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Nociception refers to the process of encoding and processing noxious stimuli. Its monitoring can have potential benefits. Under anesthesia, nociceptive signals are continuously generated to cause involuntary effects on the autonomic nervous system, reflex movement, and stress response. Most available systems depend on the identification and measurement of these indirect effects to indicate nociception-antinociception balance. Despite advances in monitoring technology and availability, their limitations presently override their benefits. Hence, their utility and applicability in present-day anesthesia care is uncertain. Future technologies might allow automated closed-loop multimodal anesthesia systems, which includes the components of hypnosis and analgesic balance for a patient.

Background: Current postoperative pain management principles are primarily based on the type and extent of surgical interventions. This clinical study measured patient’s self-anticipated pain score before surgery and compared the scores with the pain levels and analgesic requirements after surgery.Methods: This prospective observational study recruited consecutive patients who received general anesthesia for elective surgeries in E-Da Hospital (Taiwan) between June and August 2018. Patients were asked to subjectively rate their highest anticipated pain level (numerical rating scale, NRS 0-10) for their scheduled surgical intervention during their preoperative anesthesia assessment. After the operation, the actual pain intensity (NRS 0-10) experienced by the patient in the post-anesthesia care unit (PACU) and the total dose of opioids administered during the perioperative period were recorded. Pain scores ³4 on the NRS were regarded as being unacceptable levels of anticipated or postoperative pain.Results: A total of 857 patients were included in the study. The final database included 49.2% males, and 73.7% of them have had previous operations. The mean anticipated pain score was 4.9±2.5 and 72.2% of the patients reported an anticipated NRS ³4 before their operations. Females anticipated significantly higher overall pain intensities than male patients (adjusted odds ratio 1.695, 95% confidence interval 1.252-2.295; P=0.001). Patients over 40 years of age reported significantly lower overall anticipated NRS scores (4.78±2.49 vs 5.36±2.50; P=0.003). Patients scheduled to receive more invasive surgical procedures were more likely to anticipate high pain intensity in the preoperative period (PConclusion: This observational study found that females, younger patients (£40 years), and patients scheduled for more invasive surgeries anticipate significantly higher surgery-related pain. Therefore, appropriate preoperative counseling for analgesic control and management of exaggerated pain expectation in these patients are necessary to improve the quality of anesthesia delivered and patient’s satisfaction.

Introduction: The objective of this study is to determine whether elevated circulating plasma catecholamine levels significantly impact opioid requirements during the first 24 hours postoperative period in individuals with acute surgical pain. Methods: We retrospectively reviewed 15 electronic medical records (EMRs) from adults 18 years and older, with confirmed elevated plasma catecholamine levels (experimental) and 15 electronic health records (EHRs) from matched-controls for age, gender, race and type of surgery, with a follow up of 24 hours postoperatively. Results: The total morphine milligram equivalents (MMEs) requirements from the experimental group were not statistically different when compared with controls [44.1 (13 to 163) mg versus 47.5 (13 to 151) mg respectively; p 0.4965]. However, the intraoperative MMEs showed a significant difference, among the two groups; [(experimental) 32.5 (13. to 130) mg, (control) 15 (6.5 to 130) mg; p 0.0734]. The intraoperative dosage of midazolam showed a highly significant positive correlation to the total MMEs (p 0.0005). The subjects with both elevated plasma catecholamines and hypertension used significantly higher intraoperative MMEs compared to controls [34.1 (13 to 130) mg versus 15 (6.5 to 130) mg, respectively; p 0.0292)]. Those 51 years and younger, with elevated circulating levels of catecholamines, required significantly higher levels of both the postoperative MMEs [29.1 (0 to 45) mg versus 12 (0 to 71.5) mg; (p 0.0553)] and total MMEs [544.05 (13 to 81) mg versus 29.42 (13 to 92.5) mg; (p 0.00018), when compared to controls with history of nicotine and alcohol use. Conclusion: This preliminary study evaluated a biologic factor, which have promising clinical usefulness for predicting analgesic requirements that can drive clinical decisions on acute surgical pain.

There are several indications of erector spinae plane block (ESPB) for managing postoperative surgical pain. We investigated the efficacy of ultrasound-guided ESPB at T2-T3 level in five patients undergoing surgery for proximal humerus fracture and found that it provided excellent analgesia in the postoperative period. To investigate the spread of local anaesthetic at this level, we performed contrast-enhanced computed tomography studies, to understand the possible mechanism of action. We believe that ESPB at this level is a good and safe alternative to routinely used brachial plexus blocks, as it not only provides good analgesia but also spares the phrenic nerve.

