heroin and Pain--Postoperative

Intravenous dexamethasone is recommended in elective caesarean delivery to decrease postoperative pain. However, the efficacy of spinal anaesthesia with an intrathecal long-acting opioid such as morphine or diamorphine for caesarean delivery has not been systematically investigated.. We searched all randomized controlled trials (RCTs) of pregnant women undergoing caesarean delivery under spinal anaesthesia with an intrathecal morphine or diamorphine via MEDLINE, CENTRAL, EMBASE, ICTRP, and ClinicalTrials.gov on May 18, 2022. Primary outcomes were time to first rescue analgesia, consumption of oral morphine equivalents, and incidence of drug-related adverse reactions. We evaluated the risk of bias for each outcome using the Risk of Bias 2. We conducted a meta-analysis using a random effects model. We evaluated the certainty of evidence with the GRADE approach.. Five RCTs (455 patients) were included. The results of intravenous dexamethasone were as follows: time to first rescue analgesia (mean difference [MD] 0.99 h, 95% confidence interval [CI] - 0.86 to 2.84; very low certainty) and consumption of oral morphine equivalents (MD - 6.55 mg, 95% CI - 17.13 to 4.02; moderate certainty). No incidence of drug-related adverse reactions was reported (very low certainty).. The evidence was very uncertain about the efficacy of intravenous dexamethasone on time to first rescue analgesia and the incidence of drug-related adverse reactions. Intravenous dexamethasone probably reduces the consumption of oral morphine equivalents. Anaesthesiologists might want to consider intravenous dexamethasone for postoperative pain after caesarean delivery under spinal anaesthesia with an intrathecal long-acting opioid.

Topics: Analgesics, Opioid; Anesthesia, Spinal; Cesarean Section; Dexamethasone; Female; Heroin; Humans; Morphine; Pain, Postoperative; Pregnancy

The prevalence of neuraxial opioid-induced clinically significant respiratory depression (CSRD) after cesarean delivery is unknown. We sought to review reported cases of author-reported respiratory depression (ARD) to calculate CSRD prevalence. A 6-database literature search was performed to identify ARD secondary to neuraxial morphine or diamorphine, in parturients undergoing cesarean delivery. "Highest" (definite and probable/possible) and "lowest" (definite) prevalences of CSRD were calculated. Secondary outcomes included: (1) prevalence of CSRD associated with contemporary doses of neuraxial opioid, (2) prevalence of ARD as defined by each study's own criteria, (3) case reports of ARD, and (4) reports of ARD reported by the Anesthesia Closed Claims Project database between 1990 and 2016. We identified 78 articles with 18,455 parturients receiving neuraxial morphine or diamorphine for cesarean delivery. The highest and lowest prevalences of CSRD with all doses of neuraxial opioids were 8.67 per 10,000 (95% CI, 4.20-15.16) and 5.96 per 10,000 (95% CI, 2.23-11.28), respectively. The highest and lowest prevalences of CSRD with the use of clinically relevant doses of neuraxial morphine ranged between 1.63 per 10,000 (95% CI, 0.62-8.77) and 1.08 per 10,000 (95% CI, 0.24-7.22), respectively. The prevalence of ARD as defined by each individual paper was 61 per 10,000 (95% CI, 51-74). One published case report of ARD met our inclusion criteria, and there were no cases of ARD from the Closed Claims database analysis. These results indicate that the prevalence of CSRD due to neuraxial morphine or diamorphine in the obstetric population is low.

Topics: Analgesia, Epidural; Analgesia, Obstetrical; Analgesics, Opioid; Anesthesia; Cesarean Section; Female; Heroin; Humans; Morphine; Observational Studies as Topic; Pain, Postoperative; Postoperative Complications; Pregnancy; Prevalence; Respiratory Insufficiency; Treatment Outcome

Intranasal drug administration is an easy, well-tolerated, noninvasive transmucosal route that avoids first-pass metabolism in the liver. The nasal mucosa provides an extensive, highly vascularized surface of pseudostratified ciliated epithelium. It secretes mucus that is subjected to mucociliary movement that can affect the time of contact between the drug and the surface. Absorption is influenced by anatomical and physiological factors as well as by properties of the drug and the delivery system. We review the literature on intranasal administration of fentanyl, meperidine, diamorphine, and butorphanol to treat acute pain. The adverse systemic effects are similar to those described for intravenous administration, the most common being drowsiness, nausea, and vomiting. Local effects reported are a burning sensation with meperidine and a bad taste.

Topics: Absorption; Acute Disease; Administration, Intranasal; Adult; Analgesia, Patient-Controlled; Analgesics, Opioid; Butorphanol; Child; Cross-Over Studies; Fentanyl; Heroin; Humans; Meperidine; Nasal Mucosa; Pain; Pain, Postoperative; Randomized Controlled Trials as Topic

In some countries, heroin is widely used as an analgesic agent.. The literature describing the history, pharmacology and analgesic use of heroin was reviewed.. Heroin is a semi-synthetic morphine derivative. A century ago it was considered a panacea with numerous indications. Today it is best known as a drug of abuse, but is still in use as an analgesic. Most studies that compare heroin with other analgesics have methodological shortcomings; however, they generally indicate that heroin has a clinical effect not very different from morphine. An better aqueous solubility as compared to morphine may in some situations be advantageous. Because of a proposed incomplete cross-tolerance between heroin and other opioid analgesics, it may be used if the patient shows sub-therapeutic response to first-line opioids.. Although not well documented, heroin appears to be an effective analgesic with certain properties different from those of morphine. It may be of clinical value in conditions with acute and/or terminal pain.

Topics: Adult; Analgesia, Obstetrical; Analgesics, Opioid; Child; Female; Heroin; Humans; Pain; Pain, Postoperative; Pregnancy; Terminal Care

Topics: Anesthesia, General; Colon; Heroin; Hormones; Humans; Intestine, Large; Pain, Postoperative; Preoperative Care

This double-blind randomised controlled trial investigated the most appropriate dose of intrathecal diamorphine to use with high-dose diclofenac as part of a multimodal analgesic regimen for caesarean section under subarachnoid block. We also wished to establish whether it was possible to satisfy the Royal College of Anaesthetists postoperative pain audit recommendation for this patient group.. One hundred and twenty patients presenting for elective caesarean section under subarachnoid block were recruited and divided into four groups. Treatment was standard except that patients were given either placebo or one of three different doses of intrathecal diamorphine (100 microg, 200 microg or 300 microg). All patients were given regular paracetamol, high-dose diclofenac and an hourly subcutaneous diamorphine regimen for breakthrough pain.. There was a dose-dependent improvement in analgesia with intrathecal diamorphine. Only 37.9% of patients given 300 microg of intrathecal diamorphine had a visual analogue pain score of 3/10 or less throughout the study. There was a dose-dependent increase in the incidence of itching with intrathecal diamorphine although the incidence of nausea and vomiting was similar between groups.. We found that for elective caesarean section under subarachnoid block with high dose diclofenac, analgesia was optimal with 300 microg of intrathecal diamorphine. Even the highest dose of intrathecal diamorphine did not achieve the Royal College of Anaesthetists postoperative audit target that 90% of patients should have a pain score of no more than 3/10. We believe that this target is too arduous.

Topics: Analgesics, Opioid; Analysis of Variance; Anesthesia, Spinal; Anti-Inflammatory Agents, Non-Steroidal; Cesarean Section; Diclofenac; Dose-Response Relationship, Drug; Double-Blind Method; Drug Interactions; Female; Heroin; Humans; Ireland; Medical Audit; Pain, Postoperative; Postoperative Nausea and Vomiting; Pregnancy; Pruritus

Debate has proliferated as to the true site of action of opioids when placed in the epidural space. The aim of this study was to compare the analgesic effects of a bolus of diamorphine given by the epidural or intramuscular route.. Sixty patients having elective primary total knee replacements were recruited and randomized to receive epidural or intramuscular diamorphine. A lumbar epidural catheter was sited and 10 mL of bupivacaine 0.5% wt vol-1 was injected. Patients subsequently received diamorphine 5 mg into the epidural space or as an intramuscular injection. Patient-controlled analgesia with intravenous morphine was used for postoperative analgesia. The primary outcome measures included time to first patient-controlled analgesia use and total morphine consumption in 24 h. Secondary end-points considered possible treatment complications.. All primary end-points showed significant differences in favour of epidural diamorphine. Medians for times to first patient-controlled analgesia use and total 24 h morphine requirements were significantly different (P < 0.001) at 418 vs. 198 min and 11 vs. 39 mg, respectively. There were no significant differences in secondary end-points.. This study has shown the superior analgesic efficacy of epidural diamorphine when compared to intramuscular injection.

Topics: Aged; Analgesia, Epidural; Analgesia, Patient-Controlled; Analgesics, Opioid; Arthroplasty, Replacement, Knee; Female; Heroin; Humans; Injections, Intramuscular; Male; Morphine; Pain Measurement; Pain, Postoperative; Postoperative Nausea and Vomiting; Pruritus; Treatment Outcome

This randomised controlled trial examines the effects of fentanyl and diamorphine, alone and in combination, as adjuncts to spinal anaesthesia for Caesarean section. Ninety-nine women undergoing elective Caesarean section with spinal anaesthesia using 0.5% hyperbaric bupivacaine were randomly allocated to receive fentanyl 15 microg (F), diamorphine 0.25 mg (D), or fentanyl 15 microg plus diamorphine 0.25 mg (FD), intrathecally. All women received morphine via a patient controlled analgesia system after surgery. There was no significant difference between the groups in time to achieve a block, discomfort, ephedrine use, nausea and vomiting, pruritus and sedation during surgery. Significant differences were observed in morphine consumption 4, 8, 12 and 24 h after surgery between both F and D groups, and F and FD groups, and also at 2 h between F and FD groups. There was a significant difference in pruritus at 4 h between the F and FD group. Our results suggest that diamorphine alone provides optimum benefits during and after surgery, when used in combination with hyperbaric bupivacaine for Caesarean section.

Topics: Adjuvants, Anesthesia; Adolescent; Adult; Analgesics, Opioid; Anesthesia, Obstetrical; Anesthesia, Spinal; Anesthetics, Local; Bupivacaine; Cesarean Section; Drug Administration Schedule; Female; Fentanyl; Heroin; Humans; Morphine; Pain, Postoperative; Pregnancy

Opioid analgesics are commonly added to intrathecal bupivacaine to improve patient comfort during Caesarean section under spinal anaesthesia, and provide post-operative pain relief. We sought to discover if the addition of diamorphine influenced block height when given with 0.5% w/v hyperbaric bupivacaine.. Eighty ASA I and II women of at least 37 weeks gestation and planned for elective Caesarean section under combined spinal-epidural anaesthesia were recruited. They were randomized into two groups to receive intrathecal hyperbaric bupivacaine 0.5% at an initial dose of 13 mg, with the next dose determined by the response of the previous patient (dose interval 1 mg). One group also received diamorphine 400 microg intrathecally. If a block height of T5 to blunt light touch had been achieved after 20 min, the block was deemed effective. A difference in the ED50 for hyperbaric bupivacaine between the groups would indicate that diamorphine influenced block height. Intraoperative patient discomfort and need for analgesic supplementation was noted.. The median effective dose (ED50) to achieve a T5 block to light touch for Caesarean section using hyperbaric bupivacaine 0.5% was 9.95 mg [95% confidence interval (CI) 9.0-10.90] and with the addition of diamorphine it was 9.3 mg (95% CI 8.15-10.40), while the ED95 was 13.55 mg (95% CI 10.10-17.0) and 13.6 mg (95% CI 9.15-18.05), respectively. Five women who had received intrathecal diamorphine and 13 who had not received diamorphine needed intraoperative supplementation (not significant).. The addition of intrathecal diamorphine does not appear to influence block height.

