Day 1 – Day 3) була збільшена в групі PREA порівняно з групою POSA; однак ці показники протягом довгострокового періоду не мали різниці між групою PREA та групою POSA (Day 3 – Month 3). Крім того, накопичене споживання петидину на День 3 та День 7 було зменшено у групі PREA порівняно з групою POSA. Крім того, HHS у будь-який оцінений часовий момент (Day 7 – Month 3) не відрізнявся між двома групами. Крім того, не виявлено різниці у частоті побічних явищ між двома групами. Висновок: передопераційне введення мелоксикаму демонструє чудову ефективність при короткостроковому контролі болю, поліпшення задоволеності пацієнтів та зменшене споживання рятувальної анальгезії порівняно з післяопераційним введенням мелоксикаму у пацієнтів з ІАП.

Introduction: Hysterectomy is a common procedure and postoperative pain is a considerable problem. Preemptive analgesia includes analgesic administration prior to surgical stimulus. Ketamine is a short acting anesthetic drug with analgesic and anti-inflammatory properties, reducing central sensitization of pain pathway and hyperalgesia. Objectives: This study aimed to assess the efficacy of preemptive use of ketamine as an analgesic drug, either by intravenous route or by subcutaneous infiltration at the incisional site, regarding perioperative hemodynamics, postoperative pain and gastrointestinal irritation symptoms. Patients and methods: 60 patients were enrolled in this study, divided into two equal groups (30 each) according to route of preemptive ketamine administration. Group (V) received 0.5 mg.kg-1 intravenously while group (S) received 0.5 mg.kg-1 subcutaneously at incisional site. Postoperative pain assessment for 24 H. using visual analogue score (VAS) was adapted as primary outcome objective, while secondary outcomes included hemodynamic parameter and postoperative nausea and vomiting (PONV). Results: Data were analysed. VAS score showed significant difference among studied groups in early 2 postoperative hours. VAS0 (V 2.40±0.62, S 1.96±0.92, P 0.038), VAS1 (V 3.96±1.21, S 2.86±0.89, P 0.001), VAS2 (V 4.00±0.94, S 3.33±0.88, P 0.007). Also, first time to pethidine intake (V 1.50±0.93 H, S 2.36±1.27 H, P 0.004). Other study objectives were comparable. Conclusion: Preemptive use of ketamine with subcutaneous infiltration at incisional site in total abdominal hysterectomy patients provided better analgesia in early postoperative hours rather than intravenous route with comparable hemodynamic parameter and side effects.

Introduction: Diagnostic hysteroscopy-laparoscopy is an essential tool in management of infertility. Mainly, postoperative pain related to insufflated cold carbon dioxide (co2), as it creates acidic milieu causing mucosal, sub-diaphragmatic and phrenic nerve irritation. Sodium bicarbonate is an alkaline solution, neutralizing the acidic effects, hence reduces postoperative pain and irritation symptoms. Objectives: This study aimed to assess the efficacy of adding sodium bicarbonate to washing warm saline in hysteroscopic-laparoscopic patients regarding incidence and intensity of postoperative pain and gastrointestinal irritation symptoms. Patients and methods: 66 patients were enrolled, one was excluded due to ovarian bleeding. 33 patients in sodium bicarbonate (Na) group received 50 ml sodium bicarbonate 8.4% in 1000 ml warm saline as peritoneal irrigation solution. While 32 patients in saline (S) group the peritoneal irrigation solution was 1000 ml warm saline only. Results: Patients’ demographic, hemodynamic data were comparable. Postoperative pain profile regarding shoulder tip pain, visual analogue score (VAS), and total pethidine consumption were lower in Na group. Also, postoperative nausea and vomiting (PONV) was lower in Na group. Conclusion: Adding sodium bicarbonate to warm saline as a peritoneal washing solution during hysteroscopy-laparoscopy procedure resulted in better postoperative pain reduction specially shoulder tip pain and reduced the incidence of PONV. These results would improve patients’ recovery and experience towards operative practice. ABSTRACT Introduction: Diagnostic hysteroscopy-laparoscopy is an essential tool in management of infertility. Mainly, postoperative pain related to insufflated cold carbon dioxide (co2), as it creates acidic milieu causing mucosal, sub-diaphragmatic and phrenic nerve irritation. Sodium bicarbonate is an alkaline solution, neutralizing the acidic effects, hence reduces postoperative pain and irritation symptoms. Objectives: This study aimed to assess the efficacy of adding sodium bicarbonate to washing warm saline in hysteroscopic-laparoscopic patients regarding incidence and intensity of postoperative pain and gastrointestinal irritation symptoms. Patients and methods: 66 patients were enrolled, one was excluded due to ovarian bleeding. 33 patients in sodium bicarbonate (Na) group received 50 ml sodium bicarbonate 8.4% in 1000 ml warm saline as peritoneal irrigation solution. While 32 patients in saline (S) group the peritoneal irrigation solution was 1000 ml warm saline only. Results: Patients’ demographic, hemodynamic data were comparable. Postoperative pain profile regarding shoulder tip pain, visual analogue score (VAS), and total pethidine consumption were lower in Na group. Also, postoperative nausea and vomiting (PONV) was lower in Na group. Conclusion: Adding sodium bicarbonate to warm saline as a peritoneal washing solution during hysteroscopy-laparoscopy procedure resulted in better postoperative pain reduction specially shoulder tip pain and reduced the incidence of PONV. These results would improve patients’ recovery and experience towards operative practice. Keywords: Laparoscopy, Pain, VAS, Sodium bicarbonate, PONV.