Background: Pain is often a complaint that precedes total knee arthroplasty (TKA), however the procedure itself is associated with considerable post-operative pain lasting days to weeks which can predict longer-term surgical outcomes. Previously, we reported significant opioid-sparing effects of motor cortex transcranial direct current stimulation from a single-blind trial. In the present study, we used double-blind methodology to compare motor cortex tDCS and prefrontal cortex tDCS to both sham and active-control (active electrodes over non-pain modulating brain areas) tDCS. Methods: 58 patients undergoing unilateral TKA were randomly assigned to receive 4 20-min sessions (a total of 80 min) of tDCS (2 mA) post-surgery with electrodes placed to create 4 groups: 1) MOTOR (n = 14); anode-motor/cathode-right prefrontal, 2) PREFRONTAL (n = 16); anode-left-prefrontal/cathode-right-sensory, 3) ACTIVE-CONTROL (n = 15); anode-left-temporal-occipital junction/cathode-medial-anterior-premotor-area, and 4) SHAM (n = 13); 0 mA-current stimulation using placements 1 or 2. Patient controlled analgesia (PCA; hydromorphone) use was tracked during the ∼72-h post-surgery. Results: Patients in the sham group and the active-control group used 15.4 mg (SD = 14.1) and 16.0 mg (SD = 9.7) of PCA hydromorphone respectively. There was no difference between the slopes of the cumulative PCA usage curves between these two groups (p = 0.25; ns). Patients in the prefrontal tDCS group used an average of 11.7 mg (SD = 5.0) of PCA hydromporhone, and the slope of the cumulative PCA usage curve was significantly lower than sham (p

PubMedID: 28096004 Pain assessment has a key role in relief of the postoperative pain. In this study, we aimed to examine the effect of the Standard Pain Assessment Protocol (SPAP), which we developed based on acute pain guidelines, on pain level, and analgesic consumption. The study population consisted of a total of 101 patients who had arthroscopic shoulder surgery. The routine pain assessment was administered to the control group, while the SPAP was administered to the study group. The routine pain therapy of the clinic was administered to the subjects from both groups based on the pain assessment. Throughout the study, pain was assessed nearly two times more in the study group (p < 0.001) and the mean pain levels were lower at 8th–11th hours in the study group (p < 0.001). Pain assessment was not performed after 12th hour despite the severe pain in the control group, and, therefore, analgesia was administered at irregular intervals or was not administered at all. However, the hours of analgesic administration were found to be more regular according to the pain levels of the patients in the study group. In conclusion, the SPAP reduced the pain level by providing regular analgesia when used in combination with regular pain assessment. Perspective This article highlights the appropriate assessment for patients with surgical pain. In majority of literature on the subject, the authors emphasize the importance of Standard Pain Assessment Protocol to provide adequate pain relief. © 2016 Elsevier Inc.

Electroacupuncture analgesia was used for surgery in horses and donkeys. A KWD-808 electrical stimulator was used to incrementally induce a dense, dispersed wave output at frequencies from 20 to 55 Hz, which was maintained at a frequency of 55 Hz, and to change the amplitude of the wave to the best grading number for the suggested operation in each animal. Induction of analgesia lasted for 20–30 minutes, and the effect of analgesia was maintained for 20–45 minutes depending on the type of surgery performed. The exhibited clinical signs, physical examination data, and the responses of all animals were used for evaluating the periods of analgesia. Although the majority of the cases (95%) had no response to strong surgical pain, they experienced significant increases in heart rates and respiratory rates during induction. The lack of pain, relaxed surgical procedures, reduced intraoperative bleeding, and improved healing without complications were all definite benefits of using electroacupuncture analgesia in surgery. Thus, this study has provided surgical evidence supporting the effectiveness of electroacupuncture analgesia, as well as confirming its reliability, in the field of equine anesthesia and surgery.

Clinicians have long been aware of the danger of overreliance on opioids to manage acute pain, such as the pain accompanying surgery. The risk of adverse drug events is higher with opioids than with any other common class of drugs. Overreliance on opioids increases length of stay and hospital costs, while decreasing patient satisfaction. Opioids can lead to problems that continue well after discharge, including chronic pain, abuse and addiction, and even death. Increasingly, prescribed opioids have proved to lead to heroin addiction. Studies show that the same professionals who prescribe, administer, and monitor opioids lack basic knowledge about their safe and effective use. The alternative to opioid monotherapy in controlling acute pain is multimodal analgesia, an approach that relies on a nonopioid foundation with addition of adjunctive opioids as needed. An increasing number of nonopioid analgesics have proved effective in this role, with fewer side effects and a higher degree of safety than opioids. Accordingly, multimodal analgesia is recommended as best practice by most recognized authorities. Increasingly, governmental authorities hold prescribing clinicians and institutions legally liable for the downstream negative effects of opioids, including abuse and addiction. Addressing this issue should be a top priority for hospital risk managers.