Topics: Adolescent; Adult; Analgesics, Opioid; Anesthesia, Obstetrical; Anesthesia, Spinal; Anesthetics, Local; Bupivacaine; Cesarean Section; Drug Administration Schedule; Drug Interactions; Female; Heroin; Humans; Pain, Postoperative; Pregnancy

Intraoperative discomfort during spinal anaesthesia for Caesarean section is the commonest cited anaesthetic cause of litigation in obstetric practice. Intrathecal opioids are used to improve intraoperative comfort and postoperative analgesia for these operations. The minimum intrathecal diamorphine dose that prevents intraoperative supplementation requires determination.. After ethics committee approval, 200 ASA I, II women with > or = 37 weeks gestation and planned for elective Caesarean section under combined spinal-epidural anaesthesia were recruited. They were randomized into four groups to receive hyperbaric bupivacaine 0.5% 12.5 mg with diamorphine 0.2, 0.3, 0.4 or 0.5 mg by intrathecal injection. The need for intraoperative i.v. supplementation with alfentanil, time to first requests for postoperative analgesia, incidence of nausea and vomiting and requirement for antiemetic and antipruritic were noted.. Intraoperative supplementation was inversely proportional to the dose of diamorphine used (P=0.004). The ED(95) value for intrathecal diamorphine to prevent intraoperative supplementation was 0.39 mg. Mean time interval for request for postoperative analgesia was 446 min in the 0.2 mg group, 489 min in the 0.3 mg group, 601 min in the 0.4 mg group and 687 min in the 0.5 mg group (P=0.003 for trend). Incidence of nausea, vomiting and pruritus increased with dose of diamorphine used (P values for trend: nausea, 0.04; vomiting, 0.008; pruritus, 0.004). Requests for antiemetic increased with dose but achieved significance only for requirement for second antiemetic (P=0.03). Request for antipruritic did not achieve significance.. The ED(95) for the amount of intrathecal diamorphine required to prevent intraoperative supplementation during spinal anaesthesia for Caesarean section is 0.4 mg in clinical terms. Times to first requests for analgesia, incidence of nausea, vomiting and pruritus increase with dose.

Topics: Adult; Alfentanil; Analgesics, Opioid; Anesthesia, Epidural; Anesthesia, Obstetrical; Anesthesia, Spinal; Cesarean Section; Double-Blind Method; Drug Administration Schedule; Female; Heroin; Humans; Pain, Postoperative; Postoperative Complications; Postoperative Nausea and Vomiting; Pregnancy; Prospective Studies; Pruritus

Intranasal administration of lipophilic opioids has been shown to be an effective method of administration which is devoid of major side-effects. Whether it is as effective as intravenous administration for patient-controlled analgesia (PCA) has been investigated for fentanyl and pethidine, but not for diamorphine. This study reports a randomised controlled trial designed to compare the effectiveness of diamorphine administered as PCA utilising either the intranasal or intravenous routes. We investigated 52 consecutive patients undergoing primary lower limb joint replacement surgery. Patients were randomly allocated to receive PCA diamorphine, administered either intravenously (0.5 mg bolus, 3 min lockout) or intranasally (1.0 mg bolus, 3 min lockout). Pain was assessed using a Visual Analogue Score (VAS) at rest and on movement on five occasions over the first 36 h postoperatively. The results demonstrated that patients in the intranasal PCA group had significantly higher VAS scores than the intravenous group, both at rest (intranasal median 35.5 vs. intravenous median 20; p = 0.030) and on movement (intranasal median 64 vs. intravenous median 50; p = 0.016). However, significantly fewer patients in the intranasal group compared with the intravenous group suffered episodes of vomiting (intranasal 0/24 vs. intravenous 6/24 patients; p = 0.022). We suggest that if a maximal reduction in pain score is considered the goal of PCA management, the intravenous route is preferable to the intranasal route.

Topics: Administration, Intranasal; Adult; Aged; Analgesia, Patient-Controlled; Analgesics, Opioid; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Female; Heroin; Humans; Injections, Intravenous; Male; Middle Aged; Pain Measurement; Pain, Postoperative

Opioids administered to peripheral tissues can have significant analgesic effects in doses which would not be effective centrally. We have assessed the effects of regional diamorphine 2.5 mg i.v. in 14 patients undergoing surgical correction of bilateral arthritic foot deformities in a prospective, randomized, double-blind study. Patients acted as their own controls as only one foot received the active drug. Visual analogue scale (VAS) pain scores and wound tenderness were measured over 72 h. Diamorphine did not improve median VAS area under the curve pain scores during the first 6 h after surgery (33 (95% confidence intervals (CI) 25-46) vs 24 (17-35)). It also did not effect wound hypersensitivity when tested at 72 h after surgery (95 (47-125) vs 90 (50-125) g). There were no significant adverse effects.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Analgesics, Opioid; Arthritis; Double-Blind Method; Foot Deformities, Acquired; Heroin; Humans; Injections, Intravenous; Intraoperative Care; Middle Aged; Pain Measurement; Pain, Postoperative; Prospective Studies

This randomized double blind study investigates the relative efficacies of controlled analgesia (PCA) regimens in three different patient groups: epidural diamorphine 2.5 mg followed by PCA bolus 1 mg with a 20-min lockout (Gp1), subcutaneous diamorphine 2.5 mg followed by PCA bolus with a 10-min lockout period (Gp2) and epidural diamorphine 2.5 mg in 4 mL of 0.125% (w/v) bupivacaine followed by a PCA bolus of 1 mg diamorphine in 4 mL 0.125% (w/v) bupivacaine with a 20-min lockout (Gp3). Patients were evaluated at 0, 1, 2, 3, 4, 8, 12, 16, 20, 24 and 48 h. Patients in Gp2 consumed significantly more diamorphine than those in Gp1 or Gp3 (P < 0.05), but their pain scores were higher only at 1, 2 and 3 h (P < 0.05) with respect to Gp3 and at 1 h with respect to Gp1. Fewer side effects (sedation, pruritus and nausea as assessed by anti-emetic requirements) occurred in Gp2 compared to Gp1 (P < 0.05). Fewer patients in Gp2 required catheterization than in Gp3 (P < 0.05). This study indicates that the use of PCA epidural diamorphine, either alone or in combination with bupivacaine, reduces the dose requirement for analgesia but offers little clinical advantage over subcutaneous PCA diamorphine.

Topics: Aged; Aged, 80 and over; Analgesia, Epidural; Analgesia, Patient-Controlled; Analgesics, Opioid; Anesthetics, Local; Bupivacaine; Double-Blind Method; Drug Combinations; Female; Heroin; Humans; Infusion Pumps; Injections, Subcutaneous; Male; Middle Aged; Pain, Postoperative

A patient acceptability study was conducted using patient-controlled intranasal diamorphine. Patients undergoing nonemergency orthopaedic or gynaecological surgery self-administered intranasal diamorphine for 24 h postoperatively. Pain, pain relief, sedation, respiratory rate, nausea and vomiting were assessed regularly. After 24 h, patients and their attending nurses completed a questionnaire assessing satisfaction and practical aspects of the technique. Satisfaction was reported as good or complete by 69% of patients and 69% of nurses. Pain relief was assessed as better than expected by 45% of patients and better than normal by 50% of nurses. Seventy-nine per cent of patients would be pleased to use patient-controlled intranasal diamorphine again and 89% of nurses would be happy for their patients to use it again. Sedation was uncommon and mild and there were no episodes of significant respiratory depression. Fifty-three per cent of patients reported no nausea and 74% did not vomit at any stage. There were seven withdrawals, four due to problems with the device and three due to therapeutic problems. The nasal spray may need modification to improve reliability. However, we found patient-controlled intranasal analgesia an effective technique, which was well tolerated by patients and nurses and was without unpleasant side-effects. Further work to determine how it performs compared with intramuscular or intravenous analgesia is now needed.

Topics: Administration, Intranasal; Adolescent; Adult; Aged; Analgesia, Patient-Controlled; Analgesics, Opioid; Attitude of Health Personnel; Female; Heroin; Humans; Male; Middle Aged; Pain, Postoperative; Patient Satisfaction; Surveys and Questionnaires

To try to decrease the incidence of side-effects associated with postoperative extradural infusions of local anaesthetics in combination with opioids, we have used plain ropivacaine solutions in 200 children. The first 72 children received an infusion of bupivacaine 0.125% + diamorphine 20 microg x ml-1, then 200 children received plain ropivacaine solutions. The children who received ropivacaine were found to have lower incidences of nausea, pruritus, urinary retention, and were less sedated, despite comparable analgesia. The management of plain ropivacaine for extradural analgesia is discussed.

Topics: Amides; Analgesics, Opioid; Anesthetics, Local; Bupivacaine; Child; Costs and Cost Analysis; Drug Combinations; Heroin; Humans; Infusions, Intravenous; Injections, Epidural; Pain, Postoperative; Postoperative Nausea and Vomiting; Pruritus; Ropivacaine; Sleep Stages; Urinary Retention

One hundred female patients undergoing major reconstructive plastic or gynaecological surgery were randomized to either receive subcutaneous patient-controlled analgesia (PCA) (bolus dose 2.5 mg diamorphine in 1 ml with a 20-minute lockout) or intravenous PCA (bolus dose 0.5 mg diamorphine in 1 ml with a 5-minute lockout). Data were collected by questionnaire and interview to evaluate the intervention on pain scores, quality of sleep on the first postoperative night, postoperative nausea and vomiting (PONV) and overall patient acceptability. The subcutaneous PCA group experienced less 'worse pain' (P < 0.01) and less sleep disturbance due to pain (P < 0.001). Subcutaneous PCA would appear to offer patients a safe and effective means of analgesia and may offer significant advantages over the intravenous route of administration.