BackgroundTotal intravenous anesthesia (TIVA) with propofol and remifentanil is frequently used for pediatric cochlear implants (CIs) surgery as it does not suppress the electrical stapedial reflex threshold (ESRT). However, high doses of remifentanil exacerbate postoperative pain and increase opioid consumption. Intravenous lidocaine reduces pain and opioid requirement. This study investigated the effect of intravenous lidocaine on perioperative opioid consumption and ESRT in pediatric CIs.ResultsThe mean (95% CI) remifentanil consumption was significantly lower in lidocaine group than in placebo group [0.57 (0.497–0.643) vs 0.69 (0.63–0.75)] μg/kg/min,P= 0.016. The mean (95% CI) propofol consumption was significantly lower in lidocaine group than in placebo group [155.5 (146–165) vs 171 (161–181) μg/kg/min,P= 0.02. MBP and HR were significantly lower after surgical incision, laryngeal mask airway (LMA) removal, and at PACU admission in the lidocaine group compared with the placebo group. The PACU pain score was significantly lower in the lidocaine group compared to the placebo group. The mean (95% CI) pethidine consumption in PACU was significantly lower in the lidocaine group than in the placebo group 7.0 (6.17–7.83) vs. 8.9 (7.84–9.96) mg,P= 0.012. There were no differences between groups regarding ESRT response.ConclusionsIntravenous lidocaine infusion reduced perioperative opioid requirements without altering the ESRT in pediatric CIs.Trial registrationClinical registration number:NCT04194294.

Background/Aims: The recovery room used after endoscopy has limited capacity, and an efficient flow of the endoscopy unit is desired. We investigated the duration of hospital stay after endoscopy and the risk factors for prolonged hospital stay among outpatients.Methods: We retrospectively studied consecutive patients who underwent esophagogastroduodenoscopy or colonoscopy at the Toyoshima Endoscopy Clinic. We collected data on age, sex, body weight, midazolam and pethidine dosage, respiratory depression during endoscopy, and duration of hospital stay after endoscopy (scope out to check out). Risk factors for prolonged hospital stay (>100 minutes) were identified using multiple logistic regression analysis.Results: We enrolled 3,898 patients, including 3,517 (90.2%) patients tested under sedation and 381 (9.8%) patients tested without sedation. Overall, 442 (11.3%) patients had prolonged stay (>100 min). The mean time difference between sedation group and non-sedation group was 44.2 minutes for esophagogastroduodenoscopy and 39.1 minutes for colonoscopy. Age (odds ratio [OR], 1.025; 95% confidence interval [CI], 1.014−1.036), female sex (OR, 1.657; 95% CI, 1.220−2.249), and midazolam dose (OR, 1.019; 95% CI, 1.013−1.026) were independently associated with prolonged hospital stay after esophagogastroduodenoscopy, with similar results for colonoscopy.Conclusions: Old age, female sex, and midazolam dose were independent risk factors for prolonged hospital stay after endoscopy.

Background In advanced lung cancer, precision medicine requires repeated biopsies via bronchoscopy at therapy change. Since bronchoscopies are often stressful for patients, sedation using both fentanyl and midazolam is recommended in Europe and America. In Japan, bronchoscopies are generally orally performed under midazolam and oropharyngeal anesthesia. Nasal intubation creates a physiological route to the trachea, causing less irritation to the pharynx than intubation via the oral cavity; however, the necessity of oropharyngeal anesthesia remains unclear. We aimed to compare the safety, patient discomfort, and diagnostic rates for oropharyngeal anesthesia and sedation with pethidine and midazolam (Group A) and sedation with midazolam and fentanyl without oropharyngeal anesthesia (Group B) for ultrathin bronchoscopy of peripheral pulmonary lesions (PPLs) via nasal intubation. Methods We retrospectively reviewed 74 consecutive potential lung cancer patients who underwent ultrathin bronchoscopies at the Hakodate Goryoukaku Hospital between July 2019 and June 2020. We reviewed the following: diagnostic rates; cumulative doses of lidocaine, midazolam, and fentanyl; hemodynamic changes; procedural complications in both groups. Pharyngeal anesthesia in group A was administered by spraying 2% (w/v) lidocaine into the pharynx. The chi-squared test was used for statistical analyses. Results There were no significant changes in hemodynamic parameters and complications. The mean level of discomfort for bronchoscopic examinations was significantly lower in Group B (2.39 vs. 1.64; P = 0.014), with no significant inter-group difference in the diagnostic yields for PPLs (63.0% vs. 71.4%; P = 0.46). Conclusions Our findings indicate the advantages of sedation with fentanyl and midazolam without oropharyngeal anesthesia for ultrathin bronchoscopy through nasal intubation.

Objective: This study was done for comparative study of dexmedetomidine with that o tramadol and pethidine in the treatment of post-neuraxial anaesthesia shivering. Design: This was a prospective, randomised, double-blinded study. Setting And Subjects: Hundred patients of both genders, aged 18–70 years with American Society of Anesthesiologists physical status I and II undergoing neuraxial a( spinal or combined spinal and epidural)anaesthesia for elective surgery were enrolled in this study. Sixty of them developed shivering after an intrathecal injection of 0.5% hyperbaric bupivacaine 15 mg. They were then randomly allocated to receive either intravenous dexmedetomidine 0.5 μg/kg, pethidine 0.5 mg/kg or tramadol 0.5 mg/kg. Outcome measures: The response rate to treatment, the degree of sedation and the side-effects were recorded. Results: The response rate to treatment was highest in the dexmedetomidine group, and it was only signicant when compared to tramadol group (p = 0.0012). It was noted that the response rate was higher in the pethidine than in the tramadol group. This difference was not statistically signicant (p = 0.082). The sedation score post treatment was similar in all three groups, but more patients in the dexmedetomidine group developed hypotension and bradycardia (p< 0.05). Conclusion: Dexmedetomidine 0.5 μg/ml was more effective than tramadol 0.5 mg/ml and pethidine 0.5 mg/ml, and both tramadol and pethidine were found to have similar efcacy, in the treatment of post-neuraxial anaesthesia shivering. However, dexmedetomidine caused a higher incidence of hypotension and bradycardia.

