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Aim: To assess the efficiency and safety of parenteral analgesics for pain relief in acute pancreatitis., Materials and Methods: We carried out an electronic search of PubMed, Cochrane Library, EMBASE, WEIPU, CNKI and CBM and a manual search for eligible studies. The methodological quality of included trials and quality of evidence were examined by the Cochrane Collaboration's tool for assessing risk of bias and GRADE, respectively. The data were mainly analyzed descriptively and some were pooled by Review manager 5., Results: Eight randomized controlled trials with a total of 356 patients were finally included in this systematic review. Compared with procaine, pentazocine led to lower pain severity: day 1, Mean Difference (MD), 95%CI: 40.0 [35.3, 44.7]; day 2, MD, 95%CI: 24.00 [20.88, 27.12]; day 3, MD, 95%CI: 5.00 [2.17, 7.83], and it decreased the requirement for additional analgesics, Relative Risk, 95%CI: 2.23 [1.63, 3.05]. The combination of fentanyl, atropine, droperidol and lidocaine rendered lower pain score: day 1, MD, 95%CI: -5.46 [-6.95, -3.97]; day 2, MD, 95%CI: -5.78 [-7.39, -4.17]. Patients treated with metamizole tended to had lower pain than those treated with morphine, MD, 95%CI: -2.60 [-2.95, -2.25]. Nausea, emesis and vomiting were the common adverse events reported and there was almost no significant difference between different agents on safety., Conclusions: The systemic review showed that the randomized controlled trials comparing different analgesics were of low quality and did not favor clearly any particular analgesic for pain relief in acute pancreatitis., (Copyright © 2013 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

Aim: To assess the attitudes of clinicians to temperature management in haematology patients with febrile neutropenia., Method: An online scenario-based survey was circulated to consultant members of the New Zealand branch of the Haematology Society of Australia and New Zealand, to haematology advanced trainees, and to nursing representatives at each haematology department in New Zealand., Results: Eighty-eight responses were obtained, from 34 doctors and 54 nurses. Most respondents would advise a neutropenic patient to take paracetamol as needed for pain. Median temperature intervention threshold for an asymptomatic patient with febrile neutropenia was higher for doctors than for nurses (38.5 versus 38.0 degrees Celcius), despite considerable heterogeneity. Both groups indicated they would intervene at a median 38.0 degrees Celcius for a patient with rigors. Paracetamol was the preferred first-line cooling measure, with physical methods second-line, and pethidine third-line. All respondents favoured oral over intravenous or rectal paracetamol. Most believed a clinical trial of antipyretic treatment for febrile neutropenia was warranted, and indicated willingness to enrol their patients in such a study., Conclusion: This survey documents clinicians' preferred temperature intervention thresholds and methods for haematology patients with neutropenic fever, and shows considerable variation in practice. Most respondents supported a trial of antipyretic management in febrile neutropenia.

Background: The impact of cesarean section (CS) birth and pethidine for post-CS epidural analgesia on early breastfeeding behavior is unclear. This study aimed to measure infant sucking and breastfeeding behavior in infants of mothers who delivered by CS (CS group) and used pethidine patient-controlled epidural analgesia (PCEA) after CS with that of infants who were delivered by vaginal birth (V group), during secretory activation and again after the establishment of lactation., Subjects and Methods: Sucking dynamics and milk intake of breastfeeding infants were assessed on approximately 3 and 20 (follow-up) days postpartum (CS group, n=19; V group, n=15). Nipple diameters, tongue movement, and nipple position during sucking were measured from ultrasound scans of the intra-oral cavity during breastfeeding. Time of the first breastfeed and day of breast fullness were recorded, and infant neurobehavior was assessed., Results: CS infants displayed more anterior tongue movement on Day 3 than at follow-up compared with the V group, which showed a similar amount of movement at each assessment (p for interaction<0.001). Compared with the V group, the CS group showed faster suck rates, especially on Day 3 (p<0.001), later times to first breastfeed (p=0.01) and breast fullness (p=0.03), and lower neurobehavioral scores (p=0.047). Breastfeeding duration and milk intake were similar between groups., Conclusions: Although the observed effect of CS birth followed by pethidine PCEA after CS during the period of secretory activation was small, our results indicate that successful initiation of lactation may require additional breastfeeding support and monitoring at Day 3 postpartum for mothers who undergo CS.

Objective: Epigastric pain management following endoscopic submucosal dissection is an important consideration. This study aimed to investigate the utility and safety of fentanyl patches for pain relief after the procedure., Methods: Patients who were scheduled to undergo endoscopic submucosal dissection were prospectively randomised to either a transdermal fentanyl patch group or a placebo control group. An additional pethidine was intravenously administered when pain developed and a numerical rating scale was used to evaluate both pre- and post-procedural pain., Results: One hundred and ten patients were randomly assigned to receive either a 12 mcg/h fentanyl patch or a control patch on the night before the procedure. The fentanyl patch group had significantly lower pain scores immediately following the procedure (mean, 5.17 vs. 4.26, p=0.030). Maximal pain scores during the first 24 h (5.43 vs. 4.46, p=0.038) and pain scores on the day after the procedure (2.98 vs. 1.20, p<0.001) were also lower in the fentanyl patch group. In addition, the fentanyl patch group required a significantly lower dose of pethidine for pain management (24.54 vs. 11.25, p=0.004)., Conclusions: The application of a transdermal fentanyl patch is an effective, convenient, and safe method to control epigastric pain after endoscopic submucosal dissection., (Copyright © 2012 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: Wound infiltration with local anesthetics may improve postoperative analgesia. Tramadol has been shown to have effects similar to those of local anesthetics. The purpose of this study was to investigate the effects of wound infiltration with levobupivacaine and tramadol on postoperative analgesia for lumbar discectomies., Methods: Eighty adult patients who were scheduled to undergo elective lumbar discectomy operations were included in the study. Patients were randomly allocated to 4 groups: wound infiltration with 100 mg levobupivacaine (group L), 2 mg/kg tramadol (group T), 2 mg/kg tramadol plus 100 mg levobupivacaine (group LT), and saline (group C). Pain scores with the visual analog scale, patient-controlled analgesic consumption (pethidine), time to first analgesic treatment, and side effects were assessed during the postoperative period., Results: The time to first analgesia was earliest in group C (11.3±2.2 min), followed by group L (163.0±216.3 min) and group T (803.2±268.4 min) (P<0.001). None of the patients in group LT required postoperative analgesic supplementation, and the visual analog scale scores were <3 at all measurement times (P<0.05). Postoperative opioid consumption was 196.0±71.6 mg in group C, 129.0±78.3 mg in group L, and 37.0±35.4 mg in group T (P<0.001). The incidence of side effects was lower in group LT than in the other groups., Conclusions: Wound infiltration with combined levobupivacaine and tramadol resulted in elimination of postoperative analgesic demand and reduction in the incidence of side effects. We conclude that infiltration of the wound site with combined levobupivacaine and tramadol provides significantly better analgesia compared with levobupivacaine or tramadol alone.

Study Objective: To evaluate whether intraoperative low-dose lidocaine infusion decreases postoperative analgesic consumption, ileus, and duration of hospital stay., Design: Prospective, randomized, double-blinded trial., Setting: Operating room in a university hospital., Patients: 48 ASA physical status 1 and 2 men scheduled for subtotal gastrectomy., Interventions: Patients were randomly allocated to two groups to receive either intravenous (IV) lidocaine 1.5 mg/kg 20 minutes before incision followed by a continuous lidocaine infusion of 1.5 mg/kg/hr until the end of surgery (lidocaine group) or saline in a similar manner (control group)., Measurements: Outcomes such as pain intensity, postoperative analgesic consumption, duration of ileus, and hospital length of stay (LOS) were recorded., Main Results: There were no differences in total consumption of IV patient-controlled analgesia (IVPCA) or pain scores at 24, 48, or 72 hours postoperatively. However, lidocaine group patients had significantly decreased average supplemental pethidine requirement per patient for pain control until 72 hours postoperatively [150 (75-200) mg vs 50 (50-150) mg, P = 0.039] and hospital LOS (9.5 ± 3 d vs 8.7 ± 1 d, P = 0.006, 95% CI: - 0.3 - 1.9 d) than control group patients. However, no differences were noted between the groups in pain intensity or duration of ileus., Conclusions: Intraoperative IV low-dose lidocaine infusion decreased opioid consumption and hospital LOS after gastrectomy., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: To compare post-operative outcomes between tubeless and conventional large-bore nephrostomy tube drainage following percutaneous nephrolithotomy in children., Methods: The study comprised 54 patients under 14 years of age who were undergoing percutaneous nephrolithotomy at 60 renal units and met the inclusion criteria. They were randomised to placement of a 16F nephrostomy tube (Group A, 30 renal units) or tubeless drainage (Group B, 30 renal units) at the end of the procedure. Patient age, number and position of stones, operating time, change in haemoglobin, post-operative analgesia requirement, length of hospital stay and post-operative complications were compared between the two groups, using SPSS version 17 and t test., Results: Group A had 28 patients, while Group B had 26. The mean age in Group A was 7.2 +/- 3.2 years, and in Group B it was 6.3 +/- 3.6 years (age range 3-13 years and 1-13 years respectively). The mean size of stone was 28.6 +/- 16.7mm and 20.4 +/- 9.3mm; mean change in Hb was 0.78 +/- 0.69mg/dl and 0.63 +/- 0.54mg/dl; and the mean operating time was 54 +/- 20.7 minutes versus 66.9 +/- 22.9 minutes in the two groups respectively. There was significantly less requirement for post-operative pethidine in Group B versus Group A (p=0.01). The postoperative clearance and complications were comparable between the two groups, while the duration of hospital stay was significantly shorter in Group B compared to Group A (p=0.007)., Conclusion: Tubeless percutaneous nephrolithotomy in children is safe and effective. Post-operative analgesia requirement is less and hospital stay is shortened compared to the conventional nephrostomy placement after percutaneous nephrolithotomy.

Background: Colonoscopy is the gold standard in diagnosis of diseases of the colon. Sedation and antispasmodic agents are recommended during colonoscopy. Age is a limiting factor when the surgeon is deciding whether to use these medications or not., Subjects and Methods: One hundred twenty patients older than 65 years of age were randomized into two groups. The first group (n=60) received 2 mg of midazolam and 25 mg of meperidine intravenously. The second group (n=60) received 2 mg of midazolam and 20 mg of hyoscine N-butylbromide intravenously. The data collected were colonoscopy procedure time, time to cecum, visual analog pain scale, systolic blood pressure before and after the procedure, pulse, partial oxygen pressure, comfort of the endoscopist, the modified observer's assessment of alertness/sedation scale, and morbidity., Results: Total colonoscopy and cecal reach times were shorter in Group 2 (19.58±4.82 minutes and 10.57±2.54 minutes, respectively) than in Group 1 (25.05±5.93 minutes and 13.78±3.37 minutes, respectively) (P<.001). The sedation score of Group 2 (4.52±0.50) was better than that of Group 1 (3.45±0.75) (P<.001). Nine patients (15%) in Group 1 experienced diaphoresis, temporary memory loss, or lip smacking. Three patients in Group 1 and 1 patient in Group 2 had hypoxia. Three patients in Group 1 had hypotension; this was seen in 1 patient in Group 2. One patient had perforation in Group 1. The visual analog scale score was 4.37±1.38, and the endoscopist satisfaction was 6.72±0.99 in Group 1, while these values were 3.95±0.81 and 7.75±0.89, respectively, in Group 2 (P>.05)., Conclusions: Use of midazolam and hyoscine N-butylbromide during colonoscopy is safe in the elderly and significantly reduces procedure time while increasing comfort for the endoscopist.

Objective: To compare postoperative pain perception and analgesia requirements in patients undergoing cesarean section (CS) using general versus spinal anesthesia., Study Design: A prospective, observational study of patients undergoing elective CS during 2009 under either general or spinal anesthesia. Postoperative pain intensity and analgesia requirements were evaluated for up to 48 h after surgery., Results: A total of 153 women were enrolled; 77 received general and 76 received regional anesthesia. Postoperative meperidine requirements in the first 24 h were significantly higher in the general anesthesia group. Pain scores were mostly comparable between the groups. Nevertheless, lower pain scores were graded after 8 h in the general versus the spinal anesthesia and this reversed at 48 h., Conclusion: Spinal anesthesia is comparable to general anesthesia in terms of post-operative pain control. In choosing the type of anesthesia in CS, other factors such as the urgency and potential maternal and fetal hazards should be taken into account.

Objective: To evaluate the efficacy and adverse effects of an intravenous infusion of 1000 mg of paracetamol as compared with an intravenous injection of 50mg of pethidine hydrochloride for intrapartum analgesia., Methods: In a randomized prospective study at Ain Shams University, Cairo, Egypt, between April and August 2010, 102 low-risk primiparous women in active labor were allocated to received either paracetamol (n=52) or pethidine hydrochloride (n=50). The primary outcome was the efficacy of the drug to supply adequate analgesia as measured by a change in the visual analog scale (VAS) pain intensity score at various times after drug administration. The secondary outcomes included the need for additional rescue analgesia and the presence of adverse maternal or fetal events., Results: As recorded by the VAS score, there was significant pain reduction at 15 minutes, and at 1 and 2 hours in both groups (P<0.001). The reduction in pain was significantly greater in the pethidine group only at 15 minutes (P=0.004). None of the women in the paracetamol group had adverse effects, as compared with 64% of the women receiving pethidine., Conclusion: The effectiveness of intravenous paracetamol was comparable to that of intravenous pethidine, but paracetamol had fewer maternal adverse effects., (Copyright © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

Objectives: To investigate the trends and characteristics of pethidine prescriptions and users in Taiwan from 2002 to 2007., Method: All pethidine users (n = 3,301,136) in Taiwan from 2002 to 2007 were linked to National Health Insurance claims to identify pethidine prescriptions. We examined the trends in pethidine user prevalence and the proportion of pethidine prescriptions according to health care characteristics. A logistic regression model was used to compare patient demographics and health care characteristics associated with pethidine prescriptions between 2002 and 2007., Results: Despite the decline in the number of pethidine users and prescriptions over the six-year period, more than half a million people were prescribed pethidine annually. In fact, an increasing proportion of pethidine prescriptions were observed in clinics, outpatient settings, and patients who had both operations and cancer diagnoses. Pethidine prescriptions were mostly associated with a non-operation status without a cancer diagnosis (>60%). However, approximately 10% of the total pethidine prescriptions were found in patients with a cancer diagnosis but no operation. Compared to those in 2002, pethidine prescriptions in 2007 were more likely to be found in people 80 years or older, rural residents, patients from clinics, outpatient settings and operation patients with cancer diagnoses., Conclusions: A population-based survey in Taiwan demonstrated decreasing consumption of pethidine from 2002 to 2007; however, an increased proportion of prescriptions in certain health care settings was observed. In addition, 10% of the pethidine prescriptions were for cancer patients without operations. These cases need further evaluation for the determination of appropriate pethidine use.

Background/aims: Although carbon dioxide (CO2) insufflation has successfully replaced air insufflation in a variety of procedures, the effects of CO2-insufflation in esophageal endoscopic submucosal dissection (ESD) have not been adequately investigated. This study was designed to evaluate the effects of CO2 insufflation in esophageal ESD., Methodology: From January 2009 to January 2011, 57 superficial esophageal neoplasias in 54 patients (51 men and 3 women) were treated under conscious sedation with midazolam and pethidine hydrochloride, using ESD technique with a combination of small-caliber-tip transparent hood and flex knife. They were divided into air-insufflation (39 lesions, 37 patients) and CO2-insufflation (18 lesions, 17 patients) groups and therapeutic efficacy and complications were retrospectively evaluated in each group., Results: The rate of en bloc resection was 100% and there were no complications in each group. No significant differences were seen in procedural time, the amount of pethidine hydrochloride required, body temperature and white blood cell count on post-procedure day 1, and length of hospital stay after ESD. A difference in the amount of midazolam required between the air-insufflation group and the CO2-insufflation group was noted (6mg vs. 4mg, p=0.0017)., Conclusions: CO2-insufflation could be considered useful for reducing patients' discomfort in esophageal ESD.

Purpose: Gabapentin has demonstrated analgesic effects in some studies. This double blind randomized clinical trial (RCT) was conducted to evaluate whether the pre-emptive use of gabapentin 600 mg could reduce postoperative pain, nausea and vomiting, and meperidine consumption in patients after hysterectomy., Methods: Between 2009 and 2010, a total of 170 patients who were candidates for abdominal hysterectomy were assessed for eligibility to enter the study. Thirty patients were excluded for different reasons; and 140 included patients were randomly assigned to one of two groups according to the method of treatment, gabapentin or placebo, in a double-blind manner before hysterectomy. Postoperatively, the pain was assessed on a visual analogue scale (VAS) at 1, 4, 8, 12 and 24 h at rest. Meperidine intramuscularly was used to treat postoperative pain on VAS score and patients demand. Total meperidine and anti emetic drug consumption in the first 24 h after surgery was also recorded. The trial is registered at irct.ir, number IRCT201106186829N1., Results: Patients in the gabapentin group had significantly lower VAS scores at all time intervals, than those in the placebo group. The total meperidine consumed in the gabapentin group was significantly less than in the placebo group. Postoperative nausea and vomiting (PONV) and anti emetic drug consumption were significantly decreased in gabapentin group., Conclusion: Pre-emptive use of gabapentin 600 mg orally, significantly decreases postoperative pain and PONV, and also rescues analgesic and anti emetic drug requirements in patients who undergo abdominal hysterectomy.

Aim: The aim of this study was to evaluate the effectiveness of meperidine, administered during the first stage of labor in patients with uterine dystocia, on the duration of labor and neonatal acid-base status at birth., Material and Methods: We randomly assigned 240 nulliparous women with a singleton pregnancy at term who were diagnosed with uterine dystocia in labor at 4-6-cm cervical dilatation to receive either a single dose of 50 mg meperidine in 10 mL of saline (slow intravenous injection over 2 min) or 10 mL of isotonic saline (control group). The primary outcome measures were duration of labor (from the time of beginning of the intervention to the time of the expulsion of the fetal head) and umbilical cord arterial acid-base status., Results: The evidence revealed no statistically significant difference between the two groups in length of labor (188.2 ± 92.3 min in the meperidine group compared to 205.4 ± 96.1 min in the placebo group, P = 0.159). The pH of the umbilical cord arterial samples was lower in the meperidine group than in the control group, although the difference was not statistically significant (P = 0.089)., Conclusion: Because of the absence of any beneficial effect of meperidine on uterine dystocia, its use in labor should be limited to pain relief in the absence of epidural analgesia., (© 2012 The Authors. Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology.)

Purpose: To evaluate the impact of a prescriber focused individual educational and audit-feedback intervention undertaken by the Nova Scotia Prescription Monitoring Program (NSPMP) in March/April 2007 to reduce meperidine use., Method: The NSPMP records all prescriptions for controlled substances dispensed in community pharmacies in Nova Scotia, Canada. Oral meperidine use from 1 July 2005 to 31 December 2009 was examined using NSPMP data. Monthly totals for the following were obtained: number of individual patients who filled at least one meperidine prescription, number of prescriptions, and number of tablets dispensed. Data were analyzed graphically to observe overall trends. The intervention effect was estimated on the logarithmic scale with autocorrelations over time modeled by an integrated autoregressive moving average model for each outcome measure., Results: An overall trend toward decreasing use from July 2005 to December 2009 was apparent for all three outcome measures. The intervention was associated with a statistically significant reduction in meperidine use, after adjusting for the overall long-term trend. Compared with the pre-intervention period, the monthly number of patients declined by 12% (p < 0.001; 95% confidence interval [CI] = 5%-18%), prescriptions by 10% (p < 0.001; 95%CI = 3%-17%), and tablets by 13.5% (p < 0.001, 95%CI = 6%-29%) in the post-intervention period., Conclusion: Given the risks associated with meperidine, determining that this intervention successfully reduced meperidine use is encouraging. This study highlights the potential for using population data such as the NSPMP to evaluate the effectiveness of population-level interventions to improve medication use, including professional, organizational, financial, and regulatory initiatives., (Copyright © 2011 John Wiley & Sons, Ltd.)

One of the most common complications of operation and anesthesia is shivering. The purpose of this study was to compare the effectiveness of Ondanseton and Meperedine in preventing shivering after off-pump coronary artery bypass graft (OPCAB). In this double-blind randomized clinical trial, the sample consisted of 90 patients, who were candidates of CABG under general anesthesia. These patients were assigned to three groups, each containing 30 subjects: meperedine group (A), ondansetron group (B) and control group (C). Group (A) received 0.4 mg/Kg/IV of meperedine, group (B) received 8mg/IV of ondansetron and group (C) received Normal Saline. All these drugs were injected 15 minutes before the end of surgery. After the end of surgery, the intubated patients were transferred to the ICU and their body temperature was assessed through eardrum by a specialist who was blind to the research. The incidence of shivering in groups A, B, and C was 46.48%, 31.18%, and 60.83%, respectively (P=<0.01). The incidence of shivering was 64.4% in males and 35.6% in females (P=0.222). Also, the amount of incidence of shivering up to 3 hours after surgery was 75.87 % (P=0.064). Bradycardia was 3.3% in group (A) and 0.0 % in group (B). Other variables (myoclonus, seizure and rash) showed no statistically significant difference (P=0.353). According to the findings, it was demonstrated that ondansetron is more effective in preventing shivering after Off-pump CABG than meperedine.

Objective: To determine the effectiveness of preoperative parecoxib sodium injection for pain relief after laparoscopic gynecologic surgery., Material and Method: A prospective double-blind, randomized study was conducted in 268 patients who underwent laparoscopic gynecologic surgery at Vajira Hospital between November 1, 2010 and March 31, 2011. The patients were randomly allocated into two groups to receive either single intravenous 40 mg parecoxib (treatment group; n = 133) or normal saline (control group; n = 135) 30 min before surgery. The degree of postoperative pain was assessed every 2 h in the first 8 h postoperation, then every 4 h until completion of 24 h by using a verbal rating scale. Total consumption of meperidine over a 24-h period and the adverse events relevant to parecoxib sodium were also recorded., Results: Mean pain scores at all measured times in the treatment group were insignificantly lower than those in the control group (p = 0.106). The mean 24-h postoperative meperidine consumption in the treatment group was significantly lower compared to that in the control group (26.3 +/- 28.1 mg and 39.1 +/- 34.6 mg, respectively, p = 0.001). The proportion of patients requiring meperidine in the treatment group was significantly lower than that in the control group (58.6% and 70.3%, respectively, p = 0. 045). No serious adverse events were observed in both groups., Conclusion: Preoperative parecoxib sodium significantly reduced postoperative meperidine requirement and consumption, while insignificantly declined the pain scores. Serious adverse events were not encountered

Background: Remifentanil is an ultrashort-acting opioid with favorable pharmacokinetic properties that make it suitable as a labor analgesic. Although it crosses the placenta freely, it is eliminated quickly in the neonate by rapid metabolism and redistribution. We aimed to determine whether remifentanil compared with meperidine is effective in reducing pain scores in laboring parturients. Other effects on the mother, the labor process, and the neonate were also examined., Methods: MEDLINE, CINAHL, Embase, Cochrane CENTRAL, and Maternity and Infant Care databases were searched without language restriction using multiple keywords for labor analgesia, remifentanil, and meperidine. Published abstracts from 5 key research meetings and references from retrieved articles were examined for additional studies. Randomized controlled trials in laboring parturients comparing remifentanil with meperidine were selected. Risk of bias was assessed using criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We assessed for adequacy of sequence generation, allocation concealment, blinding, and completeness of follow-up. Data were extracted from each study using a standardized data collection form. The primary outcome was reduction in pain scores (visual analog scale [VAS], 0-100 mm). We also evaluated maternal side effects (sedation, oxygen desaturation, and bradypnea) and effects on the neonate (Apgar scores, umbilical cord pH, and Neurologic and Adaptive Capacity Scores)., Results: Seven studies (349 patients) were identified for inclusion; only 3 studies were suitable for quantitative synthesis in a meta-analysis (233 patients). We found that remifentanil reduces the mean VAS score at 1 hour by 25 mm more than meperidine (P < 0.001) (95% confidence interval = 19-31 mm). Limited conclusions can be made regarding the side-effect profile of remifentanil because of insufficient data., Conclusion: Compared with meperidine, remifentanil is superior in reducing mean VAS scores for labor pain after 1 hour.

Postanesthesia shivering is an undesirable event that may induce a variety of adverse consequences including patient discomfort, increased oxygen consumption and wound pain. Thus, its pharmacological treatment should be regarded. The purpose of this study was to compare the efficacy of morphine, fentanyl and pethidine for the treatment of postanesthesia shivering. Fifty patients who developed shivering were treated in a randomized double blinded manner with an intravenous bolus dose of 2 or 4 mg morphine, 25 or 50 mg pethidine, and 50 μg fentanyl. Then, they were monitored for 30 minutes and the shivering suppression grade, the time taken to stop shivering, the shivering cessation time, recurrence of shivering and opioid side effects were evaluated. Core body temperature was measured immediately before, and at 15 and 30 minute after administering the drug. The groups did not differ significantly regarding shivering suppression grade, shivering cessation time, and recurrence of shivering. There was a significant difference in the time taken to stop shivering between groups. Following injection of the drugs, the core temperatures increased in the five groups with statistical difference. All opioids were effective in treating postanesthesia shivering in a similar extent.

Background: Intramuscular pethidine is routinely used throughout the UK for labour analgesia. Studies have suggested that pethidine provides little pain relief in labour and has a number of side effects affecting mother and neonate. It can cause nausea, vomiting and dysphoria in mothers and can cause reduced fetal heart rate variability and accelerations. Neonatal effects include respiratory depression and impaired feeding. There are few large studies comparing the relative side effects and efficacy of different opioids in labour. A small trial comparing intramuscular pethidine with diamorphine, showed diamorphine to have some benefits over pethidine when used for labour analgesia but the study did not investigate the adverse effects of either opioid., Methods: The Intramuscular Diamorphine versus Intramuscular Pethidine (IDvIP) trial is a randomised double-blind two centre controlled trial comparing intramuscular diamorphine and pethidine regarding their analgesic efficacy in labour and their side effects in mother, fetus and neonate. Information about the trial will be provided to women in the antenatal period or in early labour. Consent and recruitment to the trial will be obtained when the mother requests opioid analgesia. The sample size requirement is 406 women with data on primary outcomes. The maternal primary outcomes are pain relief during the first 3 hours after trial analgesia and specifically pain relief after 60 minutes. The neonatal primary outcomes are need for resuscitation and Apgar Score <7 at 1 minute. The secondary outcomes are an additional measure of pain relief, maternal sedation, nausea and vomiting, maternal oxygen saturation, satisfaction with analgesia, whether method of analgesia would be used again, use of Entonox, umbilical arterial and venous pH, fetal heart rate, meconium staining, time from delivery to first breath, Apgar scores at 5 mins, naloxone requirement, transfer to neonatal intensive care unit, neonatal haemoglobin oxygen saturation at 30, 60, 90, and 120 mins after delivery, and neonatal sedation and feeding behaviour during first 2 hours., Discussion: If the trial demonstrates that diamorphine provides better analgesia with fewer side effects in mother and neonate this could lead to a change in national practice and result in diamorphine becoming the preferred intramuscular opioid for analgesia in labour., Trial Registration: ISRCTN14898678Eudra No: 2006-003250-18, REC Reference No: 06/Q1702/95, MHRA Authorisation No: 1443/0001/001-0001, NIHR UKCRN reference 6895, RfPB grant PB-PG-0407-13170&#95;IR5.

Objective: This study is aimed at evaluating the attitude and knowledge about the optimal use of opioids and finding out the barriers to cancer pain management especially for young doctors in South Korea., Methods: A survey through questionnaire form was conducted on 1204 physicians. Physicians were grouped by their medical specialties and personal characteristics. Specialties were grouped into internal medicine and family medicine doctors, surgeons, anesthesiologists, pediatricians, other board holders and general physicians. Personal characteristics were grouped by their past experiences and current surroundings., Results: Though many doctors thought that they were fairly well educated for pain management strategy, a large population of physicians showed a negative attitude and inadequate knowledge status about cancer pain management. The degree of attitude and knowledge status was different as their specialties and personal experiences. The factors that affected doctors' attitude and knowledge were: (i) medical specialty, (ii) past history of using practical pain assessment tool, (iii) self-perception of knowledge status about pain management, (iv) experience of prescribing opioids, (v) experience of education for cancer pain management. Although many physicians had a passive attitude in prescribing opioid analgesics, they are willingly open to use opioids for cancer pain management in the future. The most important perceived barriers to optimal cancer pain management were the fear for risk of tolerance, drug addiction, side effects of opioid analgesics and knowledge deficit about opioid analgesics., Conclusions: From this study, we found that further education and practical training will be needed for adequate cancer pain management for young physicians in their early career.

Purpose: To evaluate the analgesic efficacy of local subcutaneous (SC) anesthesia compared with intramuscular (IM) opioid sedation during extracorporeal shockwave lithotripsy (SWL) in a randomized study., Patients and Methods: After informed consent was obtained, 125 patients with urolithiasis who were scheduled for SWL were included in the study. The patients in each treatment session were randomized to receive either IM meperidine (group A) or SC infiltration of 10 mL 2% lidocaine and 10 mL 0.5% bupivacaine at the area of shockwave entry (group B). Degree of pain was rated by the patient using a five-point visual analogue scale (VAS)., Results: The study included 88 (70.4%) men and 37 (29.6%) women with a mean age of 47.6 ± 12.5 years and a mean body mass index (BMI) of 28.16 ± 4.67 kg/m2. Of the patients, 89, 26, and 10 received a single, two, or more than two treatment sessions, respectively (176 sessions). Maximum stone length was 10.68 ± 5.12 mm. Pretreatment stent placement was performed in 17 (13.6%) patients (28 sessions). Group A comprised 89 treatment sessions while 87 were involved in group B. Both groups were similar. Supplemental intrvenous sedation was needed in two (2.5%) and four (4.6%) sessions in groups A and B, respectively. VAS was not different between both groups (P = 0.063). Patients with pretreatment stent placement had significantly lower VAS score compared with patients without stents (P = 0.012). Sex and BMI had no impact on the VAS score., Conclusions: Local SC anesthesia alone is effective for analgesic purposes during extracorporeal SWL. Sex, age, and BMI have no relation to analgesia requirement.

Controversial reports exist regarding the administration of spinal anesthesia in achondroplastic dwarfs regarding safety, dose, drug choice, in obstetric patients. Bony characteristics such as vertebral anomalies, lordosis and lumbar scoliosis, limited mouth opening and cervical spine instability make the administration of anesthesia to these patients truly a challenge. Here we demonstrate that low dose meperidine and bupivacaine spinal anesthesia in an achondroplastic parturient for cesarean section, was administered successfully after careful evaluation, consideration of risks, and awareness of potential complications.

Brittle cornea syndrome (BCS) is a rare autosomal recessive disease that affects the connective tissue. The syndrome is caused by genetic changes in the 4.7-Mb interval between the D16S3423 and D16S3425 markers on the 16q24 chromosome and mutations in the Zinc-Finger 469 gene (ZNF469). BCS is characterized by thin and fragile cornea that tends to perforate spontaneously or as a result of minor trauma to the eye. In addition, the patient usually suffers from hearing loss, mental retardation, hyperextensibility of skin and joints, as well as varying degrees of scoliosis. This phenotypical expression presents an interesting challenge to anesthetic care. We briefly present the perioperative management of a patient with BCS who underwent three cesarean sections.

Background: Recurrence of Crohn's disease (CD) most commonly occurs in the neoterminal ileum near the stoma after fecal diverting ileostomy. Methods used to assess CD recurrence include small bowel series, ileostomy injection, computed tomography (CT) enterography, and capsule endoscopy. Retrograde ileoscopy via stoma is also a valuable tool for recognition of CD recurrence; however, this technique has not been formally studied., Objective: To evaluate the safety and utility of retrograde ileoscopy via stoma in patients with CD., Methods: Patients with CD who underwent ileoscopy via stoma between January 1, 2001, through December 31, 2008 were included. This was a retrospective study in a tertiary referral center. The main outcome measures were procedural complications and findings., Results: A total of 243 ileoscopies were performed on 99 patients. The most common indications for ileoscopy were CD activity assessment in 34.5% and abdominal pain in 33.3%. The procedure was outpatient in 75.8%. Meperidine and midazolam were most commonly used. Average depth of intubation was 28.4 cm. CD recurrence was detected in 70% of patients. Biopsies were obtained during ileoscopy in 117 studies, and biopsy and ileoscopy findings correlated in 111 studies (94.8%). One polypectomy, 24 balloon stricture dilations, and 8 intralesional steroid injections were performed. All patients tolerated the procedure well without procedure- or anesthesia-related complications. No hospital admissions or procedure-related deaths occurred., Conclusions: Retrograde ileoscopy via stoma is a safe and effective procedure for evaluating recurrence of CD of the neoterminal ileum. It also allows for therapeutic interventions such as balloon dilatation of ileal strictures and steroid injections.

Aims: This study aimed to compare pethidine and morphine on efficacy and toxicity in children with severe mucositis following chemotherapies., Patients and Methods: From March 2000 to November 2003, 35 hospitalized children with chemotherapy-related mucositis were randomly assigned to receive double blindly "patient-controlled analgesia" (PCA) bolus doses of morphine or pethidine. The mucositis pain score was the mean of pain measured four times a day with a Visual Analogue Scale from day 2 to 5 of PCA., Results: Study stops before total accrual for difficulties of recruitment. Out of the 29 patients with more than one day of PCA, the median (range) of the Mean Pain Score was 44 (13-72) and 33 (3-89) in the morphine (n = 14) and pethidine (n = 15) groups, respectively (P = 0.32). PCA was stopped for failure in 10 cases (five in each group). Constipation requiring specific treatment was higher in the morphine group (43% versus 0%)., Conclusions: PCA with pethidine appears not inferior to morphine, with less constipation requiring specific treatment, but a larger study is warranted to confirm this.

Background: Postoperative shivering is one of the common problems following general anesthesia and may lead to multiple complications. The aim of this study was to examine the preventive effects of Ondansetron and Meperidine on postoperative shivering., Methods: This randomized placebo-controlled double blind clinical trial included 90 patients scheduled for elective gynecologic operations, randomly divided to three groups. Ondansetron (4 mg), Meperidine (0.4 mg/kg) and 2 cc normal saline (as a control group) were administered immediately before the induction of anesthesia. Anesthesia induced equivalently for all. Patients were observed in terms of vital signs, side effects and shivering., Results: Postoperative shivering was observed in 13.3% of patients in Ondansetron group and 20% of Meperidine group, significantly lower than the controls (50%). The reduction of core and dermal temperature during the anesthesia and recovery, changes in systolic and diastolic blood pressure and heart rate were similar in all three groups. The incidence of nausea was similar among the three groups of study while vomiting occurred in 6.7% of the Meperidine group and 3.3% of the controls but none in the patients receiving Ondansetron., Conclusion: Ondansetron can effectively reduce post operative shivering.

To determine the effect of adding ketamine to pethidine in reducing post-operative pain in patients undergoing major abdominal operations, in a double blind randomized controlled trial, 100 patients aged 15-60 years who were candidate for elective major abdominal surgery allocated into two groups of pethidine + ketamine group (5 mg pethidine and 0.25 mg kg(-1) ketamine) or pethidine and placebo group (10 mg pethidine and NS) according to the regimen prescribed in postanesthesia care unit. Severity of pain (using visual analogue scale), prescribed dose of pethidine and side effects were recorded until 24 h after operation. Regarding post-operative pain, pethidine + ketamine group showed significant lower scores in all the times except 0 min, 2, 6 and 16 h. Nausea was significantly less frequent amongst pethidine + placebo group at times of 0, 15, 30 and 45 min (p < 0.05). Comparison of two groups did not show significant differences in prescribed pethedine dose in 0, 9, 12, 16, 20 and 24 h (p > 0.05). Yet, the mean dose of administered pethidine as rescue analgesic was significant lower in pethidine + ketamine group compared to pethidine + placebo group (112 +/- 31.5 mg vs. 133.5 +/- 24.5 mg, p < 0.001). In conclusion, our results showed that co-administration of ketamine and pethidine in postanesthesia care unit will improve postoperative pain and reduce narcotic consumption. It may, however, increase rate of postoperative nausea in the first hour after operation.

Objective: To examine maternal birth outcomes and birth experiences of low-risk women in the Netherlands in different sized midwifery practices., Design: Descriptive study using postal questionnaires six weeks after the estimated due date., Setting: Women were recruited from urban, semi-rural and rural areas from small-sized practices (1-2 midwives), medium-sized practices (3-4 midwives) or large-sized practices (5 or more)., Participants: 718 Dutch speaking women with uncomplicated pregnancies, a representative sample of women in 143 midwifery practices in the Netherlands who had given birth in the period between 20 April and 20 May 2007., Measurements: Distribution of place of birth categories and intervention categories, birth experience, woman-midwife relationship and presence of own midwife after referral. Data were analyzed with Statistical Package for Social Sciences (SPSS)., Findings: Women in practices with a maximum of two midwives were significantly more likely to experience lower rates of referral, interventions in general and specifically pain relief by means of pethidine, CTG registration and unplanned caesarean sections. Women with a maximum of two midwives were significantly more likely to know their midwife or midwives and were more frequently supported by their own midwife after referral in comparison to women in practices with more than two midwives. The presence of the woman's own midwife added value to the birth experience. Women with a maximum of two midwives had higher levels of a positive birth experience than women in practices with more than two midwives., Key Conclusion: Midwifery practices with a maximum of two midwives contribute to non-interventionist birth and a positive birth experience., Implications: Awareness of the study results and further study is recommended to discuss reorganization of care in order to achieve significant reductions on referral and interventions during childbirth and positive maternal birth experiences., (Copyright (c) 2010 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Despite progress in management, patients with sickle cell disease who are experiencing acute painful episode are often incompletely treated. We compared meperidine and tramadol with respect to their effects on the hemodynamics and pain relief in patients with sickle cell disease who were admitted to the emergency department with painful crisis. A total of 68 patients with sickle cell disease were randomly assigned to receive either tramadol 1.5 mg/kg (n = 34) or meperidine 1 mg/kg (n = 34). Hemodynamic parameters were recorded at regular intervals after analgesic infusions. Pain intensity and relief were documented by visual analog and pain relief scale, respectively. Sedation level was defined according to Ramsay sedation scale. Both meperidine and tramadol administration resulted in a significant reduction in systolic and diastolic blood pressure after 2 hours (P < .05). Efficacy in pain relief between the analgesics was more rapid and better in the meperidine group, although the degree of relief were significantly improved compared to baseline levels in both groups (P < .05). Sedation was more commonly seen in the meperidine arm. None of the patients had experienced neurotoxicity. In summary, both agents had proven safe and effective for emergent use in patients with sickle cell disease. Avoiding meperidine injections as recommended with previous guidelines needs to be carefully reconsidered especially when low doses are mentioned., ((c) 2010. Published by Elsevier Inc.)

Objectives: Administering analgesia to patients with abdominal pain before diagnostic imaging is now accepted as standard practice. However, analgesia before diagnostic right upper quadrant ultrasound continues to be controversial for fear of masking the sonographic Murphy's sign (SMS). This study sought to evaluate the impact of analgesia on the accuracy of the SMS in predicting cholecystitis. We hypothesized that the impact of analgesia on radiologist-performed ultrasound and emergency physician (EP)-performed ultrasound would be equivalent., Methods: Thirty patients presenting to the emergency department with abdominal pain were randomized to receive placebo or meperidine for the first two doses of medication. The patients underwent EP performed right upper quadrant ultrasound before and after the administration of medication, in addition to receiving a radiology department ultrasound postmedication. The presence of SMS was then compared with final hospital or pathological diagnosis., Results: Eleven of 30 patients (37%) had a final diagnosis of cholecystitis and only one patient had a change in their SMS postmedication. The EP assessment for postmedication SMS had a sensitivity of 0.82 [confidence interval (CI): 0.48-0.97] and specificity of 0.95 (CI: 0.71-0.99) for cholecystitis. The radiology assessment for postmedication SMS had a sensitivity of 0.17 (CI: 0.01-0.63) and specificity of 1 (CI: 0.74-1) for cholecystitis., Conclusion: This pilot study shows that analgesia does not significantly change the assessment of SMS when performed by an EP sonographer. It also suggests that EP-performed ultrasound may be more accurate in assessing this predictive sign of cholecystitis.

Introduction: Tonsillectomy is frequently associated with postoperative pain of considerable duration, which is usually accompanied by the substantial consumption of both opioid and non-opioid analgesic such as NSAIDs and local anaesthetics., Objective: The aim of this study was to evaluate the efficacy between 2% viscous lignocaine and sodium diclofenac based upon the visual analogue scores (VASs), consumption of pethidine 0.5mgkg(-1) as the rescue drug postoperatively and time taken to resume feeding., Methods: 130 patients aged between 5 and 12 years old were randomly allocated into 2 groups to be given either 2% viscous lignocaine 4mgkg(-1) body weight topically post-tonsillectomy or sodium diclofenac 1mgkg(-1) per-rectal post-induction of anaesthesia. Postoperatively visual analogues score was done for 24h, the amount of pethidine given and time when the patient start taking oral feeding of clear fluid, soft diet and normal diet were documented., Results: There was no significant difference in the visual analogue scores in both groups, however the requirement of pethidine as the rescue drug postoperatively was significant 2h post-tonsillectomy (p=0.023) in viscous lignocaine group compared to sodium diclofenac. The time taken to resume oral feeding and soft diet was also significant in viscous lignocaine group (p=0.016 and p=0.007) whereas there was no significant in taking normal diet., Conclusion: We concluded that 2% viscous lignocaine applied topically post-tonsillectomy is comparable to sodium diclofenac per-rectal in providing analgesia and faster oral feeding.

Introduction: Anxious patients can cause unexpected increases in healthcare costs that are often overlooked. There are no studies examining the use of an educational pamphlet and its effects on secondary outcomes at colonoscopy. The goal of this study was to determine if the use of an educational pamphlet lowers the anxiety levels before colonoscopy, and if its use has any effect on the quality of the prep or medication or the amount of medication use during the procedure., Methods: We prospectively enrolled 121 patients having a first-time screening colonoscopy. Patients were blinded and randomized into two groups. One group received standard prep instructions only (group P), and the other group received the American Gastroenterological Association colonoscopy educational pamphlet along with their prep instructions (group I). All information was sent by mail 3 weeks before the procedure. The endoscopists were blinded as to which of their patients were in the study and of those, which were in the standard prep group or the intervention group. Anxiety was measured immediately before endoscopy using the State portion of the 'State Trait Anxiety Index'. Procedure-related information was recorded and analyzed at the end of the study using a statistical package looking at primary and secondary endpoints., Results: Fifteen patients did not show their examination or were otherwise lost to follow-up. Of the 106 patients who completed the study, there were 55 patients in the P group and 51 in the I group. The average State Anxiety score of the P group was 45.18, and of the I group was 40.54 (P=0.014). The use of Midazolam was significantly less in the group. The use of Meperidine was lower in the I group but the difference was not statistically significant. Both the groups took the same amount of time to complete the prep, but the I group fasted longer. The I group also completed or drank more of the prep more often than the P group. The prep quality was found to be superior with less frequency of a poor prep in the I group. Most important, the I group was more likely to have a complete colonoscopy. The I group tended to have fewer questions on the day of the procedure, and less fear about what to expect on the basis of their lower anxiety scores., Conclusion: We found that providing the American Gastroenterological Association educational pamphlet to patients before colonoscopy lowers the overall anxiety level, provides a reduction in sedative use during the procedure, and leads to better colon preparation when given in addition to standard instructions.

According to the WHO, the yearly national consumption of opioids is one indicator of a country's investment on relieving moderate-to-severe pain. We implemented guidelines for treatment of pain in our emergency department (ED) and tracked the major analgesics used in this ED to monitor trends in pain management over a decade. The study was carried out in a Level I trauma center ED. Data were obtained from the pharmacy's computerized records before (1998-2002) and after (2003-2007) implementing the guidelines. The hospital's admission system provided accurate patient census data. Parenteral morphine and oral oxycodone use increased significantly (P = 0.016 and P = 0.008, respectively). Meperidine use did not change. In conclusion, our ED patients are now generally receiving more analgesics than 10 years ago. Electronically stored data on analgesics are accurate and easily accessible for tracking the nature and quantity of prescriptions, but not for correlating their association with patient outcome.

Background: Electro-acupuncture (EA) can be effective in some pain conditions, but still there have been no randomized controlled studies of EA for treatment of acute postoperative pain in nasal septoplasty. Therefore, we did a study to test whether EA of specific points is superior to sham acupuncture for complementary analgesia after nasal septoplasty., Methods: Ninety (90) patients with an American Society of Anesthesiology (ASA) physical status of I-II scheduled for elective septoplasty were randomly allocated to acupuncture group or control group. Postoperative pain was treated with intravenous meperidine. The time to the first analgesic request, and pain intensity on a 100-mm visual analogue scale (VAS-100) were used to evaluate postoperative pain, and the amount of postoperative meperidine and incidence of analgesia related to side-effects were recorded., Results: Postoperative pain intensity on VAS-100 and respiratory depression were similar in both groups (p > 0.05), but nausea and vomiting were less in the acupuncture group than in the control group (p < 0.05)., Conclusions: Findings from our study demonstrate that both uses of EA and 0.1 mg/kg IV morphine given intraoperatively resulted in a similar postoperative pain score, and meperidine was not given in any patient in the two groups during postoperative period because the VAS scores of all patients were less than 40 mm.

Objectives: To evaluate respiratory function and pain score in patients undergoing coronary bypass procedures during the first 7 postoperative days., Methods: The study was carried out as a case-control study between April 2008 and April 2009 in the Department of Cardiovascular Surgery, Firat University Faculty of Medicine, Elazig, Turkey. Thirty patients, who had undergone a median sternotomy (MS) for coronary artery bypass graft, were randomized to either the electroacupuncture and pharmacologic analgesia (acupuncture) group, or the pharmacologic analgesia alone (control) group. In each group, severity of pain, analgesic intake, respiratory function, and pulmonary complications were recorded. Pethidine hydrochloride and metamizole sodium were administered., Results: Of the 30 subjects, 15 were in the control group and 15 in the acupuncture group. There were no statistically significant differences between the 2 groups in terms of age and gender. Statistically significant differences in metamizole, pethidine, days 3, 5, 6, and 7 visual analogue scale scores were observed between the acupuncture and control groups. Postoperative complications (atelectasia) were observed in 2 (13.3%) patients, one (6.6%) in each group. The postoperative forced expiratory volume in one second/forced vital capacity value was higher than the preoperative value in the acupuncture group., Conclusions: Electroacupuncture was more effective than control treatments in decreasing pain and limiting opioid and non-opioid medication intake during the first 7 postoperative days following MS.

Introduction: Tubeless percutaneous nephrolithotomy (PCNL) in selected patients is effective and results in less postoperative discomfort without increasing complications. The challenges of PCNL in patients who had a history of open nephrolithotomy are decreased kidney mobility due to scarring around the kidney and distortion of the renal collecting system, conditions that may cause difficulty of tract access and increase retained stone and hemorrhagic complications. We compared the efficacy and safety of the tubeless versus the standard PCNL in patients who had undergone previous open nephrolithotomy., Patients and Methods: Percutaneous nephrolithotomy (PCNL) was performed in 104 patients who had a history of previous open nephrolithotomy, of which 45 received tubeless PCNL (group I) and 59 received standard PCNL with routine postoperative nephrostomy tubes (group II). All patients had only one percutaneous renal access and showed no significant bleeding, extravasation or residual stone. Of group I, PCNL was done by the standard technique with only placement of a postoperative external ureteral catheter for 48 h. The success rate, operative time, hospital stay and complications were compared between the two groups., Results: Patient's demographic data were not different between both groups. Infundibular stenosis and ureteropelvic junction obstruction were found in 2 and 4 cases of groups I and II, respectively. The success rates, operative time and complication rates were not significantly different between both groups. Hospital stay was 3.53 and 5.39 days for groups I and II, respectively, which was significantly different. Average analgesic (meperidine) usage was significantly less in the tubeless group (39 +/- 35 mg for group I and 75 +/- 32 mg for group II)., Conclusion: Tubeless PCNL in selected patients with previous open nephrolithotomy has a safe and effective advantage compared to standard PCNL as indicated by a decrease in length of hospital stay and analgesic usage., (Copyright (c) 2010 S. Karger AG, Basel.)

Objective: To determine the advantages and disadvantages of the use of diclofenac sodium instead of meperidine for postcesarean section pain control., Methods: A total of 130 patients who had undergone cesarean section at the Department of Obstetrics and Gynecology of Gazi University Hospital were prospectively randomised to receive one of two postoperative pain control regimens. The first group of patients received intramuscular diclofenac sodium at a dose of 2 x 75 mg and additional breakthrough meperidine was given intramuscularly at 50 mg dosages each time, if necessary. Patients in the second group received only 6 x 50 mg meperidine., Results: Twenty-seven of the 65 patients in the diclofenac group complained of unrelieved pain within the subsequent 24 h postoperatively. Patients receiving diclofenac alone or a combination of diclofenac + meperidine were less sedated and the time to the first passing of flatus was shorter than that in the patients treated with only meperidine., Conclusions: Diclofenac alone was safe and effective for the majority of the patients and it decreased the opioid requirements in the remaining patients.

Objective: To compare the perioperative complications, analgesics requirement, and length of hospital stay between patients undergoing urgent closed hemorrhoidectomy for prolapsed thrombosed hemorrhoid and elective closed hemorrhoidectomy., Research Design: Retrospective, comparative study., Material and Method: All records of the patients who underwent urgent and elective hemorrhoidectomy between January 2000 and December 2005 were reviewed. Perioperative complications (bleeding, urinary retention, post-operative thrombosis, and wound dehiscence), analgesic requirement, and length of hospital stay were analyzed., Statistics: Chi-Square Test and Mann-Whitney U Test., Results: From 1440 patients, 1184 patients met the inclusion criteria. All were done with closed technique. The indication for urgent hemorrhoidectomy was prolapsed thrombosed hemorrhoid in 416 patients (group 1). The indication for elective hemorrhoidectomy were grade 3 and 4 internal hemorrhoid, external hemorrhoid or combined hemorrhoid in 768 patients (group 2). There was no statistically significant difference in urinary retention and bleeding complication between two groups; 31 patients (7.5%) in group 1 and 69 patients (8.9%) in group 2 experienced urinary retention p = 0.426, five patients (1.2%) in group 1 and 10 patients (1.3%) in group 2 had postoperative bleeding, p = 1.000). On the second postoperative week, wound dehiscence was found in nine patients (2.2%) from group 1 and 15 patients (2%) from group 2. On the fourth week, all the wounds were completely healed without granulation or stricture formation. Post-operative meperidine requirement was significantly lower in the urgent hemorrhoidectomy group (0.84 +/- 0.71 vs. 0.99 + 0.81 mg/kg, p < 0.001). Post-operative length of hospital stay were not statistically different (1.017 +/- 0.129 vs. 1.016 +/- 0.124, p = 0.107)., Conclusion: Urgent closed hemorrhoidectomy for prolapsed thrombosed hemorrhoids may be a preferable option for patients suffering from this condition.

Aim: To compare the analgesic properties and efficacy of transnasal butorphanol with intramuscular meperidine after anal surgery., Methods: Sixty patients who underwent fistulectomy were enrolled in the study from January 2006 to December 2007. They were randomly divided into transnasal butorphanol (n = 30) or intramuscular meperidine (n = 30) treatment groups. Assessment of postoperative pain was made using a visual analogue scale (VAS). The VAS score was recorded 6 h after the completion of surgery, before receiving the first dose of analgesic, 60 min after analgesia and the next morning. Any adverse clinical effects such as somnolence, dizziness, nausea or vomiting were recorded. Satisfaction with narcotic efficacy, desire to use the particular analgesic in the future and any complaints were recorded by patients using questionnaires before being discharged., Results: Forty-two men and eighteen women were included in the study. There were no significant differences in VAS scores between the groups within 24 h. Length of hospital stay and the incidence of adverse effects between the groups were similar. In addition, most patients were satisfied with butorphanol nasal spray and wished to receive this analgesic in the future, if needed., Conclusion: Butorphanol nasal spray is effective for the relief of pain after fistulectomy. However, it offered patients more convenient usage and would be suitable for outpatients.

Objectives: We aimed to determine the effects of intraperitoneal administration of levobupivacaine on pain after laparoscopic cholecystectomy in a prospective, randomized, double-blinded, placebo-controlled trial., Methods: In all patients, infiltration of levobupivacaine 0.25% (15 mL) was used prior to skin incisions for trocar insertion. After pneumoperitoneum was achieved, patients were allocated randomly to receive intraperitoneally either 40 mL of 0.25% levobupivacaine (LB group, n=20) or normal saline (NS group, n=20) under direct vision into the hepatodiaphragmatic lodge and above the gallbladder. Data of intraoperative variables, postoperative pain relief, rescue analgesic consumption, side effects, and patient satisfaction were followed in both groups., Results: The postoperative pain scores were significantly lower in the first half-hour period in the LB group than in the NS group (p<0.05). However, the incidence of right shoulder pain was not significantly different between the LB group (10%) and NS group (15%). The mean dose of meperidine consumption and the number of patients needing rescue meperidine were significantly lower in the LB group than in the NS group (p<0.05). Significantly lower vomiting incidence and increased patient satisfaction were determined in the LB group compared to the NS group (p<0.05)., Conclusion: Intraperitoneal administration of 40 mL levobupivacaine 0.25% given immediately after pneumoperitoneum into the hepatodiaphragmatic lodge and above the gallbladder demonstrated useful effects on postoperative pain relief after laparoscopic cholecystectomy, especially in the early postoperative period, and reduced postoperative rescue analgesic requirement, with excellent patient satisfaction. There were no LB-related complications or side effects.

The under-treatment of postoperative pain is prevalent worldwide. This cross-sectional study examined general practitioners' (GPs) knowledge and practices regarding postoperative analgesia in Caesarean deliveries. Postoperative analgesia was said to ensure that patients were pain-free (38.7%), achieved early mobilization (19.4%) and enabled early breast feeding (16%). Pethidine was the opioid of choice; normally prescribed eight hourly (69%) and was combined with non-steroidal anti-inflammatory drugs (NSAID) by 48.6% of doctors and used solely by 51.6%. The prescription of analgesics was mainly influenced by drug availability (45.2%) and potency (19.4%). Most doctors (93.5%) had never attended a pain management course or used pain scores. Doctors at level 1 hospitals were less likely to use pethidine in combination with NSAID (odds ratio: 0.11; confidence interval: 0.02-0.59) compared to those in the specialized hospital. The GPs recognized the importance of postoperative analgesia, but their practices made patients vulnerable to pain after caesarean section.

(1) Renal colic is an acute syndrome involving unilateral flank pain, linked to an obstruction in the upper urinary tract. The pain is often intense. After having considered other diagnoses and checked for signs of complication (fever, oligoanuria), the first step is to control the pain; (2) Which non-invasive treatments have a positive risk-benefit balance in relieving this type of pain? To answer this question, we reviewed the available evidence, based on the standard Prescrire methodology; (3) According to a meta-analysis of 20 trials, nonsteroidal antiinflammatory drugs (NSAIDs) and strong opioid analgesics have comparable efficacy. The most widely studied NSAID is diclofenac, given intramuscularly at a dose of 50 mg or 75 mg. Pethidine is the best-assessed strong opioid, given intramuscularly at a dose of 50 mg to 100 mg, which corresponds to about 5 mg to 10 mg of morphine. Morphine is given intravenously; subcutaneous administration is an alternative although it has not been evaluated in renal colic; (4) In clinical trials, NSAIDs were associated with fewer adverse effects than opioids, which cause vomiting in about 20% of patients (versus about 6% with an NSAID); (5) NSAIDs expose patients to a risk of functional renal impairment, especially in patients with heart failure, renal artery stenosis, dehydration, renal impairment or ongoing treatment with a nephrotoxic drug, and the very elderly. NSAIDs should never be used during pregnancy; (6) According to one trial in 130 patients, the analgesic effect of the morphine and NSAID combination was greater than either agent used alone, in about 10% of patients; (7) Paracetamol has not been evaluated in comparative trials of renal colic, even for moderate pain; (8) Scopolamine is the only antispasmodic to have been evaluated in a comparative trial. Adding scopolamine to morphine did not seem to provide additional efficacy; (9) Other drugs, which have not been adequately tested as of early 2009, have no documented benefit in the treatment of the pain associated with renal colic; tamsulosin, nifedipine, desmopressin; (10) Among the non-drug measures tested, local active warming, taking care to avoid burns, was effective against pain according to one trial; pain was reduced by at least 50% using a device delivering 42 degrees C to the abdomen or lower back; (11) In pregnant women, morphine carries a lower risk of adverse effects than NSAIDs; (12) In practice, the treatment of renal colic is mainly based on taking an NSAID, or morphine when the NSAID does not adequately control the pain or when it is better to avoid using NSAIDs.