Topics: Adult; Female; Gynecologic Surgical Procedures; Heroin; Humans; Injections, Intravenous; Injections, Subcutaneous; Pain, Postoperative; Patient Satisfaction; Plastic Surgery Procedures; Postoperative Nausea and Vomiting; Sleep Wake Disorders; Statistics, Nonparametric

Eighty women undergoing elective Caesarean section under spinal anaesthesia using hyperbaric bupivacaine 0.5% were randomly allocated to receive, in addition, intrathecal diamorphine 0.125, 0.25 or 0.375 mg or saline. Postoperative morphine requirements, measured using a patient-controlled analgesia system, were reduced in a dose-dependent manner by diamorphine. Pain scores were significantly lower at 2 and 6 h following the two larger doses of diamorphine. Less supplemental analgesia was required intra-operatively if intrathecal diamorphine had been given. The incidences of vomiting and pruritus were also dose-related. No respiratory rates of less than 14 breath.min-1 were recorded and the incidence of oxygen saturation readings less than 95% and 90% did not differ between groups. There were no adverse neonatal effects. Intrathecal diamorphine in the present study was found to be safe in doses of up to 0.375 mg following Caesarean section. However, minor side-effects were frequently observed.

Topics: Adult; Analgesia, Obstetrical; Analgesics, Opioid; Anesthesia, Obstetrical; Anesthesia, Spinal; Apgar Score; Cesarean Section; Dose-Response Relationship, Drug; Double-Blind Method; Female; Heroin; Humans; Pain, Postoperative; Pregnancy

A randomized, double-blind study of 40 women was performed to compare patient controlled anaesthesia (PCA) morphine requirements after spinal anaesthesia for elective Caesarean section. The women received 0.2 mg of either morphine or diamorphine mixed with 0.5% bupivacaine in 8% dextrose. There were no significant differences between the groups in terms of VAS for pain, either while supine or trying to turn over. The median VAS for itching were significantly higher in the morphine group at 3, 4, 6, 8 and 12 h. Similarly, the VAS for drowsiness were significantly higher in the morphine group at 6 and 8 h. Overall there was no difference in the 24-h PCA morphine demands between the two groups (diamorphine patients 5.5 mg, morphine patients 5.0 mg.

Topics: Adult; Analgesia, Obstetrical; Analgesia, Patient-Controlled; Analgesics, Opioid; Anesthesia, Spinal; Cesarean Section; Double-Blind Method; Female; Heroin; Humans; Morphine; Pain Measurement; Pain, Postoperative; Pregnancy

We have compared the i.v. and s.c. routes of administration for diamorphine infusions in children undergoing abdominal surgery. Subjects received general anaesthesia with extradural block and diamorphine up to 20 micrograms kg-1 h-1 after operation. There were no differences between the groups in diamorphine consumption, pain scores or incidence of side effects. The s.c. route appeared to be as effective and safe as the i.v. route for administration of diamorphine infusions in children undergoing elective surgery.

Topics: Abdomen; Acute Disease; Analgesia; Analgesics, Opioid; Anesthesia, General; Child; Child, Preschool; Heroin; Humans; Infant; Infusions, Intravenous; Infusions, Parenteral; Pain, Postoperative

Twenty-two patients were studied while receiving epidural analgesia with diamorphine after major lower abdominal surgery under combined regional and general anaesthesia. Epidural PCA began when the intraoperative epidural block with bupivacaine wore off enough for the patient to request treatment. It was started with 2 mg of diamorphine and continued with a reducible background infusion that was initially set at 0.2 mg h-1 and supplemented by on-demand doses of 0.2 mg, with a lockout time of 15 min. The patients received routine post-operative monitoring and care, with pain at rest being assessed on a four-point verbal rating scale (VRS, none, mild, moderate, severe) at 5, 10, 15, 30, 45, 60, 90 and 120 min from the start of ePCA, then hourly until 24 h and then 2-hourly until 48 h. VRS on coughing and a 10 cm visual analogue score (VAS) at rest and on coughing were recorded at the same times at 4 h, then 4 hourly until 24 h and then at 48 h, at which times, blood samples were also taken to measure morphine concentrations by radioimmunoassay. Analgesia started promptly and reached a maximum at between 30 and 45 min, accompanied by maximum sedation. Thereafter clinically acceptable analgesia was maintained without undue sedation for 48 h, though pain on coughing was less well controlled than pain at rest. After the initial loading dose of diamorphine, the 95% confidence intervals (CI) for further consumption were 3.7 to 17 mg (average 9.7) in the first 24 h and 2.1 to 12.9 mg (average 6.7 mg) in the second 24 h. The plasma morphine concentrations rose to a plateau by about 15 min, with concentrations within 95% CI from 0 to 11 ng mliters-1 (average 5 ng mliters-1. The VRS and VAS pain scores were analysed by a conservative approach that treated them as ordinal data, and by a parametric approach that treated them as interval data. Both approaches conveyed broadly similar information about the post-operative analgesia.

Topics: Abdomen; Analgesia, Epidural; Analgesia, Patient-Controlled; Analgesics, Opioid; Anesthesia; Cough; Female; Hemodynamics; Heroin; Humans; Male; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative

The neuroendocrine response following major surgery has not been previously influenced by either regional anaesthetic techniques or opioid analgesia probably due to insufficient intraoperative afferent neural blockade. In this study we attempted to determine whether significant inhibition of these pathways could be achieved by combining preoperative high spinal anaesthesia with postoperative thoracic epidural anaesthesia. In theory too, there may be additional benefits over perioperative thoracic epidural anaesthesia on pain and pulmonary dysfunction.. 20 ASA 1-3 patients undergoing elective colonic surgery were studied. Gp 1 (n = 10) received a high spinal intraoperative block to T4 using 6mls of 0.5% bupivacaine plus continuous epidural 0.125% bupivacaine/0.0025% diamorphine. Gp 2 (n = 10) patients received epidural 0.5% bupivacaine block to T4 plus continuous epidural infusion of 0.125% bupivacaine/0.0025% diamorphine. We measured a) plasma glucose and cortisol at 0, 1, 2, 3, 4, 8 and 24 h; b) forced vital capacity (FVC), forced expiratory volume in the first second (FEV1) and peak flow rate (PFR) preoperatively, at 8 and 24 h; c) visual analogue pain scores (VAS 0-10) at rest, cough and mobilisation at 8 and 24 h; d) block height every hour for 12 hours then 3 hourly; e) 24-hour urine volumes for dopamine, adrenaline and noradrenaline f) 24-hour PCA morphine requirements.. The two groups did not differ in age, sex, height, weight, duration of surgery, blood loss or serum albumin. Pain relief was excellent and similar in both groups. The average 24 hour morphine consumption was 10 mg in both groups with no differences in the block height. All the patients had a 30-50% reduction in FEV1, FVC and PFR (P > 0.05). Metabolically, there was no statistical difference between the 2 groups except a higher rise in glucose in Gp1 at 2 and 3 h (P = 0.0312 and 0.014). 24-hour catecholamine studies showed no differences for noradrenaline (P = 0.8), adrenaline (P = 0.47) and dopamine (P = 0.36).. Thoracic epidural bupivacaine/diamorphine infusion provided excellent postoperative analgesia following colonic surgery. An intraoperative combined spinal/epidural technique conferred no additional benefit on analgesia, pulmonary function and the neuroendocrine response.

Topics: Adult; Analgesia, Epidural; Analgesics, Opioid; Anesthesia, Spinal; Anesthetics, Combined; Anesthetics, Local; Blood Glucose; Bupivacaine; Colectomy; Forced Expiratory Volume; Heroin; Humans; Hydrocortisone; Intraoperative Period; Middle Aged; Pain Measurement; Pain, Postoperative; Peak Expiratory Flow Rate; Respiratory Mechanics; Vital Capacity

Forty-five boys undergoing repair of hypospadias were allocated randomly to one of two groups. After induction of anaesthesia, 22 patients received 0.25% caudal bupivacaine 0.5 ml kg-1 and diamorphine 30 micrograms kg-1 and the remaining 23 patients received 0.25% caudal bupivacaine 0.5 ml kg-1 alone. Pain scores (Children's Hospital of Eastern Ontario Pain Scale), sedation scores, ventilatory frequency, analgesic requirements and associated side effects were recorded for the first 24 h after operation. The two groups were indistinguishable in age, weight and duration of surgery. There was a statistically significant reduction in early pain scores. There was also a statistically significant increase in the time to first passage of urine in those boys in the diamorphine group who were not catheterized during operation.

Topics: Analgesics, Opioid; Anesthetics, Local; Bupivacaine; Child; Child, Preschool; Consciousness; Drug Therapy, Combination; Heroin; Humans; Hypospadias; Infant; Injections, Spinal; Male; Pain, Postoperative; Postoperative Period; Respiration; Urination

Intrathecal midazolam for use as a post-operative analgesic when given alone and in conjunction with intrathecal diamorphine was assessed. Fifty-two patients scheduled for elective Caesarean section under spinal anaesthesia were randomly allocated to receive either bupivacaine (B), bupivacaine with diamorphine (BD), bupivacaine with midazolam (BM) or all three (BMD) by intrathecal injection. Post-operatively, no differences in visual analogue score (VAS), sedation or post-operative nausea and vomiting (PONV) could be demonstrated between groups. Patient-controlled analgesia system (PCAS) usage was significantly greater in group B when compared with the other groups. Pruritus was commoner in patients receiving diamorphine (BMD & BD). No side effects attributable to midazolam were identified. Intrathecal midazolam at this dose appears safe and has clinically detectable analgesic properties. The duration of useful analgesia appears to be short-lived.

Topics: Analgesia, Patient-Controlled; Analgesics; Anesthesia, Obstetrical; Anesthesia, Spinal; Anesthetics, Local; Bupivacaine; Cesarean Section; Double-Blind Method; Female; Heroin; Humans; Injections, Spinal; Midazolam; Morphine; Pain Measurement; Pain, Postoperative; Pregnancy

Analgesia with preoperative naproxen after laparoscopic sterilization was assessed in a prospective, double-blind, randomized study of 80 women; 42 women received oral naproxen 1 g, approximately 90 min before surgery, and 38 received placebo. Preoperative naproxen did not significantly influence postoperative pain scores, but was associated with a reduction in parenteral opioid administration (P = 0.04).

Topics: Adult; Ambulatory Surgical Procedures; Analgesics; Double-Blind Method; Drug Administration Schedule; Female; Heroin; Humans; Laparoscopy; Naproxen; Pain, Postoperative; Preanesthetic Medication; Prospective Studies; Sterilization, Tubal

In order to investigate the analgesic effect of timing of administration of ketorolac 10 mg i.v., we recorded patient-controlled use of diamorphine at 2, 4 and 12 h after abdominal hysterectomy. In a randomized, double-blind trial, 30 patients received ketorolac before skin incision and 28 after skin closure. A control group of 32 patients did not receive ketorolac. We measured operative blood loss and assessed nausea, vomiting and pruritus. After 2 h of patient-controlled analgesia, the median cumulative diamorphine dose in the group given ketorolac before operation was less than that of the control group (95% confidence interval 8-66 micrograms kg-1; P = 0.01). There were no other statistically significant differences in diamorphine consumption between the groups. The frequency of nausea and vomiting was similar in all groups Median blood loss in the group given ketorolac before operation exceeded that of the patients who did not receive ketorolac before operation (95% confidence interval 20-149 ml; P = 0.01). We conclude that the diamorphine-sparing effect of ketorolac attributable to timing of administration was small, conferred no clinical benefit and was accompanied by increased bleeding. No patient given ketorolac complained of pruritus.