Background: A standard obstetric analgesic should have a good analgesic effect without reducing the intensity of uterine contraction. The present study aimed to evaluate and compare the efficacy of intramuscular tramadol and pethidine on labor pain and duration. Material and Methods: A total of 170 multigravida women in active labor were randomly assigned to two identical groups, so that 85 pregnant women received pethidine (50mg/2ml) and 85 pregnant women received tramadol (100mg/2ml) intramuscularly. Results: The labor duration in the tramadol group was shorter than in the pethidine group. In 1st stage of labor, 64.7% of the participants in the tramadol group received the drug for 120±30 minutes, while 67.1% in the pethidine group received the drug for 180±30 minutes. In the 2nd stage, 44.7% of the participants in the tramadol group received the drug for 15±5 minutes, while 51.8% in the pethidine group received the drug for 25±5 minutes. The Visual Analog Scale (VAS) was used before, and 1 and 3 hours after drug administration. The pethidine group obtained a lower VAS mean score compared to those in the tramadol group at 1 hour after drug administration (4 vs 6; P≤.001). Moreover, there was a significant higher level of vomiting and dizziness among women in the pethidine group (29.4% vs 1.2%; P≤.001). Conclusion: Tramadol appears to lead to a shorter labor duration and cause lower maternal side-effects, although its analgesic efficacy was not as much as pethidine.

BACKGROUND: Postoperative pain, nausea, and vomiting are the most common side effects of laparoscopic cholecystectomy (LC). In the present study, we investigated the differences in postoperative pain, nausea, and vomiting between Veress needle and direct trocar entry methods among patients undergoing LC. METHODS: 96 patients with gallstones were studied. They were randomly divided into two groups: the patients in the first group (n=48) were insufflated 8.1 liters per minute CO2 gas by direct trocar port, and the patients in another group (n=48) were insufflated 2.1 liters per minute CO2 gas by Veress needle. Pain intensity, nausea, and vomiting were assessed at 20 minutes, 4 hours, and 12 hours after the operations. RESULTS: The duration of CO2 gas insufflation in Veress needle was 88.7±10.7 seconds and indirect trocar was 16.6±1.6 seconds. Visual analog scale (VAS) score significantly reduced in Veress needle compared with direct trocar (0.39±0.98 vs. 1.68±1.48) at 20 min after the operation, while there was no difference at 4 hours and 12 hours after the operation. The requirement and dose of pethidine injection were significantly lower in Veress needle than direct trocar. In addition, nausea and vomiting occurred in Veress needle less than direct trocar at 20 min, 4 hours, and 12 hours after LC. CONCLUSIONS: Pain intensity just in the short term after LC in the group with CO2 gas insufflation in Veress needle was significantly less than the other group, while nausea and vomiting were significantly less during the whole follow-up periods in the group with CO2 gas insufflation in Veress needle.

Aim: The study aimed to compare the effect of intravenous administration of the NSAID (Non-steroidal anti-inflammatory drugs) ketorolac to that of intravenous administration of the opioid pethidine in the suppression of pain in patients with biliary colic. Methodology: The present study is a trial study. Among all the biliary colic patients in Mashhad Referral Hospital Emergency in Iran, 58 patients with inclusion criteria were selected using convenience sampling. They were randomly divided into two groups of 29 patients. In the first group, 1 mg/kg IV pethidine, and in the second group, 30 mg IV ketorolac was injected. The pain severity was assessed prior to the treatment and 15, 30, and 60 minutes after the onset of the treatment using the Visual Analogue Scale (VAS). The data were analyzed using SPSS 20 and Chi-square tests. Findings: The patients' mean age was 45±15 years old (age ranged from 30 to 60 years old). The results showed no significant relationship between pain suppression and medicine type after 15 minutes (P=0.5), 30 minutes (P=0.6), and 1 hour (P=0.7). It means that pethidine and ketorolac have an equal effect on pain suppression in patients with biliary colic. Also, the more time passes from the injection, the more the medicines suppress pain. Conclusion: the results of this study show that the efficacy of NSAIDs in the suppression of moderate to severe pain; therefore, a plan to use NSAIDs instead of narcotics for this purpose is essential.

Naser Al-Husban,1 Mohammad Sami Elmuhtaseb,1 Hedaieh Al-Husban,2 Mohammed Nabhan,3 Hamza Abuhalaweh,3 Yasmine Mohamed Alkhatib,3 Maysa Yousef,3 Bayan Aloran,3 Yousef Elyyan,3 Asma Alghazo3 1Faculty of Medicine, The University of Jordan, Amman, Jordan; 2Al-Noor Fertility Center, Eye Specialty Hospital, Amman, Jordan; 3Obstetrics and Gynecology Department, Jordan University Hospital, Amman, JordanCorrespondence: Naser Al-HusbanFaculty of Medicine, The University of Jordan, P O Box 2194, Amman, 11941, JordanTel +962-772086080Fax +96264643217Email Husban48@yahoo.comBackground: Cesarean section is a widely performed surgery.Objective: To compare anesthetic types regarding feto-maternal outcomes.Materials and Methods: Retrospective comparative study of 3599 cesarean sections (emergency and elective categories).Results: Mean APGAR score was statistically higher in the spinal than general anesthesia among the emergency category, P = 0.000 and 0.026, respectively, with no significant difference in the elective category. Estimated blood loss among the elective category was statistically significantly higher in the spinal than general anesthesia, P = 0.001. However, among the emergency category, it was significantly higher in the general than in spinal or epidural anesthesia, P = 0.000. Diclofenac sodium was used more after spinal than general anesthesia (P = 0.000), with no significant difference between epidural and general or between epidural and spinal anesthesia. Pethidine hydrochloride (HCL) was used more after general than after spinal anesthesia (P = 0.000). However, pethidine HCL use was not statistically significantly different between spinal and epidural anesthesia. In the elective category, paracetamol was requested more after spinal than epidural or general anesthesia, P = 0.000. No significant difference was seen between epidural and general anesthesia, P = 1.000. No statistically significant difference was found among the anesthetic types in both categories regarding tramadol HCL. Length of hospital stay, operative time and neonatal intensive care unit admission were not statistically different between anesthetic modes. In the emergency category, significantly higher percentage of patients were satisfied with and would recommend epidural anesthesia.Conclusion: There was no statistically significant difference among the three types of anesthesia regarding neonatal intensive care admission and length of hospital stay for emergency and elective categories. APGAR score was higher with spinal than with general anesthesia in the emergency category with no significant difference in the elective category. More diclofenac sodium and paracetamol and less opioids were used after regional than after general anesthesia. Satisfaction was higher with epidural anesthesia.Limitations: Retrospective and single centered.Keywords: cesarean section, spinal, epidural, general, anesthesia, feto-maternal, outcome