The introduction of local anesthetics revolutionized the practice of dentistry. Prior to their introduction, general anesthesia was the only viable method of managing surgical pain. Among various local anesthetics available in India, lidocaine is most widely used. But lidocaine cannot provide 100% anesthesia, this leads to development of other anesthetics, one such is articaine. However, little to no evidence-based medicine exists demonstrating any superiority of articaine over other available local anesthetics. However dentists in clinical practice have claimed that articaine possesses properties that other local anesthetics don't.

Over the past two decades, the prescription of high dose opiate therapy has continued to accelerate in an attempt to treat patients with chronic pain. This presents a substantial challenge when patients on high dose opiate therapy require surgery, as opiate pain relief is a cornerstone of postoperative pain management. These patients have exceptionally challenging pain to control. This is likely due to downregulation of existing opiate receptors and the reluctance of clinicians to increase doses of opiates to exceptionally high levels to facilitate pain relief. We hypothesize that using the method of ultra-rapid opiate detoxification (UROD), it would be possible to rapidly increase the number of opiate receptors and return patients to a more naive state, which would be susceptible to exogenous opiate administration. Validation of this hypothesis is supported by two mechanisms, the first of which are reports of patients that underwent UROD for opiate addition that subsequently suffer respiratory arrests when beginning to rapidly abuse opiates shortly after treatment. Additionally there are data demonstrating the tapering of opiate therapy prior to elective surgery results in better pain control. In conclusion, we hypothesize that patients on chronic high dose opiates could obtain substantially better pain relief if they underwent UROD prior to surgery. This technique could be administered shortly before surgery and may dramatically improve the patients' recoveries.

Management of pain continues to be an important consideration in livestock on which surgical procedures are performed. A balance must be achieved between the need to mitigate discomfort and the economic constraints of the production enterprise. Moral and ethical dilemmas have increased among consumers and these concerns have stimulated interest to reexamine the methods used to achieve the shared goals of humane production of safe, affordable animal products for human consumption. This article discusses drug and anesthetic protocols for field surgery of cattle, including nonsteroidal antiinflammatory drugs, opioids, local and regional anesthesia, epidural anesthesia, and electroacupuncture.

Background Intravenous Regional Anesthesia (IVRA) is a well-known technique for producing analgesia during surgical procedures in the extremities. However, the rapid onset of pain following the deflation of a double-cuff tourniquet during IVRA is a serious disadvantage, leading patient suffering. Objectives The aim of this study was to evaluate the clinical effectiveness of a pneumatic arm tourniquet applied 2 cm above the double-cuff tourniquet in controlling the pain that occurs after its deflation. Patients and methods Twenty patients undergoing outpatient hand surgery were operated on under IVRA, using 40 - 50 mL of a solution containing 3 mg/kg of lignocaine. A simple pneumatic tourniquet was applied proximal to the double-cuff tourniquet, 3 min before its deflation, while the procedure was being conducted. The severity of pain on the basis of the Numerical Rating Scale (NRS) was assessed throughout the operation, and continued until an hour after the double-cuff tourniquet was removed. Results The mean operation time after the deflation of the double-cuff tourniquet was 20.12 ± 6.1 minutes. Moreover, the mean NRS for the post-deflation time was insignificant (NRS = 2), and only one patient during first 20 minutes received opioids. Conclusions This study showed that a pneumatic arm tourniquet as an adjunct to IVRA provides acceptable analgesia following the deflation of the double- cuff tourniquet for relieving surgical pain.

All chronic pain begins at some discrete point in time. Significant strides in the understanding of mechanisms and risk factors associated with the transition from a new, or acute, pain experience to a chronic pain condition have been made over the past 20 years. These insights provide the hope of one day being able to modify or even halt this pathophysiologic progression. This article reviews some of the current knowledge of this transition as well as the evidence currently available to best prevent and treat it using persistent surgical pain as a model.