Topics: Adult; Aged; Analgesia, Patient-Controlled; Analgesics, Non-Narcotic; Analgesics, Opioid; Blood Loss, Surgical; Double-Blind Method; Drug Administration Schedule; Female; Heroin; Humans; Hysterectomy; Ketorolac; Middle Aged; Pain, Postoperative; Preanesthetic Medication; Tolmetin

Sixty patients undergoing elective total hip replacement under spinal anaesthesia were randomly assigned to receive either intrathecal (IT) diamorphine 0.75 mg (n = 30) or IT morphine 1.0 mg (n = 30). Postoperative pain scores, analgesic requirements and side effects were assessed by a blinded observer. Postoperative pain scores were broadly similar and satisfactory for both groups but the amount of additional IV morphine required to achieve this was significantly reduced in the morphine compared with the diamorphine group (P < 0.05). Twelve of the morphine group required no postoperative analgesics compared with four in the diamorphine group (P < 0.02). There were no differences between the groups in the incidence of side effects such as emesis and pruritus. No significant postoperative respiratory depression was noted. In the doses used intrathecal morphine provided superior postoperative analgesia to that of intrathecal diamorphine.

Topics: Adult; Aged; Elective Surgical Procedures; Female; Heroin; Hip Prosthesis; Humans; Injections, Spinal; Male; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative

The requirements for supplementary 3 ml epidural injections of bupivacaine 0.5% (top-ups) were used in a randomized double-blind study to compare the effects of five types of thoracic epidural infusions given at 2.5 ml h-1 for the first 24 h after major surgery to the upper abdomen in 99 patients and the lower abdomen in 72. The infusions were: bupivacaine 0.167% alone; diamorphine 0.167 mg ml-1 (0.417 mg h-1) in bupivacaine 0.167%; sufentanil 2 micrograms ml-1 (5 micrograms h-1) in 0.167% bupivacaine; sufentanil 4 micrograms ml-1 (10 micrograms h-1) in 0.167% bupivacaine; and sufentanil 4 micrograms ml-1 (10 micrograms h-1) in normal saline. The patients who had upper abdominal surgery were on average older than those having lower abdominal surgery and a larger proportion of them were female. They received on average fewer top-ups. After both upper and lower abdominal surgery, epidural infusions of bupivacaine alone required the most frequent supplementation (inter-quartile range 6-14 top-ups in 24 h) and the two sufentanil-bupivacaine mixtures required the fewest (interquartile range 0-12 top-ups in 24 h). The infusions of sufentanil without bupivacaine were significantly less effective than the sufentanil-bupivacaine mixtures after upper (but not lower) abdominal surgery. Although the two sufentanil-bupivacaine mixtures were indistinguishable in analgesic effectiveness after either upper or lower abdominal surgery, the lower (5 micrograms h-1) dose rate of sufentanil gave a significantly higher average breathing rate and lower average PaCO2 for the first 24 h after lower (but not upper) abdominal surgery. Blood samples were taken (as an afterthought) from 11 patients receiving sufentanil 10 micrograms h-1, just before the epidural infusion was stopped. The concentrations were mostly above the range for systemic analgesia, but below the values that would have been expected if a steady state had been achieved.

Topics: Abdomen; Adolescent; Adult; Aged; Analgesia, Epidural; Bupivacaine; Double-Blind Method; Female; Heroin; Humans; Male; Middle Aged; Pain, Postoperative; Sufentanil

Phantom limb pain may appear in up to 85% of patients after amputation. There is no effective treatment. Perioperative epidural infusion of morphine and bupivacaine, alone or in combination, is effective in preventing phantom limb pain in patients with pre-existing limb pain. Serious side-effects, however, make them difficult to manage on a general ward. Clonidine has been shown to be an effective postoperative analgesia when applied epidurally. To mitigate the potentially serious side-effects of all these drugs, we have studied their combined efficiency in preventing phantom limb pain in a prospective controlled study of 24 patients undergoing lower limb amputation. In the study group (n = 13), an epidural infusion containing bupivacaine 75 mg, clonidine 150 micrograms and diamorphine 5 mg in 60 ml normal saline was given at 1-4 ml/h 24-48 h preoperatively and maintained for at least 3 days postoperatively. The control group (n = 11) received on-demand opioid analgesia. Pain was assessed by visual analogue scale at 7 days, 6 months and 1 year. At 1 year follow-up, one patient in the study group and eight patients in the control group had phantom pain (P < 0.002) and two patients in the study group versus eight patients in the control group had phantom limb sensation (P < 0.05). There was no significant improvement in stump pain. We conclude that perioperative epidural infusion of diamorphine, clonidine and bupivacaine is safe and effective in reducing the incidence of phantom pain after amputation.

Topics: Adult; Aged; Aged, 80 and over; Amputation, Surgical; Analgesics; Bupivacaine; Clonidine; Drug Combinations; Female; Follow-Up Studies; Heroin; Humans; Infusions, Parenteral; Leg; Male; Middle Aged; Pain, Postoperative; Phantom Limb; Premedication; Prospective Studies

Forty patients who underwent upper or mid-abdominal surgery were randomly allocated to receive a post-operative epidural infusion of 0.083 mg ml-1 of diamorphine in either 0.167% bupivacaine or 0.9% NaCl solution. The nursing staff, who were unaware of which solution was being infused, managed the patients' pain according to a standardized scheme. They adjusted the epidural infusion rates to 3, 5 or 7 ml h-1 according to the patient's hourly reports of pain on a four point verbal rating scale (none, mild, moderate or severe), aiming to use the lowest allowed infusion rate to prevent or reduce any pain that was more than mild. Additional analgesia was given as diclofenac 75 mg intramuscularly if the patients report moderate pain while on the highest infusion rate. The nurses were instructed to summon anaesthetic help if pain relief was still unsatisfactory after diclofenac, but this was never necessary. Diclofenac was needed by six patients receiving diamorphine in saline and one receiving diamorphine in bupivacaine (P < 0.05). The range of average hourly epidural infusion rates was constrained by design to between 3 and 7 ml h-1 but the median of these values was 5 ml h-1 in the diamorphine-saline group and 3.35 ml h-1 in the diamorphine-bupivacaine group (P < 0.02). In patients receiving diamorphine in saline, a median of 6 (range 0-16) of the 24 h reports were of more than mild pain, whereas in the diamorphine-bupivacaine group, the corresponding figures were 2 (range 0-13) (P < 0.02)).(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Abdomen; Adult; Age Factors; Aged; Analgesia, Epidural; Bupivacaine; Cough; Diclofenac; Drug Combinations; Female; Heroin; Humans; Injections, Intramuscular; Male; Middle Aged; Pain Measurement; Pain, Postoperative; Regression Analysis; Rest

Intravenous morphine and diamorphine are routinely used for postoperative analgesia but the relative histamine releasing abilities of these drugs have not been compared in man. Thirty-eight patients were randomly allocated to receive morphine (0.16 mg.kg-1) or diamorphine (0.08 mg.kg-1) after abdominal surgery. Blood samples for histamine were taken before, and at timed intervals after, opioid administration and analysed by an isotopic radioenzymatic technique. Haemodynamic parameters and pain scores were recorded before and after analgesic administration, and a series of eight basophil histamine release studies was also performed. Significant histamine release (plasma concentration > 2 ng.ml-1 or rise of > 700% baseline) occurred in 23.5% of the morphine group and 21.1% of the diamorphine group. Histamine was released earlier in those receiving diamorphine, but no significant change in haemodynamic parameters occurred, and no histamine release was demonstrated in the basophil histamine release studies. These findings suggest that morphine and diamorphine release histamine from mast cells rather than basophils.

Topics: Adolescent; Adult; Aged; Blood Pressure; Double-Blind Method; Female; Heroin; Histamine; Histamine Release; Humans; In Vitro Techniques; Male; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative

We have examined the efficacy, duration of action and side effects of extradural diamorphine alone and in combination with 1:200,000 adrenaline in a randomized, double-blind controlled study of 45 patients who underwent Caesarean section under spinal anaesthesia. Saline 10 ml, diamorphine 2.5 mg in saline 10 ml or diamorphine 2.5 mg in 1:200,000 adrenaline 10 ml were administered via the extradural route at delivery of the baby. Both diamorphine and diamorphine with adrenaline provided significantly prolonged analgesia compared with control (mean time to next analgesia (95% confidence interval) 17.3 h (12.0, 22.1 h), 15.9 h (10.6, 21.1 h), 5.7 h (1.5, 9.9 h), respectively) (P < 0.01). The addition of adrenaline increased the quality of analgesia 8 h after operation, but had no effect on the total amount of i.m. morphine administered during the first 24 h. The incidence of side effects was similar in all groups.

Topics: Adult; Analgesia, Epidural; Analgesia, Obstetrical; Anesthesia, Obstetrical; Anesthesia, Spinal; Cesarean Section; Double-Blind Method; Drug Combinations; Epinephrine; Female; Heroin; Humans; Middle Aged; Pain, Postoperative; Pregnancy

In a randomised study of analgesia following Caesarean section, we compared the efficacy and side effects of on-demand epidural diamorphine 2.5 mg with intravenous patient-controlled analgesia using diamorphine from the Baxter infusor system. Pain scores fell more rapidly in the epidural group, but by the fourth hour, and thereafter, both techniques had a similar analgesic effect. The patient-controlled analgesia group used significantly more diamorphine (p < 0.001), median 62 mg (range 18-120 mg) compared to the epidural group, median 10 mg (range 2.5-20 mg), over a significantly longer time period (p < 0.001), median 54.25 h (range 38-68 h) compared to the epidural group, median 40.75 h (range 6-70 h). The frequency and severity of nausea, vomiting and pruritus were similar in the two groups, however, the patient-controlled analgesia group were more sedated during the first postoperative day. This reached statistical significance (p < 0.05) between 9-24 h. Overall satisfaction scores (0-100) were high, but the patient-controlled analgesia group scored significantly higher: mean 85.5 (SD 12.2) compared to mean 77.0 (SD 11.7) in the epidural group.

Topics: Adult; Analgesia, Epidural; Analgesia, Obstetrical; Analgesia, Patient-Controlled; Cesarean Section; Female; Heroin; Humans; Infusions, Intravenous; Nausea; Pain, Postoperative; Patient Satisfaction; Pregnancy; Pruritus; Time Factors; Vomiting

Analgesia provided by either 5 mg diamorphine, or 5 mg methadone administered by the epidural route during elective caesarean section was compared in 40 women. The median time to further analgesia in the methadone group was 395 min, and 720 min in the diamorphine group, P = 0.0003. Linear analogue scores to assess pain were measured 2-hourly for 12 h, then again at 24 h postoperatively. Pain scores were significantly lower in the diamorphine group at 8 and 10 h. The median cumulative i.m. morphine dose administered during the first 24 h was 20 mg in the methadone group and 0 mg in the diamorphine group (P = 0.0005). Nausea and pruritus were common side effects in both groups. Continuous pulse oximetry data were available for 12 h post-operatively in 15 patients receiving methadone, and in 17 patients receiving diamorphine. One or more episodes of significant desaturation (< 90% for 30 s), occurred in three patients receiving methadone, and in nine patients receiving diamorphine. Desaturation to 90-92% occurred in a further three patients given epidural diamorphine, and in one further patient given epidural methadone.

Topics: Analgesia, Epidural; Analgesia, Obstetrical; Cesarean Section; Double-Blind Method; Female; Heroin; Humans; Hypoxia; Incidence; Methadone; Morphine; Nausea; Oxygen; Pain Measurement; Pain, Postoperative; Pregnancy; Prochlorperazine; Pruritus; Time Factors

In a randomised, double-blind study, the effect of addition of 1 mg of diamorphine to 4 ml of 0.5% bupivacaine for spinal anaesthesia was studied in two groups each of 30 patients presenting for either transurethral genito-urinary surgery, or for lower limb arterial surgery or inguinal herniorrhaphy. Addition of 1 mg diamorphine to intrathecal 0.5% bupivacaine produced a prolonged and satisfactory analgesia in more than half the patients undergoing lower limb arterial or inguinal surgery, and the analgesic requirements of the remainder during the first postoperative 24 h were much less than those who received bupivacaine alone. In the urological surgery set there were no significant differences between the group who received bupivacaine and diamorphine, and the group who received bupivacaine alone. The mixture of diamorphine 1 mg in 4 ml 0.5% bupivacaine was slightly less hypobaric (0.9981 at 37 degrees C) than bupivacaine alone.

Topics: Aged; Anesthesia, Spinal; Bupivacaine; Double-Blind Method; Female; Heroin; Humans; Male; Pain, Postoperative; Postoperative Complications; Specific Gravity; Time Factors

We have examined postoperative pain in patients allocated randomly to receive extradural bolus diamorphine 3.6 mg, extradural infusion of 0.15% bupivacaine with 0.01% diamorphine or patient-controlled i.v. administration of diamorphine at a maximum rate of 1 mg per 5 min, after total abdominal hysterectomy. Extradural infusion analgesia produced the smallest pain scores from 12 to 24 h after surgery (P < 0.05). More patients in the extradural infusion group were moderately hypoxaemic (SpO2 < 90% > 12 min h-1) after operation, compared with the two other groups (P < 0.05). The group using patient-controlled analgesia received more diamorphine and suffered a greater incidence of emetic sequelae (P < 0.05).

Topics: Abdomen; Adult; Aged; Analgesia, Epidural; Analgesia, Patient-Controlled; Bupivacaine; Female; Heroin; Humans; Hypoxia; Hysterectomy; Middle Aged; Pain Measurement; Pain, Postoperative

The influence of an intravenous infusion of naloxone 1 microgram kg-1 h-1, in combination with intrathecal diamorphine, on analgesia and hormonal stress responses after laminectomy was assessed in a blinded, randomized, placebo-controlled study. Twenty-seven patients undergoing laminectomy with postoperative analgesia provided by intrathecal diamorphine were investigated. Analgesia was reduced by naloxone (P less than 0.05), and the duration of analgesia was shortened by 180 min. The postoperative concentrations of both blood glucose and serum cortisol were reduced in the naloxone group compared to the control group (P less than 0.05). These results may indicate an excitatory role for the hypothalamic mu receptor in hypothalamo-pituitary-adrenocortical axis regulation.

Topics: Adult; Aged; Blood Glucose; Female; Heroin; Humans; Hydrocortisone; Infusions, Intravenous; Injections, Spinal; Male; Middle Aged; Naloxone; Pain, Postoperative; Stress, Physiological; Surgical Procedures, Operative

In a randomised double-blind study, the efficacy, duration of action and side effects of five diamorphine analgesia regimens following Caesarean section are described. The time to next analgesia was shorter in the 5 mg intramuscular group (3.53 hours) than in any of the four epidural groups: 5 mg (5.7 hours, p = 0.007), 2.5 mg (4.76 hours, p = 0.103), 5 mg with adrenaline 1/200,000 (7.2 hours, p = 0.001) and 2.5 mg with adrenaline 1/200,000 (6.05 hours, p = 0.007). Multiple regression analysis showed that the addition of adrenaline significantly increased the duration of action of epidural diamorphine (p less than 0.05). The 5 mg dose with adrenaline showed no advantage when compared with 2.5 mg with adrenaline (p = 0.16). No serious side effects were reported in any group.

Topics: Adolescent; Adult; Analgesia, Epidural; Analgesia, Obstetrical; Cesarean Section; Double-Blind Method; Epinephrine; Female; Heroin; Humans; Injections, Intramuscular; Pain, Postoperative; Pregnancy; Time Factors

The dose requirements and side effects of morphine were compared with those of diamorphine administered by patient-controlled analgesia in 40 patients following elective total hip replacement. Patients were allocated randomly to receive in a double-blind manner either morphine or diamorphine for postoperative pain relief. There were no significant differences between the two groups with regard to postoperative sedation, nausea, well-being, pain relief and requirements for antiemetic drugs. The dose requirement for diamorphine was approximately 50% of that for morphine.

Topics: Adult; Aged; Aged, 80 and over; Analgesia, Patient-Controlled; Double-Blind Method; Female; Heroin; Hip Prosthesis; Humans; Male; Middle Aged; Morphine; Nausea; Pain Measurement; Pain, Postoperative

Twenty-two patients received a single dose of diamorphine 5 mg through a lumbar epidural catheter before thoracic surgery. The patients were transferred after surgery to a high dependency unit where they were allocated randomly to receive either an infusion of epidural diamorphine at a rate of 1 mg/hour (group 1) or bolus doses of epidural diamorphine 5 mg on demand (group 2). There was no statistically significant difference between the groups in visual analogue pain scores in the first 18 postoperative hours. Arterial carbon dioxide tension was elevated in both groups and was consistently higher in group 1 than in group 2, with a statistically significant intergroup difference 12 hours after operation. Respiratory rate was not a useful index of respiratory depression. The commonest nonrespiratory side effect was urinary retention, but the incidences of this and other minor side effects were similar in the two groups.

Topics: Adult; Aged; Analgesia, Epidural; Carbon Dioxide; Female; Heroin; Humans; Male; Middle Aged; Pain Measurement; Pain, Postoperative; Partial Pressure; Respiration; Thoracic Surgery

The influence of route of administration (extradural as compared with intravenous) of diamorphine 0.5 mg/hour as a supplement to extradural bupivacaine (0.125% at 15 ml/hour) was investigated in two groups of 20 patients who underwent major abdominal gynaecological surgery. Significantly more patients in the intravenous group withdrew because of inadequate analgesia (p less than 0.05). Those in the extradural group were significantly more drowsy throughout the study (p less than 0.01), but no major side effects were encountered.

Topics: Abdomen; Adolescent; Adult; Aged; Anesthesia, Epidural; Anesthesia, Local; Bupivacaine; Drug Therapy, Combination; Female; Genitalia, Female; Heroin; Humans; Injections, Intravenous; Middle Aged; Pain, Postoperative

A direct comparison of the analgesic activities of heroin and hydromorphone was carried out in cancer patients with postsurgical pain. Intramuscular doses of 5 and 10 mg of heroin were compared with 1 and 2 mg of hydromorphone in a randomized, double-blind, 4-point parallel group assay. Design innovations in the study provided that about half the patients would receive prior repeated doses of the same drug as the test medication, and half would receive the alternate medication. Both test drugs were found to be potent, relatively short acting analgesics with similar profiles of action. Hydromorphone was about 5 times as potent as heroin on a milligram basis. The comparison of those patients who had repeated doses of the same treatment prior to the test dose and those who had repeated doses of the alternate drug demonstrated no significant effect on the relative potency estimates. Side effect occurrence was similar for both drugs, with sleepiness the most prominent effect. The study supports the view that hydromorphone and heroin produce similar clinical effects, and that either drug may adequately substitute for the other. Covariate analysis indicated that time since last analgesic was positively related to analgesia, and amount of prior opioid had a negative relationship. To a lesser extent, increase in patient age was associated with an increase in analgesic scores. Taking these covariates into account served to increase the sensitivity of the analysis.

Topics: Affect; Analgesics; Female; Heroin; Humans; Hydromorphone; Hypnotics and Sedatives; Male; Neoplasms; Pain Measurement; Pain, Postoperative; Time Factors

Arterial oxygen saturation (SaO2) was analysed continuously before and for 24 h after lower abdominal surgery in 30 patients breathing air using one of three postoperative analgesic regimens: i.v. diamorphine using a patient-controlled analgesia system (PCAS), extradural diamorphine or i.m. morphine. Hypoxaemia was defined as SaO2 less than 94% for more than 6 min h-1. Before operation there was no difference between the three analgesia groups assessed by the duration when SaO2 was less than 94%. After operation the pattern of SaO2 vs time distribution was either stable, with little variation from hour to hour with no hypoxaemia, or unstable with large variation with 30% of patients hypoxaemic. Thus three patterns of SaO2 distribution were seen in the postoperative period: stable without hypoxaemia (4/10 PCAS, 0/10 extradural, and 1/10 i.m. patients), unstable without hypoxaemia (4/10 PCAS, 5/10 extradural and 7/10 i.m. patients) and unstable with prolonged nocturnal periods with SaO2 less than 94% for a mean of 17.7 min h-1, 95% confidence limits (CL) 10-25 min h-1, (2/10 PCAS, 2/10 i.m. and 5/10 extradural patients). Before operation, the unstable group with hypoxaemia spent longer at less than 94% SaO2 (mean 4.8 min h-1, 95% CL 1.0-8.6 min h-1) than the stable group (mean 0.4 min h-1, 95% CL 0.17-0.61 min h-1) and this was a predictor of postoperative hypoxaemia. Hypoxaemia occurred in all analgesia groups, but extradural diamorphine tended to cause longer periods. Some patients at risk of postoperative hypoxaemia may be predicted by preoperative monitoring of SaO2 although extradural diamorphine boluses were associated with hypoxaemia in patients with normal preoperative values.

Topics: Abdomen; Adolescent; Adult; Female; Heroin; Humans; Hypoxia; Infusions, Intravenous; Injections, Epidural; Injections, Intramuscular; Male; Middle Aged; Morphine; Oximetry; Oxygen; Pain, Postoperative; Postoperative Complications; Self Administration

In a randomized double-blind study we examined the effect of adding diamorphine 0.25 mg and 0.5 mg to intrathecal bupivacaine anaesthesia for major orthopaedic surgery. Duration of postoperative analgesia was considerably greater in patients given either doses of intrathecal diamorphine than in a control group of patients given bupivacaine alone (P less than 0.001). However, there was no significant difference between the two diamorphine doses (0.25 mg and 0.5 mg), each providing prolonged analgesia (10.8 and 9.9 h, respectively). Although there was no evidence of late respiratory depression, the frequency of adverse effects, in particular urinary retention, nausea and vomiting, was high in both groups receiving intrathecal diamorphine.