Background: Postoperative delirium (POD) is a condition of cerebral dysfunction and a common complication after surgery. This study aimed to compare and determine the relative efficacy of pharmacological interventions for preventing POD using a network meta-analysis (NMA).Methods: We performed a systematic and comprehensive search to identify and analyze all randomized controlled trials until June 29, 2020, comparing two or more pharmacological interventions, including placebo, to prevent or reduce POD. The primary outcome was the incidence of POD. We performed a network meta-analysis and used the surface under the cumulative ranking curve (SUCRA) values and rankograms to present the hierarchy of the pharmacological interventions evaluated.Results: According to the SUCRA value, the incidence of POD decreased in the following order: the combination of propofol and acetaminophen (86.1%), combination of ketamine and dexmedetomidine (86.0%), combination of diazepam, flunitrazepam, and pethidine (84.8%), and olanzapine (75.6%) after all types of anesthesia; combination of propofol and acetaminophen (85.9%), combination of ketamine and dexmedetomidine (83.2%), gabapentin (82.2%), and combination of diazepam, flunitrazepam, and pethidine (79.7%) after general anesthesia; and ketamine (87.1%), combination of propofol and acetaminophen (86.0%), and combination of dexmedetomidine and acetaminophen (66.3%) after cardiac surgery. However, only the dexmedetomidine group showed a lower incidence of POD than the control group after all types of anesthesia and after general anesthesia.Conclusions: Dexmedetomidine reduced POD compared with the control group. The combination of propofol and acetaminophen and the combination of ketamine and dexmedetomidine seemed to be effective in preventing POD. However, further studies are needed to determine the optimal pharmacological intervention to prevent POD.

Introduction The purpose of this study was to investigate the analgesic effect of 3 different regimens of combination analgesics administered to patients undergoing thyroidectomy. Material and methods A total of 152 patients undergoing total or subtotal thyroidectomy were enrolled. Patients allocated to group A received a combination of intravenous (IV) paracetamol and intramuscular (IM) pethidine, patients in group B received a combination of IV paracetamol and IV parecoxib, while patients in group C received IV paracetamol monotherapy. Results The analgesic regimens of groups A and B were found to be of equivalent efficacy (p-value = 1.000). In contrast, patients in group C (paracetamol monotherapy) had higher numerical rating scale scores, compared to both patients in groups A (p-value < 0.001) and B (p-value < 0.001). Conclusions The combinations of IV paracetamol with either IM pethidine or IV parecoxib are superior to IV paracetamol monotherapy in achieving pain control in patients undergoing thyroid surgery.

Background & Objective:Patients undergoing a caesarean section (CS) frequently experience shoulder pain, which is often neglected. However, there are some recommendations to prevent or relieve this pain. This study examined the effect of intravenous dexamethasone and ketamine on reducing shoulder pain in patients who underwent a CS under spinal anesthesia. Materials & Methods:The cohort of this prospective study comprised 231 subjects, all of whom were candidates for a CS during 2016. The patients were evaluated based on the type of medication received. After undergoing spinal anesthesia, the first group received 0.5 mg/kg ketamine intravenously and the second group received 0.1 mg/kg dexamethasone intravenously. The patients in these two groups were compared with a control group made up of patients who had not received any medication. Levels of pain severity during and immediately after, as well as 1 h, 6 h, 12 h, 18 h, and 24 h after the CS, were recorded based on the visual analogue scale (VAS). The amount of pethidine consumed was also documented. Results:Compared to the control group, the intravenous administration of ketamine and dexamethasone significantly reduced shoulder pain resulted from CS under spinal anesthesia (PP Conclusion:The results showed that prophylactic administration of dexamethasone and ketamine is effective in relieving shoulder pain after a CS.

Background & Aims: The multimodal analgesia provides superior pain relief and reduces opioid consumption and its side effects. Gabapentin has been used successfully in multi-modal analgesia in different doses. We designed a double-blind randomized control trial to find the minimal effective dose of gabapentin in multimodal analgesia for postoperative pain following total abdominal hysterectomy. Material & Methods: After informed consent, total of 87 patients were randomly assigned to A, B & C groups to receive gabapentin orally 300 mg, 600 mg, and 900 mg respectively one to two hours before surgery. Postoperatively pain was managed by patient-controlled analgesia (PCA) using pethidine. Pain score, opioid consumption, and side effects of gabapentin were monitored. Rescue analgesia was given and monitored. Results: There was no statistically significant difference among the groups with respect to age, weight, height, pethidine consumption, and rescue analgesia. Mean pain scores were statistically insignificant at baseline, 8, 12, and 24 hours postoperatively. Only at 4 hours, the highest pain score (mean) was found in group A, which is statistically significant. The side effects of gabapentin like nausea, vomiting, somnolence, and dizziness were also statistically insignificant. Conclusion: A single preoperative oral gabapentin 300 mg was found to be minimal effective dose in multimodal analgesic regimen for reducing post-operative pain and analgesic requirement following total abdominal hysterectomy.

Purpose: The purpose of the study is to evaluate the analgesic effect of adding magnesium sulfate to bupivacaine in Fascia Iliaca Compartment Block (FI-CB). Patients and Methods: Ninety-six burn patients scheduled for skin-grafting procedures were allocated into two equal groups. After induction of general anaethesia, forty-eight patients received US guided FICB using 35 ml bupivacaine 0.25% + 5 ml isotonic sodium chloride solution with a total volume of 40 ml. The other forty-eight patients received 35 ml bupivacaine 0.25% + 250 mg of magnesium sulfate with a total volume of 40 ml. Results: Total postoperative pethidine consumption in the first 24 h post-operative showed a highly statistically significant decrease in the magnesium group in comparison to the bupivacaine group. Conclusion: Adding magnesium sulfate to bupivacaine in FICB in skin grafting procedures decreased the pain scores post-operative, delayed the first request of analgesia and reduced the total analgesic consumption in the first 24 h post-operative without any significant side effects.

Introduction: Labor pain is the most severe pain a women would experience and several treatment modalities have been adopted since decades. Labor analgesia using epidural technique is considered as the efficient and effective treatment options available. Parturients in India especially rural areas are less aware regarding labor analgesia using epidural technique. Aim: To study the effects of labor analgesia using epidural technique in nulliparous women. Materials and Methods: Sixty full term nulliparous women with singleton vertex pregnancy were made aware of labor analgesia using epidural technique and included, those willing were grouped epidural(n=30), those not keen were grouped control(n=30). In 1st stage labor, parturients in epidural group received bupivacaine and fentanyl, whereas in control group received intramuscular Inj. tramadol, and Inj. pethidine if needed. Duration of 1st and 2nd stage labor, pain relief, maternal satisfaction, adverse effects, instrumental deliveries, 1st and 5th minute Apgar score and NICU admission were recorded. Results: The mean duration of first stage labor was shorter (p=0.071) in epidural group (250.17±106.33 minutes) compared with control group (302.0±111.99 minutes) and statistically insignificant prolongation (p=0.892) (18.73±6.82 minutes) of 2nd stage labor as compared to control (18.33±14.53 minutes). Pain relief in epidural group was statistically significant (pst (p=0.306) and 5th minutes (p=1.00), NICU admission rate were statistically insignificant (p=0.143) between groups. Conclusion: Labor epidural analgesia using Inj.bupivacaine and Inj.fentanyl provides good pain relief, safe for mother and baby. It does not affect labor duration, instrumental delivery rate or neonatal outcome. Keywords: Labor analgesia, Epidural, Bupivacaine, Fentanyl, Labor stages, Apgar score, NICU admission.

Introduction: Spine surgeries, especially spine fusion surgeries cause severe postoperative pain, hampering convalescence. This is a randomized double blind controlled study comparing the analgesic efficacy of postoperative intravenous pethidine and dexmedetomidine in patients undergoing lumbosacral spine surgeries. Materials and Methods: After connecting patients to vital parameters monitor, patients were given general anaesthesia, induced with fentanyl 2mcg/kg, propofol 2mg/kg in graded doses and rocuronium 0.6mg/kg to facilitate tracheal intubation. All patients received 1 gram paracetamol iv slow infusion intraoperatively. After one and a half hours of surgery, injection fentanyl 1mcg/kg was repeated. After extubation and shifting the patients to PACU, patients were randomly allotted either group P/pethidine group or group D/dexmedetomidine group by computerised randomization. Group P patients received injection pethidine 0.5mg/kg loading dose diluted in 5 ml of distilled water slow iv, followed by 0.15mg/kg/hr infusion for 24hrs. Group D patients received injection dexmedetomidine 1mcg/kg bolus over 15 minutes followed by infusion of 0.5mcg/kg/min. Pulse rate, blood pressure, oxygen saturation, respiratory rate, VAS score and sedation score were monitored every 5 minutes for first 15 minutes, every 15 minutes for 1 hour, every hour till 6th hour, then 12th hour, and 24th hour. Results: Dexmedetomidine has a faster on set of analgesic effect (10 minutes) compared to pethidine (30 minutes), provides better analgesia and manageable hemodynamics but, causes more sedation with an average sedation score of 2.83 compared to pethidine. Conclusion: Dexmedetomidine is a better analgesic in the postoperative period compared to pethidine. Keywords: Dexmedetomidine, Lumbosacral spine surgeries, Pethidine.

Objective Catheter-related bladder discomfort (CRBD) that manifests as agitation and bladder hyperactivity is a common problem in young male patients. Local anaesthetics are typically recommended for this problem. Hence, this study was conducted to determine the effect of intravesical diluted bupivacaine on CRBD in young male patients during postanaesthetic recovery. Methods This double-blinded randomised clinical trial included 68 consecutive patients, aged 20-60 years, who underwent urinary catheterisation during surgery and anaesthesia at a university hospital during 2017-2018. Patients were randomly assigned to receive either 50 ml of intravesical diluted (0.2%) bupivacaine (n=37) or normal saline (n=31). The incidence and severity of CRBD were then evaluated in PACU and compared between the two groups. Results In this study, 16.2% of patients in the bupivacaine group and 83.9% in the saline group had discomfort at arrival in the recovery room, exhibiting a significant intergroup difference (p=0.0001). Moreover, after 15-20 min, the incidence of CRBD was 16.2% and 90.3% in the bupivacaine and normal saline groups, respectively, which again demonstrated a significant statistical difference (p=0.0001). In addition, the severity of CRBD was lower in the bupivacaine group, during both periods (p=0.005). The saline group reported significantly higher use of pethidine and midazolam (p=0.005). Conclusion It may be concluded that intravesical diluted bupivacaine can significantly decrease the incidence and severity of CRBD in young male patients during recovery from anaesthesia. Therefore, the use of this method is highly recommended.

To compare the efficacy of tramadol with pethidine on the treatment of post spinal anaesthesia shivering. Electronic databases including PubMed, Google Scholar, Embase and Cochrane were searched to find the randomized controlled trials (RCTs) comparing the efficacy of tramadol with pethidine on the treatment of post spinal anaesthesia shivering. Review Manager 5.3 was used. The meta-analysis was conducted with fixed-effect model or random-effect model according to the heterogeneity. Seven randomized controlled trials involving 463 patients were included. Compared with pethidine, tramadol had a significantly higher incidence of effective rate of shivering treatment (OR: 3.02, 95% CI 1.25 to 7.28, P = 0.01; I2 = 0%), shorter time to cease shivering (mean difference − 1.72, 95% CI − 2.59 to − 0.84, P = 0.0001; I2 = 89%) and lower recurrent rate of shivering (OR 0.18, 95% CI 0.05 to 0.57, P = 0.004; I2 = 0%), with a lower incidence of nausea and vomiting (OR 0.20, 95% CI 0.09 to 0.41, P

Background: Pain after Cesarean delivery is the main postoperative complain in parturients, pregabalin and gabapentin have been shown to decrease acute postoperative pain in parturient. Objective: The aim of the study was to compare gabapentin and pregabalin as oral premedication in patients for elective cesarean section under spinal anesthesia for postoperative pain relief and the need to rescue analgesia. Methods: This study was carried out at Obstetric Operating Rooms, Zagazig University Surgical Hospitals. The study included 54 consenting women aging 20–40 yrs old with uncomplicated pregnancies that were scheduled to undergo elective Cesarean section delivery under spinal anesthesia. They were randomly allocated into three equal groups. Group (P) received 300 mg pregabalin, group (G) received 900 mg gabapentin, and control group (C). The study medication given orally one hour before the anticipated time of the surgical incision, and data measured included visual analogue scale (VAS), the total doses of analgesia, the incidence of post-operative nausea and vomiting (PONV) and the level of sedation. Results: The VAS was comparatively low in patients of group P as compared to G and C groups (P value < 0.05). Total analgesic requirement of pethidine in first 24 h was significantly lower in groups P as compared to groups G & C (P value < 0.001). We found that there was statistically significant increase in the sedation scores of the patients in P group as compared to G & C groups. Conclusion: Pregabalin 300 mg was more effective than gabapentin300 mg in reducing post Cesarean section pain, opioid consumption, nausea, and vomiting.

Introduction: The thermoregulatory system plays an important role in coordinate the defense system against the environment in regulating the normal body temperature in homoeothermic species. Hypothermia result is an important complication-Shivering, which is a complicated response of the body resulting in a pattern of muscular activity. Aim: This study aims to compare the efficacy of I.v. hydrocortisone with I.v. low dose ketamine for prevention of shivering during spinal anesthesia. Material & Methods: A Prospective Randomized trial with a sample size of 60 where patients allocated randomly using slot into 2 groups of Group-H (n=30) who received Inj. Hydrocortisone 2mg/kg and Group K (n=30) who received Inj. Ketamine 0.25mg/kg undergoes lower abdominal surgery under spinal anesthesia with 0.5% Bupivacaine of dosage 3ml. Parameters such as heart rate, blood pressure, oxygen saturation, temperature, were observed intraoperatively and postoperatively. The shivering grade, sedation score, patient requiring Inj. Pethidine as a rescue dose, motor, and sensory block was observed along with any side effects such as bradycardia, hypotension, or desaturation. Result: In this study, there was no statistically significant difference (p>0.05) between the two drug groups in the grades of shivering. Clinically there were lower grades of shivering in the Hydrocortisone group when compared to the ketamine group at all timelines. Conclusion: I.v. hydrocortisone 2mg/kg compared with the low dose I.v. ketamine 0.25mg/kg was clinically effective in reducing the incidence and intensity of shivering under spinal anesthesia on prophylactic use for lower abdominal surgery.

In recent years, promising results were achieved with the use of ultrasound (US)-guided interfascial plane blocks for effective postoperative analgesia in several surgeries. Erector spina plane (ESP) block and mid-transverse to pleura plane (MTP) block are the latest techniques in this area. The aim of this prospective and randomized study was to compare the postoperative analgesic efficacy of bilateral ESP and MTP blocks in patients undergoing lumbar spinal surgery under general anesthesia (GA). A total of 120 adult patients were included in the study and randomized into 3 groups: group ESP (n = 40), group MTP (n = 40) and group Control (n = 40). The patients in the group ESP received a bilateral block by injecting 20 ml of 0.25% bupivacaine at a vertebrae level in the mid-point of the incision before GA. The same LA was administrated bilaterally at the T12/L1 level in the group MTP. Postoperatively, a multimodal analgesic regimen including an intravenous tramadol patient-controlled analgesia (PCA), paracetamol and dexketoprofen was used in all groups. Postoperative pain was assessed using a visual analogue scale (VAS) during the first 48 postoperative hours. Pethidine was used as a rescue analgesic when VAS score was >3. Primary outcome measure was mean pain scores. Secondary outcome measures were consumption of rescue analgesic and the amount of tramadol delivered by PCA. A p MTP > ESP; p MTP > ESP; p

Eun Kyung Choi, Ji-il Kim, Sang-Jin Park Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Republic of KoreaCorrespondence: Sang-Jin ParkDepartment of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Hyeonchung-ro, Nam-gu, Daegu, Republic of KoreaTel +82-53-620-3366Fax +82-53-626-5275Email apsj0718@naver.comPurpose: Ultrasound-guided thoracic paravertebral block (TPVB) is an established means for providing postoperative analgesia in thoracic surgery. However, there are conflicting results regarding the efficacy of post-thoracotomy pain management of ultrasound-guided TPVB when compared with that using traditional landmark approach. We therefore conducted a comparative study to evaluate the analgesic efficacy of TPVB when pressure measurement during needle advancement is combined with an ultrasound-guided approach.Patients and Methods: The patients scheduled for lobectomy through thoracotomy were randomly allocated to receive either the ultrasound-guided approach only group (U group) or the ultrasound-guided approach combined with pressure measurement group (UP group) (n = 36 per group). Before thoracic muscle closure, 0.375% ropivacaine (20 mL) was administered as a bolus, followed by a continuous infusion of 0.2% ropivacaine (0.1 mL/kg/hr) in both groups. Postoperative pain was assessed using the visual analogue scale (VAS) pain score while resting and coughing. Local anesthetics and pethidine usage and sensory block area were also evaluated.Results: The UP group showed significantly lower VAS scores, local anesthetics and pethidine usage, and a wider sensory block area than the U group.Conclusion: A combined technique with ultrasound guidance and pressure measurement provided a superior analgesic effect over that of an ultrasound-guided approach alone for the management of post-thoracotomy pain.Keywords: postoperative analgesia, pressure measurement, thoracic surgery, ultrasound-guided, visual analogue scale

Is fentanyl and midazolam non-inferior to pethidine and diazepam in pain relief during oocyte retrieval under conscious sedation?A randomized double-blinded non-inferiority trial of 170 infertile women undergoing oocyte retrieval under conscious sedation in an assisted reproduction centre. The women were randomized to receive intravenously either 0.1 mg fentanyl and 5 mg midazolam or 25 mg pethidine and 5 mg diazepam, plus paracervical block with 10 ml 1% lignocaine. The primary outcome was abdominal pain level during retrieval assessed by linear visual analogue scale from 0-10. Secondary outcomes included vaginal pain levels during and after retrieval and postoperative abdominal pain levels and side-effects, satisfaction level, clinical pregnancy and ongoing pregnancy rates. A pre-defined non-inferiority margin of 1 for the difference in pain levels between two groups was set.Vaginal and abdominal pain levels during retrieval were significantly lower in the fentanyl and midazolam group compared with the pethidine and diazepam group (per-protocol analysis, vaginal pain: 1.6 versus 4.3; mean difference: -2.7, 95% CI -3.7, -1.8; P0.001; abdominal pain: 2.9 versus 5.2; mean difference: -2.3, 95% CI -3.3 to -1.3; P0.001 for non-inferiority). No differences were observed in these pain levels after retrieval. Most women experienced no postoperative side-effects. The fentanyl and midazolam group had better sedation level, satisfaction level on pain relief and satisfaction on the overall retrieval procedure than the pethidine and diazepam group. No significant differences were found in clinical pregnancy and ongoing pregnancy rates between the two groups.The fentanyl and midazolam group had significantly lower vaginal and abdominal pain levels during oocyte retrieval than the pethidine and diazepam group.

Introduction: Urinary stones are the third most common disease of the genitourinary tract after urinary tract infections and prostate diseases. One of the ways to remove a urinary stone is extracorporeal shock wave lithitripsy, which crushes the stones for easier removal, and it is often used to reduce pain, reduce anxiety, and stabilize the patient. In this regard, the use of effective analgesics with less serious side effects seems reasonable. Methods: This randomized clinical trial study was performed with 90 patients who were divided into two groups according to a random number table. The first group received pethidine, and the second group received midazolam and fentanyl (midazolam-fentanyl). The type of medication used and demographic information were recorded, and the patients’ pain was assessed by a visual analog pain scale at 15, 30, 45, and 60 minutes. Results: Of the subjects, 59 (65.5%) were male and 30 (33.5%) were female. The mean age of the patients was 38.4 ± 13.5 years. The level of pain at 15 minutes was 3.71 ± 2.4 in the midazolam-fentanyl group and 5.33 ± 2.9 in the pethidine group. At 45 minutes, the pain level was 4.2 ± 3.1 in the midazolam-fentanyl group and 5.26 ± 2.72 in the pethidine group. The differences between groups was significant at 15 and 45 minutes. At 30 and 60 minutes, the pain was lower in the midazolam-fentanyl group than in the pethidine group, but these differences were not statistically significant. There was no significant difference between the two groups with respect to the incidence of nausea and vomiting, restlessness, and anxiety. Conclusion: This study showed that the pain reported by patients using fentanyl-midazolam was lower than the pain reported by patients on pethidine, and the pain decreased with time in both groups. Therefore, if there is no other indication for the use of drugs, the combination of fentanyl-midazolam will have a better effect on pain and should be used. Trial registration: Current Controlled Trials IRCT2016051427893N1.

Background: Meperidine, a synthetic opioid, has a rapid onset and short duration of action. Mounting evidence has challenged meperidine’s analgesic benefits, and concerns have been raised about its safety profile. Despite recommendations to restrict the prescription of meperidine, the drug remains frequently used. Objectives: The aim of this study was to evaluate the evidence regarding the efficacy and safety of meperidine for acute postoperative and labor pain. Study Design: This was a narrative review of the analgesic efficacy and side effects of meperidine compared to other analgesic drugs for acute postoperative and labor pain in adults. Setting: Randomized controlled trials that compared the analgesic efficacy and side effect profile of meperidine versus another analgesic drug in adult patients were evaluated. Methods: A systemized search of randomized controlled trials studying meperidine for acute postoperative or labor pain in the adult patient population from PubMed, Medline, and EMBASE was performed. Included studies reported on different routes of meperidine administration including intramuscular, intravenous, and patient-controlled analgesia in various surgical procedures such as abdominal surgery, Cesarean section, gynecological surgery, orthopedic surgery, cardiothoracic surgery, as well as for labor analgesia. Meperidine’s analgesic efficacy and safety profile were compared to other opioids (morphine, tramadol, fentanyl, buprenorphine, nalbuphine, and pentazocine), nonsteroidal anti-inflammatory drugs (ketorolac, diclofenac, and indomethacin), dipyrone, ketamine, and bupivacaine. Results: A total of 62 randomized controlled trials published between 1972 and 2018 were reviewed. Meperidine had a similar or inferior analgesic efficacy compared to other analgesics for acute postoperative or labor pain. Meperidine was associated with more sedation and respiratory depression. Limitations: The sample sizes of many clinical studies were small, and therefore probably insufficiently powered to detect differences in uncommon side effects, such as central nervous system toxicity. In addition, some of the included clinical studies were old. Conclusion: Considering the availability of other effective analgesics with potentially fewer side effects, the use of meperidine for acute postoperative or labor pain should not be recommended. Key words: Acute postoperative pain, adverse effects, labor analgesia, meperidine, pethidine

Objectives The aim of this study was to compare the quality of sedation with three different anaesthetic protocols (alfaxalone combined with butorphanol, methadone or pethidine) administered intramuscularly in cats, and to evaluate the influence of the injection site (between supraspinatus and quadriceps muscles) on the onset and quality of sedation. Methods A total of 151 cats were selected for this study. Cats were sedated with alfaxalone (3 mg/kg) combined with either butorphanol (0.3 mg/kg; n = 50), methadone (0.3 mg/kg; n = 53) or pethidine (5 mg/kg; n = 48). The combination was injected intramuscularly into the supraspinatus (n = 79) or quadriceps muscle (n = 72). The data included a scoring system for the quality of sedation and physiological parameters, such as heart rate (HR), respiratory rate, body temperature and occurrence of mydriasis, monitored during the first 30 mins of anaesthesia. Results The opioid associated with alfaxalone influenced the overall sedation score, the degree of myorelaxation, the occurrence of mydriasis and HR. The overall sedation score was poorer with butorphanol than with methadone ( P = 0.008), and butorphanol induced a lower degree of myorelaxation than methadone ( P = 0.013). The injection into the supraspinatus showed better qualitative results for sedation and a faster onset time (in about 3 mins) than that into the quadriceps ( P Conclusions and relevance All three protocols provided a good quality of sedation and allowed performing the scheduled procedure. Moreover, the injection into the supraspinatus muscle showed superior results in all the qualitative scores of sedation and quicker onset time than that into the quadriceps muscle.

Background: Pain relief during labor is a part of standard care in modern obstetrics. Several modalities used for pain relief have their own disadvantages and benefits in terms of side effects, effectiveness, availability, and satisfaction. The objectives of this study are primarily to compare the effectiveness and patients’ satisfaction for pain relief during labor between pethidine and inhaled 50% nitrous oxide (Entonox®). Methods: Laboring women at 37–41 + 6 weeks of gestation were randomly allocated to receive pethidine (50 mg intravenously) or Entonox® for reducing labor pain. Pain scores were evaluated at 0, (baseline), 30, 60, 90, and 120 min after initiation, using the visual analog scale (VAS) and also satisfaction score after delivery using the verbal rating scale (VRS). The secondary outcomes were also assessed, including APGAR scores, labor course, side effects, and cesarean section rate. Results: A total of 136 laboring women underwent randomization into two groups, but only 58 and 65 in the pethidine group and the Entonox® group were available for analysis. The median pain scores at baseline, 30, 60, and 90 min were comparable between both groups (p-value > 0.05); however, pain score at 120 min in the pethidine group was significantly higher (p-value: 0.038). The median of satisfaction score was significantly higher in the Entonox® group (4 vs. 3; p-value 0.043). All of the secondary outcomes were comparable between the two groups. Conclusions: Both have comparable effectiveness, but Entonox® has a higher satisfaction score. Entonox® could be an alternative to pethidine for reducing labor pain, because of its efficacy, ease for self-adjustment for satisfaction, and no serious effects on the labor course and newborns.

The use of a tourniquet and patients’ preference for general anesthesia (GA) limit performing ankle blocks (AB) as a sole anesthetic technique for orthopedic foot surgery. The aim of this prospective and randomized study was to test the hypothesis that administration of an AB before GA could be effective for postoperative pain relief in patients undergoing outpatient hallux valgus surgery. Primary outcome measure was mean pain score and secondary outcome measures were time to mobilization of patients, time to hospital discharge, and complications. A total of 110 adult patients were randomly assigned into two groups: group GA (n = 55) and group GA + AB (n = 55). Group GA + AB received an AB using 100 mg lidocaine 2% and 75 mg bupivacaine 0.5% before the induction of GA. Pain intensity was evaluated using a visual analogue scale (VAS). Mean VAS scores were higher and times to first rescue analgesic were shorter in group GA compared to group GA + AB (p = 0.001). More patients required rescue analgesic in group GA and pethidine consumption was higher (p = 0.001). Time to mobilization was shorter in GA + AB group (p = 0.001) but hospital discharge time was similar between groups (p = 0.269). The incidence of nausea and vomiting was higher in group GA (p = 0.002). Ankle block is an effective and simple technique for reducing postoperative pain and opioid consumption. It reduced the time to mobilization without a delay in hospital discharge. It is concluded that the routine administration of AB before GA may be an effective and simple method for pain relief after foot surgery.