Concerns over interactions between analgesics and experimental outcomes are a major reason for withholding opioids from rats undergoing surgical procedures. Only a fraction of morphine injected intravenously reaches receptors responsible for analgesia in the central nervous system. Intrathecal administration of morphine may represent a way to provide rats with analgesia while minimizing the amount of morphine injected. This study aimed to assess whether morphine injected intrathecally via direct lumbar puncture provides sufficient analgesia to rats exposed to acute surgical pain (caudal laparotomy).In an initial blinded, randomised study, pain-free rats received morphine subcutaneously (MSC, 3mg.kg-1, N = 6), intrathecally (MIT, 0.2mg.kg-1, N = 6); NaCl subcutaneously (NSC, N = 6) or intrathecally (NIT, N = 6). Previously validated pain behaviours, activity and Rat Grimace Scale (RGS) scores were recorded at baseline, 1, 2, 4 and 8h post-injection. Morphine-treated rats had similar behaviours to NaCl rats, but their RGS scores were significantly different over time and between treatments. In a second blinded study, rats (N = 28) were randomly allocated to one of the following four treatments (N = 7): MSC, 3mg.kg-1, surgery; MIT, 0.2mg.kg-1, surgery; NIT, surgery; NSC, sham surgery. Composite Pain Behaviours (CPB) and RGS were recorded as previously. CPB in MIT and MSC groups were not significantly different to NSC group. MSC and MIT rats displayed significantly lower RGS scores than NIT rats at 1 and 8h postoperatively. RGS scores for MIT and MSC rats were not significantly different at 1, 2, and 8h postoperatively. Intraclass correlation value amongst operators involved in RGS scoring (N = 9) was 0.913 for total RGS score. Intrathecal morphine was mostly indistinguishable from its subcutaneous counterpart, providing pain relief lasting up to 8 hours in a rat model of surgical pain. Further studies are warranted to clarify the relevance of the rat grimace scale for assessing pain in rats that have received opioid analgesics.

We examined the pre-emptive analgesic effect of a cyclooxygenase (COX)-2 inhibitor in a rat surgical pain model and characterised the changes in cutaneous COX-2 around a surgical site. Thermal hyperalgesia and mechanical allodynia were tested in the rats for three days after incision and skin tissues were collected for analysis of COX-2. There was decreased expression of cutaneous COX-2 one day after surgical incision. Pre-incision injection of the COX-2 inhibitor significantly inhibited expression of COX-2 and also reduced thermal hyperalgesia (but not mechanical allodynia) compared with the post-incision COX-2-inhibitor injection group, one day after incision.

Severe postoperative pain and wound hyperalgesia, a clinical sign of central sensitization, are risk factors for the development of chronic postsurgical pain. This article describes the neuronal changes that surgical pain and possibly high opioid doses cause in the central nervous system. It also relates how regional anesthesia might oppose these changes and block both the pain sensitization and the pain chronification following surgery.

Purpose. Little attention has been given to syringe design and local anaesthetic administration methods. A microprocessor-controlled anaesthetic delivery device has become available that may minimize discomfort during injection. The purpose of this study was to document the pain experience associated with the use of this system and to compare it with use of a conventional syringe. Methods. A prospective, randomized clinical trial was designed. 40 patients undergoing carpal tunnel release were block randomized according to sex into a two groups: a traditional syringe group and a microprocessor-controlled device group. The primary outcome measure was surgical pain and local anaesthetic administration pain. Secondary outcomes included volume of anaesthetic used and injection time. Results. Analysis showed that equivalent anaesthesia was achieved in the microprocessor-controlled group despite using a significantly lower volume of local anaesthetic (P=.0002). This same group, however, has significantly longer injection times (P<.0001). Pain during the injection process or during surgery was not different between the two groups. Conclusions. This RCT comparing traditional and microprocessor controlled methods of administering local anaesthetic showed similar levels of discomfort in both groups. While the microprocessor-controlled group used less volume, the total time for the administration was significantly greater.

Tissue damage associated with surgery often produces peripheral and central sensitization that may outlast the stimuli, leading to exaggerated postoperative pain. Paradoxically, the use of opioid analgesia, which is essential for surgical pain management may induce pain sensitization leading to enhanced postoperative pain and an increased risk of developing chronic pain. We studied whether a surgical incision in the rat hindpaw may favor the development of long-term pain vulnerability by estimating hyperalgesia induced by an inflammatory stimulation of the unlesioned contralateral hindpaw 3 wk later. We also evaluated the ability of nefopam, an analgesic drug commonly used in postoperative pain management, to prevent not only exaggerated postoperative pain but also long-term pain vulnerability. The efficacy of morphine was assessed 1 day after surgical incision.On Day 0, a surgical plantar incision was performed in one hindpaw of rats treated or untreated with fentanyl (4 x 100 microg/kg, one injection every 15 min). Nefopam (10 mg/kg) or saline was subcutaneously injected 30 min before injury. Three weeks later, once pain measures had returned to basal values, a subsequent nociceptive stimulus, specifically intraplantar carrageenan injection, was performed to evaluate pain sensitivity in incision- and fentanyl-experienced rats. Pain was measured by the paw-pressure vocalization test and the weight bearing test.Surgical incision in rats induced latent and long-term pain hypersensitivity, which was manifested by exaggerated hyperalgesia on carrageenan injection. Administering fentanyl in association with the surgical incision induced exaggerated postoperative pain. When injected before incision, nefopam reduced the exaggerated postoperative pain induced by perioperative fentanyl treatment and prevented the development of long-term pain hypersensitivity. Preoperative nefopam administration also improved morphine analgesic efficacy in the context of fentanyl-induced postoperative hyperalgesia.Given preemptively, nefopam may be effective at improving postoperative pain management and at reducing the risk of developing postoperative chronic pain, because the drug has both analgesic and antihyperalgesic properties.

Introduction: Transcutaneous electrical nerve stimulation (TENS) is a noninvasive, nonmedical modality. There are a lot of dilemmas and opposing attitudes regarding the use of TENS in pain management after lower limb amputations. Objective: To establish the role of TENS for the management of postoperative surgical pain after lower limb amputations. Material and methods: Randomized controlled trial, which included forty-six subjects who had undergone lower limb amputations, randomly divided into control and treatment group. The control group received standard postoperative care, whereas the treatment group received standard postoperative care plus TENS. Forty subjects successfully completed the study according to the study protocol. The majority of the individuals had undergone transtibial amputation due to complication of diabetes. Five TENS XL-A1 portable devices with four self-adhesive electrodes were used. This was the conventional TENS mode, characterized by the delivery of electrical impulses with a duration of 200 microseconds, frequency of 110 Hz, and amplitude of 44V. Treatment was carried out for 2 hours a day, during 10 days. The evaluation of TENS efficacy was performed using the horizontal VAS (0-100 mm). Student T test was used in the statistical analysis. Results: Pain intensity was significantly diminished in both groups at the tenth in comparison with the first postoperative day. There were no significant differences between the control (VAS = 4.18±1.48) and the treatment group (VAS= 3.59±1.44) according to the daily mean pain intensity (t = 1.25; df =38). Pain intensity on the tenth postoperative day was significantly lower in the treatment (VAS = 1.65± 0.80) when compared with the control group (VAS = 3.2± 1.15; t = 5; df = 38; p< 0.01). Conclusion: Conventional TENS (dose: 200 microseconds, 110 Hz, 44V), administered two hours a day during ten days, significantly reduced postoperative surgical pain in twenty subjects who had undergone lower limb amputations.

This is a review of Ibn al Quff's account of surgical pain relief in his surgical book Al Omdah, in which he mentioned the word anesthetic (Al moukhadder) and the involvement of physician (al tabbaaee) to give mixture of drugs to prevent pain in a surgical condition to relieve the patient from pain or to make surgical management possible. Hich indicated one rare occasion to such description in Arabic medical texts. Methods of administration of these drugs were inhalation, ingestion and by rectal suppositories. The drugs used in anesthetic sponges include all the drugs that are recorded in the modern literature of anesthesia. They are as follows: opium, mandrake, Hyocymus albus, belladonna, Cannabis sativus, Cannabis indica, wild lettuce. The anesthetic sponge, mentioned in many references as an inhalation method, may be of symbolic value to surgery.

Many studies on the efficacy of preemptive analgesia have been processed in different ways. But the value of preemptive analgesia is still controversial. The goal of this study was to compare analgesic effects of a nonsteroidal anti-inflammatory drug (NSAID) for oral surgical pain according to 3 different administration times.Using a randomized, parallel-group, single-center, and active-controlled test design, this study was conducted with 80 healthy patients undergoing a surgical removal of an impacted mandibular third molar requiring bone removal. The oral NSAID was first administered 1 hour preoperatively, or 1 hour postoperatively, or no scheduled administration pre- or postsurgery. Whenever patients felt at least moderate pain (scoreor =5 on a 10-point scale) after surgery, they were instructed to take the same drug. Pain intensities and times to the first and second onsets of postoperative pain from the end of surgery were assessed for 24 hours.Of the 80 enrolled subjects in this study, 25 patients were assigned to the preemptive group, 26 to the posttreatment group, and 29 to the no-treatment group. The demographic distribution and duration of surgery in the 3 groups were statistically similar. The mean time to first onset of postoperative pain was significantly prolonged in the posttreatment group (277.2 minutes, P.05) compared to the preemptive group (158.4 minutes) and the no-treatment group (196.5 minutes). The mean time to second onset of postoperative pain was not significantly different among the 3 groups. No significant statistical difference was found among the mean pain intensities at the first and second onsets of postoperative pain in the 3 groups.In this small selected group of subjects and limited study design, the analgesic effects of NSAID administered preoperatively were no longer effective for postoperative pain. The results in this population imply that scheduled postoperative analgesics before pain development are adequate for postoperative analgesia without preoperative administration.