Topics: Aged; Analgesia, Epidural; Clinical Trials as Topic; Double-Blind Method; Drug Administration Schedule; Heroin; Hip Prosthesis; Humans; Knee Prosthesis; Middle Aged; Pain, Postoperative; Random Allocation

Twenty patients who had abdominal hysterectomy under general anaesthesia were randomly assigned to receive either epidural ketamine (30 mg), or epidural diamorphine (5 mg) peri-operatively and on first request for analgesia. Failure to obtain satisfactory analgesia with one of the agents was treated by epidural administration of the other. Pain was assessed by an independent observer, and by the patient using a visual analogue scale. The mean (SD) pain score on recovery from general anaesthesia, on a scale of 0-4, was 2.9 (1.2) for the ketamine group and 1.0 (1.0) for the diamorphine group (p less than 0.01). The mean (SD) time to first request for analgesia was 272 (206) and 72 (41) minutes in the diamorphine and ketamine groups respectively (p less than 0.01). All patients in the diamorphine group obtained adequate analgesia, but all patients in the ketamine group were changed to epidural diamorphine. Epidural ketamine does not appear to be a sufficiently effective alternative to epidural diamorphine for routine use in postoperative pain.

Topics: Adult; Aged; Analgesia, Epidural; Clinical Trials as Topic; Double-Blind Method; Female; Heroin; Humans; Hysterectomy; Ketamine; Middle Aged; Pain Measurement; Pain, Postoperative; Random Allocation; Time Factors

A randomised double-blind study compared the dose-response relationship of intrathecal diamorphine (0, 0.25, 0.75, 1.5, and 2.5 mg) for postoperative pain relief, in 35 subjects who underwent total knee replacement surgery. Assessments commenced 2 h after the opioid injection and continued for 20 h. Pain, analgesic effect, supplementary analgesic requirements and adverse effects were noted. Intrathecal diamorphine was unable to delay the initial perception of discomfort. It was, however, capable of postponing the onset of severe pain requiring analgesic supplementation (control 5.25 h vs approximately 8 h: P less than 0.05). There was no significant difference in the quality of analgesia between the groups. Pruritus was the only undesirable feature unique to intrathecal diamorphine administration. Intrathecal diamorphine was safe and was not associated with clinically apparent respiratory depression. Its effects were inconsistent and its use was associated with irritating side effects. Possible explanations for the erratic behaviour of the diamorphine are discussed.

Topics: Aged; Dose-Response Relationship, Drug; Double-Blind Method; Female; Heroin; Humans; Injections, Spinal; Knee Prosthesis; Male; Middle Aged; Pain, Postoperative; Randomized Controlled Trials as Topic

Three solutions administered by continuous extradural infusion for postoperative analgesia were compared in a randomized, double-blind manner. All patients underwent major abdominal gynaecological surgery and received 0.125% bupivacaine in 0.9% saline, diamorphine in 0.9% saline (0.5 mg in 15 ml) or diamorphine mixed with 0.125% bupivacaine (0.5 mg in 15 ml), at a rate of 15 ml h-1. The bupivacaine-diamorphine mixture provided significantly superior analgesia compared with either bupivacaine or diamorphine alone. No major side effects were encountered.

Topics: Abdomen; Adolescent; Adult; Aged; Anesthesia, Epidural; Bupivacaine; Clinical Trials as Topic; Double-Blind Method; Female; Heroin; Humans; Infusions, Parenteral; Middle Aged; Pain, Postoperative; Random Allocation; Time Factors

In a randomized double-blind study the effect of the addition of adrenaline to extradural diamorphine was assessed in 54 patients after Caesarean section. Patients received extradural diamorphine 5 mg in saline 10 ml with or without adrenaline 1 in 200,000 for postoperative pain relief. Analgesia was profound and of rapid onset in both groups. Duration of analgesia was greater in the adrenaline group (time to next analgesia 12.51 +/- 0.94 h, mean +/- SEM), than in the saline group (9.87 +/- 0.98 h) (P = 0.057). Analgesia was also more consistent in the adrenaline group, with 77% of patients having more than 8 h of good analgesia compared with 48% in the saline group (P less than 0.05). Plasma morphine concentrations, measured in 12 patients, were lower, although not significantly so, in the adrenaline group and mean time to peak concentration markedly delayed. No serious side effects were observed, but there was a higher incidence of vomiting in the adrenaline group.

Topics: Cesarean Section; Double-Blind Method; Drug Therapy, Combination; Epinephrine; Female; Heroin; Humans; Injections, Epidural; Morphine; Pain, Postoperative; Pregnancy; Random Allocation

A randomized, double-blind study of the efficacy, duration of action and side effects of three analgesic regimens following Caesarean section is described. Patients received i.m. diamorphine 5 mg, extradural phenoperidine 2 mg or extradural diamorphine 5 mg. Analgesia was of rapid onset in all groups, as judged by reductions in linear analogue pain scores and rank pain scores. Time to next analgesia was significantly greater after extradural phenoperidine (5.96 h) and extradural diamorphine (8.39 h) than after i.m. diamorphine (3.40 h) (P less than 0.001). Itching was reported on direct questioning by 50% of patients in the extradural groups. No serious side effects were reported. Factors affecting the disposition of extradurally administered diamorphine are discussed.

Topics: Adult; Cesarean Section; Double-Blind Method; Female; Heroin; Humans; Injections, Epidural; Injections, Intramuscular; Pain Measurement; Pain, Postoperative; Phenoperidine; Pregnancy; Time Factors

Seventy-three patients undergoing elective perianal surgery were randomly divided into a control group, a group who received a caudal injection of 20 ml bupivacaine 0.5% plain and a group who received diamorphine 2.5 mg in 10 ml normal saline by caudal injection; a comparison was then made of postoperative analgesia requirements. The bupivacaine group had better analgesia than the control group for the first 8 hours, after which there was no difference. The diamorphine group had better analgesia than the control group for the first 24 hours postoperatively. Side effects were less in the diamorphine group than the control, or the bupivacaine group. In particular, 41% of the bupivacaine group complained of some degree of urinary retention and one patient required temporary catheterisation. It is concluded that caudal diamorphine gives good postoperative analgesia for perianal operations, particularly when motor blockade is not wanted by the surgeon.

Topics: Adolescent; Adult; Aged; Anal Canal; Anesthesia, Caudal; Anesthesia, Epidural; Bupivacaine; Carbon Dioxide; Female; Heroin; Humans; Injections, Intramuscular; Male; Middle Aged; Opium; Pain, Postoperative; Respiration

Intrathecal diamorphine is associated with a high incidence of emetic symptoms. Six anti-emetic drugs representing various chemical groups were given in random order to patients undergoing total hip replacement and who had received intrathecal diamorphine 0.5-1.0 mg. The phenothiazines, perphenazine and prochlorperazine, were more effective than the others. It is suggested that this might be a useful model for the evaluation of new anti-emetics.

Topics: Aged; Antiemetics; Drug Evaluation; Heroin; Hip Prosthesis; Humans; Injections, Spinal; Nausea; Pain, Postoperative; Random Allocation; Vomiting

Twenty-seven patients undergoing thoracotomy received either morphine sulphate 2 mg or diamorphine hydrochloride 2 mg by thoracic extradural injection for postoperative analgesia. Arterial plasma morphine concentrations were measured by specific radioimmunoassay, and the analgesic, respiratory and biochemical effects noted. The plasma morphine concentrations were significantly greater after extradural diamorphine than after extradural morphine in the first 30 min after injection. The maximum increase in plasma morphine concentration was significantly (P less than 0.02) greater after extradural diamorphine, and mean peak values occurred at 5 and 10 min for diamorphine and morphine, respectively. There were significant decreases in respiratory rate and plasma cortisol concentration with maximum effects between 90 and 180 min after the extradural injection. The analgesia produced by these doses was inadequate. The role of lipophilicity is discussed.

Topics: Adult; Blood Glucose; Epidural Space; Female; Heroin; Humans; Hydrocortisone; Injections; Male; Middle Aged; Morphine; Pain, Postoperative; Respiration

The effects of diamorphine hydrochloride 0.1 mg/kg, given either extradurally or intramuscularly for postoperative analgesia were compared in two randomised double-blind studies involving 39 patients undergoing thoracotomy and major gynaecological surgery. Assessments were made at fixed intervals after the administration of diamorphine and consisted of the measurement of pain or analgesic effect. Segmental, sympathetic and any adverse effects were sought. There was no significant difference in the quality of analgesia between the two groups in either trial. Extradural diamorphine provided safe and effective analgesia of rapid onset, with no specific undesirable side-effects. In both studies, analgesia was more prolonged following extradural administration. The relative proportion of spinal binding may be increased after extradural administration and this may be reflected in the prolonged analgesia observed.

Topics: Adult; Aged; Analgesia; Anesthesia, Epidural; Clinical Trials as Topic; Double-Blind Method; Female; Genitalia, Female; Heroin; Humans; Injections, Intramuscular; Male; Middle Aged; Pain, Postoperative; Random Allocation; Thoracic Surgery; Time Factors

The analgesic effects of systemically administered diamorphine, caudal analgesia with 0.5% bupivacaine plain and caudal analgesia with 0.5% bupivacaine plain to which morphine sulphate had been added were studied in boys undergoing circumcision. Postoperative analgesia was assessed using a linear analogue scale. The time interval between operation and subsequent analgesic administration and the number of analgesic doses in 24 h were compared. The frequency of vomiting was noted. All three methods provided satisfactory results. The only detectable difference between the groups was a more rapid, but transient, recovery in the group receiving plain bupivacaine only. The frequency of vomiting was high in all groups. Caudal analgesia, with or without the addition of morphine, did not confer any advantage over injected diamorphine, and did not justify the extra time, risk and expense required to carry it out.

Topics: Anesthesia, Caudal; Anesthesia, Epidural; Bupivacaine; Child; Child, Preschool; Circumcision, Male; Heroin; Humans; Male; Morphine; Pain, Postoperative; Postoperative Complications; Time Factors; Vomiting

We designed a study to determine the relative analgesic potency of intramuscular heroin and morphine and to compare mood and side effects in 166 cancer patients with postoperative pain. Heroin was about twice as potent as morphine (95 per cent confidence limits, 1.6 to 2.6 times) in graded-dose, twin-crossover assays. Heroin provided an analgesic peak effect earlier than morphine (1.2 plus or minus 0.08 and 1.5 plus or minus 0.10 hours, respectively [mean plus or minus S.E.M.]). Doses with equal analgesic effects provided comparable improvements in various elements of mood, particularly feelings of peacefulness. Peak mood improvement occurred earlier after heroin than after morphine (1.2 plus or minus 0.10 and 1.8 plus or minus 0.13 hours, respectively). Both analgesia and mood improvement were less sustained after heroin at doses providing equal peak analgesic effects. The drugs shared the most common side effects, with no marked differences in their occurrence; sleepiness was the most frequent side effect after both drugs (46 per cent with each). Heroin has no apparent unique advantages or disadvantages for the relief pain in patients with cancer.

Topics: Clinical Trials as Topic; Dose-Response Relationship, Drug; Emotions; Female; Heroin; Humans; Injections, Intramuscular; Male; Morphine; Neoplasms; Pain, Postoperative; Time Factors

The results of this study in postoperative patients have, thus far, revealed little that was not expected from a review of the literature. Heroin hydrochloride appears to be about two to three times more potent than morphine sulfate as an analgesic, to act more promptly and to have a slightly shorter duration of action. There is a suggestion that heroin may have a somewhat different spectrum of side effects and mood effects compared to morphine, but the effects of both drugs on mood were inversely correlated with the patients' feelings at the time of drug administration. Regardless, as a group, patients responded to both drugs with significantly improved moods. A lag time between the peak intensity of analgesic and mood effects of both heroin and morphine suggest a dissociation between these effects. Whether or not these early impressions will be reinforced as this study proceeds, and whether or not the effects of the drugs in patients with chronic pain due to advanced cancer will be any different than in these patients with postoperative pain, remains to be seen.

Topics: Affect; Clinical Trials as Topic; Double-Blind Method; Heroin; Humans; Morphine; Neoplasms; Pain, Postoperative

To describe current UK clinical practice around the use of intrathecal diamorphine as analgesia for major elective laparoscopic colorectal surgery.. Online self-administered survey.. Acute public hospitals in the UK (National Health Service - NHS) .. Consultant anaesthetists involved in colorectal surgery lists.. Rate of intrathecal opioids used by anaesthetists for elective laparoscopic colorectal procedures; minimum, most common and maximum doses of intrathecal diamorphine used, timing of administration of intrathecal injection, and relationship between the number of patients anaesthetised for laparoscopic colorectal resections per month by each anaesthetist, and the doses of intrathecal diamorphine they administer.. In total, 479 responses were received. Of these, 399 (83%) use intrathecal opioid routinely: 351/399 (88%) use diamorphine, 35 (8.8%) use morphine, 8 (2%) use fentanyl, and 7 (1.3%) use other drugs. The median intrathecal diamorphine dose most commonly administered by anaesthetists was 500 µg (IQR 400-750 [(range 200-1500])). The median of the maximum dose administered by anaesthetists was 600 µg (IQR 500-1000 [(range 200-2000])). Greater intrathecal diamorphine dosing was positively associated with higher number of cases per month (rho=0.113, pp=0.033).. Intrathecal diamorphine is widely used by UK anaesthetists for patients undergoing major elective laparoscopic colorectal surgery. However, there is little consensus regarding optimal dosing. Therefore, high-quality randomised dose-response trials are needed to investigate the relationship between doses of intrathecal diamorphine and patient outcomes.

Topics: Analgesia; Analgesics, Opioid; Colorectal Neoplasms; Colorectal Surgery; Cross-Sectional Studies; Heroin; Humans; Morphine; Pain, Postoperative; State Medicine; United Kingdom

Topics: Analgesics, Opioid; Heroin; Humans; Pain, Postoperative; Prescriptions

Topics: Breast Neoplasms; Female; Heroin; Heroin Dependence; Humans; Mastectomy; Pain, Postoperative

Post-operative pain management following laparoscopic bariatric surgery can be challenging. There are concerns regarding the use of opioids. The rate of cardiorespiratory problems following neuraxial opioids is unclear. There is little published data on their use in bariatric surgery. This study aimed to assess technique feasibility, pain outcomes, patient acceptability, and the side effects and complications of a 'high-dose' (1.0 mg) intrathecal diamorphine technique for patients undergoing primary laparoscopic bariatric surgery.. Fifty patients were included. Eleven patients (22%) had a diagnosis of OSA. All patients had a spinal anaesthetic with 2.0 mL of 0.25% isobaric bupivacaine containing 1.0 mg diamorphine. General anaesthesia followed together with multi-modal analgesia and anti-emesis. Post-operative pain scores, complications, and side effects in the first 24 h post-operative period were documented. Patients were followed up 6 to 8 weeks after discharge.. All patients had a working spinal anaesthetic with thirty-nine insertions (78%) on the first attempt. Pain scores were similar to previously published data where they were found to be superior to a non-spinal analgesic regime. The median 24 h post-operative oral morphine equivalent consumption was 5 mg. Eight patients (16%) required urinary catheterisation. Four patients (8%) complained of pruritus. Eighteen patients (36%) had post-operative nausea or vomiting. Thirty-three patients (66%) responded to the follow-up request. Thirty of the thirty-three patients (91%) stated they would have the spinal anaesthetic again.. We have demonstrated that neuraxial blockade is a simple, practical, and feasible technique to adopt. Our case series demonstrated a high level of patient acceptability.

Topics: Analgesics, Opioid; Bariatric Surgery; Bupivacaine; Heroin; Humans; Laparoscopy; Morphine; Obesity, Morbid; Pain, Postoperative

The exponential increase in chronic opioid consumers resulted in more challenges regarding post-operative pain management. Considering the usual hyperalgesic response to pain and the increased opioid-tolerance, a multidrug approach should be desirable.. We described the strategy in pain management of a patient receiving methadone maintenance treatment, who underwent surgery associated with moderate post-operative pain. The combination of balanced general anaesthesia and intraoperative continuous low-dose infusion of ketamine assured an appropriate control of post-operative pain without increasing opioid consumption. Besides, it was not associated with psychomimetic effects.. Ketamine can effectively reduce opioid requirements in chronic opioid users on methadone maintenance therapy and should therefore be considered promptly as part of a multimodal perioperative analgesia management in this category of patients.

Topics: Analgesics, Opioid; Heroin; Humans; Hyperalgesia; Ketamine; Male; Methadone; Middle Aged; Opioid-Related Disorders; Pain Management; Pain, Postoperative; Perioperative Care; Postoperative Period

Abnormal restricted diffusion on magnetic resonance imaging is often associated with ischemic stroke or anoxic injury, but other conditions can present similarly. We present six cases of an unusual but consistent pattern of restricted diffusion in bilateral hippocampi and cerebellar cortices. This pattern of injury is distinct from typical imaging findings in ischemic, anoxic, or toxic injury, suggesting it may represent an under-recognized clinicoradiographic syndrome. Despite initial presentation with stupor or coma in the context of obstructive hydrocephalus, patients may have acceptable outcomes if offered early intervention.. We identified an ad hoc series of patients at our two institutions between years 2014 and 2017 who presented to the neurocritical care unit with severe, otherwise unexplained cerebellar edema and retrospectively identified several commonalities in history, presentation, and imaging.. Between two institutions, we identified six patients-ages 33-59 years, four male-with similar presentations of decreased level of consciousness in the context of intoxicant exposure, with acute cytotoxic edema of the cerebellar cortex, hippocampi, and aspects of the basal nuclei. All patients presented with severe cerebellar edema which led to obstructive hydrocephalus requiring aggressive medical and/or surgical management. The five patients who survived to discharge demonstrated variable degrees of physical and memory impairment on discharge and at follow-up.. We present findings of a potentially novel syndrome involving a distinct pattern of cerebellar and hippocampal restricted diffusion, with imaging and clinical characteristics distinct from ischemic stroke, hypoxic injury, and known toxidromes and leukoencephalopathies. Given the potential for favorable outcome despite early obstructive hydrocephalus, early identification and treatment of this syndrome are critical.

Topics: Adult; Alcoholic Intoxication; Amphetamines; Basal Ganglia; Benzodiazepines; Brain Edema; Central Nervous System Stimulants; Cerebellar Cortex; Cerebellum; Cocaine; Coma; Female; Heroin; Hippocampus; Humans; Hydrocephalus; Hydromorphone; Magnetic Resonance Imaging; Male; Middle Aged; Opiate Alkaloids; Pain, Postoperative; Stupor; Substance-Related Disorders; Syndrome

Thoracic epidural (TE) analgesia has been the standard of care for transthoracic esophagectomy patients since the 1990s. Multimodal anesthesia using intrathecal diamorphine, local anesthetic infusion catheters (LAC) into the paravertebral space and rectus sheaths and intravenous opioid postoperatively represent an alternative option for postoperative analgesia. While TE can provide excellent pain control, it may inhibit early postoperative recovery by causing hypotension and reducing mobilization. The aim of this study is to determine whether multimodal analgesia with LAC was effective with respect to adequate pain management, and compare its impact on hypotension and mobility. Patients receiving multimodal LAC analgesia were matched using propensity score matching to patients undergoing two-phase trans-thoracic esophagectomy with a TE over a two-year period (from January 2015 to December 2016). Postoperative endpoints that had been evaluated prospectively, including pain scores on movement and at rest, inotrope or vasoconstrictor requirements, and hypotension (systolic BP < 90 mmHg), were compared between cohorts. Out of 14 patients (13 male) that received LAC were matched to a cohort of 14 patients on age, sex, and comorbidity. Mean and maximum pain scores at rest and movement on postoperative days 0 to 3 were equivalent between the groups. In both cohorts, 50% of patients had a pain score of more than 7 on at least one occasion. Fewer patients in the LAC group required vasoconstrictor infusion (LAC: 36% vs. TE: 57%, P = 0.256) to maintain blood pressure or had episodes of hypotension (LAC: 43% vs. TE: 79%, P = 0.05). The LAC group was more able to ambulate on the first postoperative day (LAC: 64% vs. TE: 43%, P = 0.14) but these differences were not statistically significant. Within the epidural cohort, three patients had interruption of epidural due to dislodgement or failure of block compared to no disruption in the multimodal local anesthesia catheters group (P = 0.05). Therefore, multimodal anesthesia using spinal diamorphine with combined paravertebral and rectus sheath local anesthetic catheters appears to provide comparable pain relief post two-phase esophagectomy and may provide more reliable and safe analgesia than the current standard of care.

Topics: Aged; Analgesia; Analgesia, Epidural; Analgesics, Opioid; Catheters; Esophagectomy; Female; Heroin; Humans; Injections, Spinal; Male; Middle Aged; Pain, Postoperative; Retrospective Studies; Thoracotomy; Treatment Outcome

Topics: Acetaminophen; Analgesia; Analgesics, Non-Narcotic; Analgesics, Opioid; Anti-Inflammatory Agents, Non-Steroidal; Cesarean Section; Codeine; Diclofenac; Female; Heroin; Humans; Ibuprofen; Pain Management; Pain, Postoperative; Patient Discharge; Personal Satisfaction

The prescribing of opioid pain medication has increased markedly in recent years, with strong opioid dispensing increasing 18-fold in Tayside, Scotland since 1995. Despite this, little data is available to quantify the problem of opioid pain medication dependence (OPD) and until recently there was little guidance on best-practice treatment. We report the case of a young mother prescribed dihydrocodeine for postoperative pain relief who became opioid dependent. When her prescription was stopped without support, she briefly used heroin to overcome her withdrawal. After re-exposure to dihydrocodeine following surgery 9 years later and treatment with methadone for dependency, she was transferred to buprenorphine/naloxone. In our clinical experience and in agreement with Department of Health and Royal College of General Practitioner guidance, buprenorphine/naloxone is the preferred opioid substitution treatment for OPD. Our patient remains within her treatment programme and has returned to work on buprenorphine 16 mg/naloxone 4 mg in conjunction with social and psychological support.

Topics: Adult; Analgesics, Opioid; Buprenorphine; Codeine; Disease Management; Female; Heroin; Heroin Dependence; Humans; Methadone; Naloxone; Opiate Substitution Treatment; Opioid-Related Disorders; Pain, Postoperative; Substance Withdrawal Syndrome; Young Adult

We compared single-shot epidural analgesia (20 mL 0.125% levobupivacaine and 3 mg diamorphine) followed by regular tramadol versus morphine patient-controlled analgesia (PCA) for postoperative pain following donor nephrectomy.. We retrospectively evaluated 12 patients who received single-shot epidural analgesia (SSE group) before anesthesia induction, followed by regular tramadol, and 14 patients who received morphine PCA (PCA group) for postoperative pain after donor nephrectomy. Postoperative pain scores were recorded at 0, 1, 12, 24, and 48 hours after nephrectomy. We also collected data regarding morphine consumption, additional analgesia, nausea, antiemetic use, time to oral intake, mobilization, and discharge.. The 2 groups were similar for age, gender, body mass index, American Society of Anesthesiologists status, duration of surgery, laparoscopic/open nephrectomy ratio, and intra- and postoperative additional analgesia. There were no significant between-group differences in pain and nausea scores. The SSE group showed lower intra- and postoperative antiemetic use than the PCA group (25% vs 78.5% and 1 dose vs 2.5 doses, respectively; P<.05). The average time to oral fluid and solid food intake and for assisted mobilization were similar in the 2 groups. However, independent mobilization and hospital discharge were significantly sooner in the SSE group (34 hours vs. 47.4 hours; [P<.05] and 3.7 days vs 4.7 days [P<.05], respectively).. In this small pilot study, SSE with 20 mL 0.125% levobupivacaine and 3 mg diamorphine, followed by regular tramadol, provided postoperative analgesia similar to morphine PCA. However, patients in the SSE group used less antiemetic medication, were independently mobile earlier, and were discharged from the hospital earlier than patients in the PCA group.

Topics: Adult; Analgesia, Epidural; Analgesia, Patient-Controlled; Analgesics, Opioid; Anesthetics, Local; Antiemetics; Bupivacaine; Drinking; Eating; England; Female; Heroin; Humans; Injections, Epidural; Kidney Transplantation; Length of Stay; Levobupivacaine; Living Donors; Male; Middle Aged; Morphine; Nephrectomy; Pain Measurement; Pain, Postoperative; Patient Discharge; Pilot Projects; Postoperative Nausea and Vomiting; Retrospective Studies; Time Factors; Tramadol; Treatment Outcome

Intrathecal opioids are now used routinely in the UK for intra- and postoperative analgesia. The opioids of choice have altered over recent years and the dosage regimens used can vary between institutions. Concerns over safety have been reduced probably because much lower doses of opioids are now being used. This survey explored the practice of intrathecal opioid usage in the UK.. We sent a questionnaire survey to 270 anaesthetic departments and received 199 replies, a response rate of 73.7%.. Intrathecal opioids were used in 175 (88.4%) departments. Of these departments, 107 (61.1%) had local guidelines or protocols in place. Opioids such as diamorphine (used in 136 (78.2%) of departments) and fentanyl (129 (74.1%)) with a shorter duration of action are now more commonly used than morphine (37 (21.3%)) for intrathecal analgesia. In 96 (54.5%) departments, patients were nursed on regular surgical wards following administration of spinal opioids.. The use of low-dose lipophilic intrathecal opioids for postoperative analgesia is widespread in the UK. Patients are commonly nursed in low-dependency post-anaesthetic care areas. The low incidence of adverse events reported by the respondents along with the popularity of the technique suggests that low-dose spinal opioid administration is safe.

Topics: Analgesics, Opioid; Anesthesia Recovery Period; Drug Utilization; Fentanyl; Guidelines as Topic; Health Care Surveys; Heroin; Humans; Injections, Spinal; Pain, Postoperative; Surveys and Questionnaires; United Kingdom

Pain is necessary for survival but chronic pain is disabling and causes significant health and economic problems. Chronic stump pain (pain localized in the stump for >3 months) after amputation is a significant problem among amputees (5-10%). The mechanism of this phenomenon is not very clear yet. In this study we attempted to better understand the role of peripheral and central mechanisms in this condition.. 12 patients with established lower limb post-amputation stump pain were given lumbar epidural diamorhpine 5 mg in 20 ml normal saline (NS) and levobupivacaine 0.5% (20 ml) 1 week apart. Baseline pain was recorded and then analgesic and side effects as well as their onset and duration were also assessed.. Epidural diamorphine was found to relieve the pain of all patients. Its onset was relatively rapid being started within 5-9 min (median = 5.5) by a smooth sensation of warmth involving the lower trunk and legs. Analgesia was complete in 30 min and had a median duration of 20.5 h. Pruritus in 6 patients was the only side effect due to epidural diamorphine. Epidural levobupivacaine, on the other hand, usually relieved the discomfort but failed to do so in 3 patients only despite adequate neural blockade. Its onset of action was slower (10-20 min, median = 11) and duration of effect (median = 12 h) was also shorter than diamorphine. The effects of levobupivacaine were inferior to diamorphine due to the associated motor and sensory paralyses as well as absence of euphoria. Epidural diamorphine provided profound analgesia with normalization of stump sensations and euphoria, probably due to absorption into the spinal cord causing segmental action.. While peripheral mechanisms played a role, central mechanisms involving the spinal cord were more important in the modulation of established stump pain in the evaluated patients.

Topics: Adult; Aged; Aged, 80 and over; Amputation Stumps; Analgesia, Epidural; Bupivacaine; Female; Heroin; Humans; Levobupivacaine; Male; Middle Aged; Pain, Postoperative; Single-Blind Method; Time Factors

Topics: Analgesia, Epidural; Analgesics, Opioid; Heroin; Humans; Pain, Postoperative; Respiratory Insufficiency

Topics: Analgesics, Opioid; Cesarean Section; Drug Administration Schedule; Female; Heroin; Humans; Pain, Postoperative; Pregnancy

Postoperative analgesia in patients who receive regular oral opioids pre-operatively is frequently suboptimal. To improve management we introduced a regimen using subcutaneous diamorphine infusions with incremental doses. Infusion doses were calculated as half the daily pre-operative dose of oral morphine with the increments as one-sixth of the infusion dose. Results were recorded on the first two postoperative days before (n = 13) and after (n = 23) commencing the new regimen. The percentage of patients reporting severe pain at rest and on movement were significantly reduced by the new regimen (54% and 69% vs. 13% and 40%, respectively) since the opioid dose as a percentage of the pre-operative dose was significantly higher (160% vs. 352%). There were no instances of excessive sedation or slow respiratory rate in any patient. The use of the regimen has resulted in greater doses of opioids being administered with fewer patients in severe pain without significant complications.

Topics: Adult; Aged; Aged, 80 and over; Analgesics, Opioid; Anti-Inflammatory Agents, Non-Steroidal; Chronic Disease; Drug Administration Schedule; Drug Therapy, Combination; Female; Heroin; Humans; Male; Middle Aged; Pain Measurement; Pain, Postoperative; Treatment Outcome

Topics: Analgesia, Obstetrical; Analgesics, Opioid; Cesarean Section; Female; Heroin; Humans; Pain, Postoperative; Posture; Pregnancy

Topics: Analgesia, Obstetrical; Analgesics, Opioid; Cesarean Section; Female; Heroin; Humans; Pain, Postoperative; Pregnancy

Topics: Analgesia, Obstetrical; Analgesics, Opioid; Cesarean Section; Female; Heroin; Humans; Pain, Postoperative; Pregnancy

Continuous axillary nerve block was used to relieve pain after a chemical burn to the arm in a child on mechanical ventilation after liver transplantation. The analgesia was sufficient to replace parenteral analgesia and allow extubation.

Topics: Aprotinin; Arm Injuries; Axilla; Brachial Plexus; Bupivacaine; Burns, Chemical; Female; Heroin; Humans; Infant; Intraoperative Complications; Liver Transplantation; Nerve Block; Pain, Postoperative; Ventilator Weaning

We describe 4-yr experience providing extradural infusion analgesia in a district hospital for treatment of postoperative pain. A total of 770 patients recovering from major surgery were treated on general surgical wards between April 1989 and March 1993. The results of a retrospective audit showed that pain control, assessed with both a visual analogue scale (VAS score (0-10 cm)) and a verbal rating scale (VRS), was good. At rest, more than 80% of patients scored pain as absent or mild (VAS score 0-3) during the first 24 h, with only 4% experiencing severe pain (VAS score 7-10). On movement, 50% of patients had good pain control (VAS score 0-3) while 20% of patients experienced severe pain (VAS score 7-10). Minor complications such as emetic sequelae and pruritus were common; these conditions were mild and rarely required treatment. Hypotension (< 100 mm Hg) occurred in 34% of patients in the first 24 h. Ventilatory frequencies of 8 b.p.m. or less occurred in 2.6% of patients. Four patients (0.52%) developed severe respiratory depression. These patients demonstrated increased sedation but only one had a low ventilatory frequency. Three patients died while receiving extradural infusion analgesia.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Analgesia, Epidural; Bupivacaine; Female; Heroin; Humans; Infusion Pumps; Male; Medical Audit; Middle Aged; Pain, Postoperative; Patient Care Team; Retrospective Studies

One hundred and fifty extradural infusions of diamorphine and bupivacaine after major surgery in children were audited over a 15 month period. The majority of the children (69%) were less than 5 years of age. Analgesia was assessed or self-rated as 'very good' in over 75% of patients. Urinary retention was seen in 11% of patients and pruritus in 10%. Respiratory depression requiring intervention was only seen in one patient--a premature infant of 39 weeks post-conceptual age. Technical complications resulted in the early loss of 16.7% of the infusions. Although analgesia was good the complexity of the extradural infusion technique demanded significant medical and nursing time especially to overcome technical problems.

Topics: Adolescent; Analgesia, Epidural; Bupivacaine; Child; Child, Preschool; Heroin; Humans; Infant; Infant, Newborn; London; Medical Audit; Pain, Postoperative; Patient Satisfaction; Pruritus; Respiratory Insufficiency; Treatment Outcome; Urinary Retention

Topics: Analgesia, Epidural; Bupivacaine; Heroin; Humans; Pain, Postoperative

An audit of postoperative epidural analgesia in a District General Hospital is presented. Three hundred and forty-eight patients received epidural infusions of a bupivacaine and diamorphine mixture, and were managed on general surgical wards using a standard protocol of observations and instructions. Good analgesia was achieved in 339 (97%) patients. Respiratory depression, defined as a respiratory rate of eight breaths.min-1 or less, occurred in 22 (6%) patients, was of gradual onset, and was simply and successfully managed without morbidity. There were no respiratory arrests. Other complications, and the significance of catheter insertion level are discussed.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Analgesia, Epidural; Bupivacaine; Female; Heroin; Humans; Male; Medical Audit; Middle Aged; Pain, