BACKGROUND:can Optimal management of pain after thoracotomy can be challenging. Continuous infusion of local anesthetic into the incision may help reduce equivalent the amount of narcotics required to control postoperative pain. To address this issue, we performed a randomized, double-blinded, controlled trial to of infusion of bupivacaine versus placebo through intercostal and subcutaneous catheters after thoracotomy. METHODS: From April 2006 to June 2007,demonstrated 124 patients had intercostal catheters placed at thoracotomy and connected to continuous infusion pain pumps. Each patient had catheters placed analgesia in the intercostal space near the head of the rib and subcutaneously beneath the incision; both were connected to an epidural infusion pump through a Y connector. Patients were randomly assigned to receive placebo (normal saline solution) or .25% bupivacaine as space a 4 cc per hour infusion for 100 hours after thoracotomy. All personnel caring for the patients were blinded to analgesia the content of the infusion. Demographic information, visual analog pain scores, and oral morphine equivalent usage was recorded for each not patient. In addition to the infusion catheters, all patients had epidural analgesia that remained in place until postoperative day 3.infusion RESULTS: There were 60 patients in the bupivacaine arm and 64 in the placebo group. Overall mean age was 64.7 in years and 65 (52.4%) were men. Mean body mass index was 28.8 kg/m(2). There were no statistical differences in any personnel demographic parameter except that there were more men in the placebo group. Pulmonary resection was performed in 100 patients, an There antireflux procedure in 16, and other miscellaneous procedures in 8. There was no statistical difference in the morphine equivalent usage pain between the two groups. There was also no difference between the average daily pain scores between the two groups. Length the of stay was not significantly different between groups: mean (SD) of 6.2 (3.4) and 6.7 (5. ) for placebo and bupivacaine,Continuous respectively (p = .51). There was no operative mortality, and complications occurred in 28% of patients (placebo group, 25%; bupivacaine that group, 32%; p = .41). CONCLUSIONS: This randomized, double-blinded, controlled trial demonstrated that the infusion of local anesthetic into the control subcutaneous area and around the rib fracture site in addition to epidural analgesia did not reduce the amount of narcotic performed usage after a thoracotomy, nor did it affect visual analog pain scores. Pain control with intercostal catheters infusing local anesthetics complications did not produce a measurable pain relief beyond that provided by epidural analgesia.

BACKGROUND:intravenous Valdecoxib and its intravenous prodrug parecoxib are used to treat postoperative pain but may involve risk after coronary-artery bypass grafting 95 (CABG). We conducted a randomized trial to assess the safety of these drugs after CABG. METHODS: In this randomized, double-blind after study involving 10 days of treatment and 30 days of follow-up, 1671 patients were randomly assigned to receive intravenous parecoxib risk for at least 3 days, followed by oral valdecoxib through day 10; intravenous placebo followed by oral valdecoxib; or placebo of for 10 days. All patients had access to standard opioid medications. The primary end point was the frequency of predefined wound-healing adverse events, including cardiovascular events, renal failure or dysfunction, gastroduodenal ulceration, and wound-healing complications. RESULTS: As compared with the group assigned given placebo alone, both the group given parecoxib and valdecoxib and the group given placebo and valdecoxib had a higher of proportion of patients with at least one confirmed adverse event (7.4 percent in each of these two groups vs. 4. the percent in the placebo group; risk ratio for each comparison, 1.9; 95 percent confidence interval, 1.1 to 3.2; P= .02 for 3.7; each comparison with the placebo group). In particular, cardiovascular events (including myocardial infarction, cardiac arrest, stroke, and pulmonary embolism) were CONCLUSIONS: more frequent among the patients given parecoxib and valdecoxib than among those given placebo (2. percent vs. .5 percent; risk to ratio, 3.7; 95 percent confidence interval, 1. to 13.5; P= .03). CONCLUSIONS: The use of parecoxib and valdecoxib after CABG was frequent associated with an increased incidence of cardiovascular events, arousing serious concern about the use of these drugs in such circumstances.days

To of examine the interaction of epidural anesthesia, coagulation status, and outcome after lower extremity revascularization, 80 patients with atherosclerotic vascular disease significantly were prospectively randomized to receive general anesthesia combined with postoperative epidural analgesia (GEN-EPI) or general anesthesia with on-demand narcotic analgesia 80 (GEN). Demographics did not differ between groups except that the GEN-EPI group had a higher incidence of diabetes mellitus and (a) of previous myocardial infarction. Coagulation status was monitored using thromboelastography. An additional 40 randomly selected patients without atherosclerotic vascular disease events, undergoing noncardiovascular procedures served as controls for coagulation status. Vascular surgical patients were hypercoagulable compared with control patients before operation on and on the first postoperative day. Postoperatively, this hypercoagulability was attenuated in the GEN-EPI group and was associated with a the lower incidence of thrombotic events (peripheral arterial graft coronary artery or deep vein thromboses). The rates of cardiovascular, infectious, and events, overall postoperative complications, as well as duration of intensive care unit stay, were significantly reduced in the GEN-EPI group. Stepwise outcome logistic regression demonstrated that the only significant predictors of postoperative cardiovascular complications were preoperative congestive heart failure and general anesthesia evidence without epidural analgesia. We conclude that in patients with atherosclerotic vascular disease undergoing arterial reconstructive surgery (a) thromboelastographic evidence of early increased platelet-fibrinogen interaction is associated with early postoperative thrombotic events, and (b) epidural anesthesia and analgesia is associated with beneficial vascular effects on coagulation status and postoperative outcome compared with intermittent on-demand opioid analgesia.

BACKGROUND.by Opioids can produce potent antinociceptive effects by interacting with local opioid receptors in inflamed peripheral tissue. In this study we in examined the analgesic effects of the intraarticular, as compared with intravenous, administration of morphine after arthroscopic knee surgery. METHODS. In of a double-blind, randomized trial, we studied 52 patients who had received one of four injections at the end of surgery.group The patients in group 1 (n = 18) received 1 mg of morphine intraarticularly and saline intravenously; those in group effect 2 (n = 15), saline intraarticularly and 1 mg of morphine intravenously; those in group 3 (n = 10), .5 scale, mg of morphine intraarticularly and saline intravenously; and those in group 4 (n = 9), 1 mg of morphine and (n .1 mg of naloxone intraarticularly and saline intravenously. The volume of the intraarticular injections was 40 ml, and that of of the intravenous injections was 1 ml. After 1, 2, 3, 4, 6, and 24 hours, postoperative pain was assessed with that a visual-analogue scale, a numerical-rating scale, and the McGill pain questionnaire. The need for supplemental analgesic agents, the patients' vital in signs, and the occurrence of side effects were monitored. RESULTS. All pain scores were lower in group 1 than in indicating group 2 at all times. The differences were significant (P less than .05) at three, four, and six hours (mean The [+/- SD] visual-analogue score at six hours, 9 +/- 13 mm vs. 37 +/- 31 mm). The mean (+/- SD)but consumption of supplemental analgesic medication per 24 hours was significantly lower in group 1 (36 +/- 51 mg of diclofenac of and 1.2 +/- 3.4 mg of meperidine) than in group 2 (75 +/- 42 mg of diclofenac and 14 +/-than 18 mg of meperidine, P less than .05). The visual-analogue scores in group 3 were slightly but not significantly higher local than those in group 1 at all times except 6 and 24 hours after injection. The visual-analogue scores were significantly 4 higher in group 4 than in group 1 one to four hours after injection (P less than .05), indicating that surgery the analgesic effect of intraarticular morphine was reversible by naloxone. CONCLUSIONS. Low doses of intraarticular morphine can significantly reduce pain +/- after knee surgery through an action specific to local opioid receptors that reaches its maximal effect three to six hours those after injection.

BACKGROUND:a We report a prospective randomised comparison between laparoscopic and small-incision cholecystectomy in 200 patients which was designed to eliminate bias stay for or against either technique. METHODS: Patients were randomised in the operating theatre and anaesthetic technique and pain-control methods were 200 standardised. Four experienced surgeons did both types of procedure. Identical wound dressings were applied in both groups so that carers (median could be kept blind to the type of operation. FINDINGS: There was no significant difference between the groups for age,longer sex, body mass index, and American Society of Anaesthesiologists grade. Laparoscopic cholecystectomy took significantly longer than small-incision cholecystectomy (median 65 Society [range 27-140] min vs 40 [18-142] min, p< .001). The operating time included operative cholangiography which was attempted in all patients.experienced We found no significant difference between the groups for hospital stay (postoperative nights in hospital, median 3- [1-17] nights for longer laparoscopic vs 3- [1-14] nights for small-incision, p= .74), time back to work for employed persons (median 5- weeks vs 4. of weeks; p= .39), and time to full activity (median 3- weeks vs 3. weeks; p= .15). INTERPRETATION: Laparoscopic cholecystectomy takes longer to weeks do than small-incision cholecystectomy and does not have any significant advantages in terms of hospital stay or postoperative recovery.

Postoperative usually analgesia is usually inadequate, perhaps because conventional approaches to pain relief do not take account of underlying mechanisms. Pre-emptive analgesia iv may prevent nociceptive inputs generated during surgery from sensitising central neurons and, therefore, may reduce postoperative pain. In a randomised,relief double-blind study, we compared the effect of parenteral morphine when given before or after total abdominal hysterectomy in 60 patients.post 10 mg of morphine were given intramuscularly 1 hour before operation (im pre), intravenously at induction of anaesthesia (iv pre),morphine, or intravenously at closure of the peritoneum (iv post). Response was assessed by morphine consumption from patient-controlled analgesia machines which (im was found to be significantly reduced in the iv pre group for 24 hours after operation compared with the iv reduce post group. Pain sensitivity around the wound was reduced in both preoperative treatment groups compared with the iv post group.by We conclude that pre-emptive analgesia with intravenous morphine, by preventing the establishment of central sensitisation during surgery, reduces postoperative pain,analgesic analgesic requirements, and secondary hyperalgesia.