Background Surgical pain typically combines superficial and deep pain. We wished to generate pain that resembled surgical pain, reliably and reproducibly, in volunteers. Methods We constructed a computer-controlled pneumatic device to apply pressure to the anterior tibia. The reproducibility of the pain was tested by rating the pressure that caused pain rated 4–5 on a visual analogue scale (VAS) on days 0, 7, and 24 in 10 volunteers. The effect of remifentanil (0.025, 0.05, 0.075, and 0.1 μg kg−1 min−1) on pain tolerance in another set of volunteers (n=11) was used as an indirect measure of the reliability of pain production. Results The pressure needed (0.7 (0.3) to 0.9 (0.4) atm (mean ( sd )) to induce pain rated 4–5 (VAS) did not vary, showing long-term reproducibility of the method. When pressure was applied to cause increasing pain in volunteers (n=11) 0.05 μg kg−1 min−1 remifentanil increased pain tolerance by 50%. An approximate doubling of the dose (0.1 μg kg−1 min−1) increased pain tolerance significantly more. The linear logarithmic dose-effect relationship shows that the device causes pain reliably, and this can be reduced with opioid treatment. Conclusion This pneumatic device can apply pain reliably and reproducibly.

In outpatient knee surgery, perineural catheter techniques are an important advance to further ensure a comfortable same-day discharge after procedures typically associated with significant pain. For outpatients, attention should be directed both to the multimodal treatment of pain as well as to the multimodal prophylaxis of postoperative nausea and/or vomiting. The ability to titrate local anesthetic doses to provide sensory-specific analgesia with minimal motor block is a significant benefit of the perineural catheter technique. For a successful program, key aspects of the facility’s infrastructure need to be addressed, including staffing and teamwork issues. The relevant anatomy is of extreme importance, but equally important is a clear outline of surgical indications such that patients are neither overtreated nor undertreated for surgical pain. Descriptions of technical aspects are included for the following continuous nerve blocks: (i) femoral, (ii) psoas compartment lumbar plexus, (iii) posterior gluteal sciatic, and (IV) posterior subgluteal sciatic.

Before the discovery of anesthesia, clergy and shamans used opium, herbal extracts, and alcohol to diminish surgical pain. Infection and mortality were great. By 1847, ether anesthesia was used in Peru, Uruguay, Brazil, Argentina, and Venezuela, and in 1848, in Chile. By 1850, chloroform displaced ether. Surgeons gave or directed anesthetic delivery by colleagues, nurses, medical students, orderlies, midwives, priests or sisters. Chloroform use continued until the late 1800s when reports of cardiac arrest and liver damage decreased its appeal. French surgeon Ombredanne invented an ether inhaler in 1908 that became the preferred method of anesthetic delivery in the first half of the 1900s. Waters’ 1930s experiences with cyclopropane prompted its use until fatalities from explosions occurred in Chile and Peru. Various barbiturates were given in the 1920s and 1930s, with thiopental becoming the preferred induction agent throughout Latin America. Curare was used by the early-mid 1940s in Brazil, Venezuela, Argentina, and Uruguay. Many Latin American countries took up anesthesia with the inexpensive combination of procaine and thiopental, after its description in Argentina in 1949. Halothane replaced ether in the 1960s.

To determine patients' knowledge and attitudes towards patient-controlled analgesia (PCA) costs through the use of our acute pain service quality assurance (QA) programme.Quality Assurance questionnaires were distributed to all patients receiving PCA opioids for12 hr. Patients were asked to note the presence of side effects (nausea/vomiting, pruritus, urinary retention), to indicate their satisfaction with regard to their pain relief, follow-up assessments, treatment of side effects, and to recall the previous method of pain relief and their satisfaction with it. Patients were also asked to estimate the total cost of PCA (0-$50, $50-100, $100-200,$200), and what amount if any they would be willing to pay (0-$50, $50-100, $100-200,$200). Results obtained over a recent four month period were reviewed.One hundred and thirty-three questionnaires were distributed and 103 (77%) were returned. The percentage of patients rating their satisfaction as very good or excellent was 86% for pain relief, 96% for follow-up, 71% for side effect treatment, but only 43% for their previous surgical pain relief (P0.001). The distribution of cost estimates was 10% $50-100, 37% $100-200 and 53%$200 with 60% willing to pay a portion of this cost. Those willing to pay were more likely to have had very good or excellent pain relief (94% vs 71%, P0.05) and treatment of side effects (71% vs 48%, P0.05) than those not willing to pay.Patients continue to be highly satisfied with PCA therapy and are aware of the costs involved. A majority of patients were willing to pay to obtain this service if necessary. Patients who had poorer pain relief and less efficacious treatment of their side effects were less willing to pay.

This study aimed to develop a behaviour-based pain assessment system for rabbits following ovariohysterectomy. Behaviour was analysed to assess the severity and duration of pain induced and determine the effects of administration of meloxicam. The results suggest that pain associated with ovariohysterectomy induced changes in the frequency and duration of a number of behaviours. The most indicative was inactive pain behaviour, which was observed very infrequently prior to surgery compared to very frequently immediately following surgery. This strongly suggests that this increase is a direct response to the surgical pain and/or stress. The frequency of inactive pain behaviour also decreased over the four days post-surgery suggesting that pain is decreasing during this time. High dose meloxicam (initial 1 mg/kg followed 0.5 mg/kg/day) induced some degree of analgesia. However, higher doses of meloxicam or in combination with an opioid may be required to provide consistent analgesia in rabbits following soft-tissue surgery.

Stephen R Southworth,1 Emily J Woodward,2 Alex Peng,2 Amy D Rock21North Mississippi Sports Medicine and Orthopaedic Clinic, PLLC, Tupelo, MS, 2Department of Research and Development, Cumberland Pharmaceuticals Inc., Nashville, TN, USAAbstract: Intravenous (IV) nonsteroidal anti-inflammatory drugs such as IV ibuprofen are increasingly used as a component of multimodal pain management in the inpatient and outpatient settings. The safety of IV ibuprofen as assessed in ten sponsored clinical studies is presented in this analysis. Overall, 1,752 adult patients have been included in safety and efficacy trials over 11 years; 1,220 of these patients have received IV ibuprofen and 532 received either placebo or comparator medication. The incidence of adverse events (AEs), serious AEs, and changes in vital signs and clinically significant laboratory parameters have been summarized and compared to patients receiving placebo or active comparator drug. Overall, IV ibuprofen has been well tolerated by hospitalized and outpatient patients when administered both prior to surgery and postoperatively as well as for nonsurgical pain or fever. The overall incidence of AEs is lower in patients receiving IV ibuprofen as compared to those receiving placebo in this integrated analysis. Specific analysis of hematological and renal effects showed no increased risk for patients receiving IV ibuprofen. A subset analysis of elderly patients suggests that no dose adjustment is needed in this higher risk population. This integrated safety analysis demonstrates that IV ibuprofen can be safely administered prior to surgery and continued in the postoperative period as a component of multimodal pain management.Keywords: NSAID, surgical pain, fever, perioperative analgesia, critical care, multimodal pain management

This thesis is an investigation into the effects of meloxicam and carprofen on renal function in dogs, when administered prior to anesthesia with painful stimulation designed to mimic surgical pain. Meloxicam and carprofen fulfill many of the requirements of the ideal analgesic; they are inexpensive, injectable, non-sedating and long-lasting. Increasing recognition of the advantages of pre-emptive analgesia has led clinicians to consider administering these drugs pre-operatively. Older drugs in this non-steroidal anti-inflammatory (NSAID) class were known to interfere with physiologic, renal-protective mechanisms that occur during anesthesia and surgery, making their use in the pre-surgical setting relatively contra-indicated. Meloxicam and carprofen, more recently developed NSAIDs, confer the advantage of being preferential for cyclo-oxygenase 2, and thus, potentially less nephrotoxic. The objective of the group of studies in this thesis was (1) to determine the intra-class correlation coefficient of measurement of glomerular filtration rate when determined by plasma clearance of 99mTc-diethylenetriaminepentaacetic acid, (2) to evaluate renal function in dogs following administration of meloxicam or carprofen prior to anesthesia with painful stimulation, and (3) to evaluate renal function in dogs subsequent to administration of meloxicam or carprofen prior to anesthesia with painful stimulation and concurrent hypovolemia. These studies demonstrate that plasma clearance of 99mTcDTPA, as performed by the author, has an intraclass correlation coefficient of 0.77. No significant differences in renal function were noted when meloxicam or carprofen, administered before anesthesia with painful stimulation, were compared to a saline placebo. Similarly, no significant differences in renal function were detected when meloxicam or carprofen, administered in the same experimental setting with the addition of hypovolemia, were compared to a saline placebo.

WOS: 000226069300053 PubMed: 15617601 WE REVIEWED MANY of the essential Greek myths to identify the methods used at that time to relieve the pain of both illness and surgery, and we discovered many pioneering methods. Both gods and demigods implemented these methods to ease pain, to conduct surgery, and, on occasion, to kill mythological beings. The myths describe the three most common components of anesthesia: hypnosis, amnesia, and (an)algesia. Drugs and music-aided hypnosis were two of the most common methods use to treat emotional and surgical pain. This article identifies highlights in the development of concepts to treat pain in Greek mythology. The examples found in the Greek myths remind us of the historical significance of pain treatment.

Effect of surgical pain stress on the blood-brain barrier permeability was investigated in rats. The animals were divided into four groups: Group 1: control, Group 2: immobilization stress, Group 3: acute hypertension, Group 4: immobilization stress + surgical pain stress. Bilateral hid paw surgical wounds for cannulations were applied in animals' inguinal regions under diethyl-ether anesthesia, then the animals were awaken from anesthesia to produce surgical pain stress. Evans-blue was used as a blood-brain barrier tracer. There is no significantly blood-brain barrier breakdown after short-time immobilization stress, but after adrenalin hypertension blood-brain barrier permeability was increased especially on frontal and occipital cortices in 50% of the animals. Surgical pain stress increased blood-brain barrier permeabiliy in comparison to acute adrenalin-induced hypertension (p < 0.01). In surgical pain stress-induced animals distinct Evans-blue leakage was observed in the occipital, frontal and parieto-temporal cortices.

Ovariohysterectomy in the rat led to the induction of abdominal postures and referred mechanical allodynia in the hind paws. The latter was differentiated into static and dynamic subtypes. The abdominal postures were present up to 4-5 h, whilst the two types of allodynia lasted for at least 2 days. A single administration of morphine 30 min before surgery dose-dependently (0.1-3 mg/kg, s.c.) blocked the development of abdominal postures and the two types of mechanical allodynia. The highest dose of morphine almost completely blocked these responses. The duration of action of 3 mg/kg morphine was short and similar (1.5-2 h) when administered either before or after surgery. However, multiple administrations of morphine (0.5 h before, and 0.5 and 2 h after surgery) blocked the development of abdominal postures and both allodynias for up to 2 days. In contrast, administration of three doses of morphine (3 mg/kg) in a similar dosing regime but starting 24 h after surgery, only blocked the two types of allodynia for 4 h. These data indicate the importance of blocking the induction phase of surgical pain and support the concept of pre-emptive analgesia. It is suggested that the ovariohysterectomy model should prove to be useful for studying mechanisms and designing novel therapeutic strategies for the treatment of post-operative pain.

Single oral doses of 100 and 200 mg indoprofen were compared with 600 mg aspirin and placebo in a double-blind, completely randomized study of hospitalized patients with postoperative, post-fracture, or musculoskeletal pain. The patients evaluated their pain for 5 hours after administration of the study drug. Each of the three active treatments performed significantly better than placebo. The 200-mg dose level of indoprofen demonstrated the greatest analgesic activity based on pain intensity and pain relief scores and on the patients' global evaluations. The analgesic activity of 100 mg indoprofen fell between that of 200 mg indoprofen and 600 mg aspirin and was not significantly different from either.

Fifty-four noncesarean cases in which epidural analgesia was used as the primary control of surgical pain in the dog are presented. The technique, indications, mechanisms of action, advantages, and disadvantages are discussed. Our experience with this proven technique has shown epidural analgesia to be an effective, practical, and simple means of operative pain control with wide application beyond the usual indication of cesarean section.

Twenty-six patients were treated for hemorrhoids by a combination of cryodestruction and closed operative hemorrhoidectomy. Patients were able to draw their own conclusions about the efficacies of these treatments. They had no difficulty in distinguishing exactly which area was causing pain. The operative site was a source of greater pain until the second day after the procedure, when the pain resulting from cryodestruction equalled surgical pain; then cryodestruction associated pain continued longer. Cryodestruction was associated with production of a foul discharge. Residual hemorrhoids were present in 50 per cent of patients' cryodestruction sites. Given the choice at the one year follow-up examination, 65 per cent preferred surgical treatment and 35 per cent preferred cryodestruction.

Dosage estimates of antiinflammatory drugs in human arthritis Phase II trials are difficult to obtain and prolong such trials unnecessarily. Antiinflammatory drugs almost always have analgesic properties in man and good dose estimates for analgesic activity can be obtained. In 140 patients with surgical pain, 300, 600, and 1200 mg of aspirin were compared to 75, 150, and 300 mg of 43–715 (1–isopropyl–4 phenyl–7–methyl–2 (1H) quinazolone), an antiinflammatory quinazolone derivative, for analgesia in a double—blind trial using subjective response methodology. The test drug was shown to be analgesic at a level four times more potent, milligram for milligram, than aspirin, an estimate that should be useful for later definitive Phase II trials in arthritis.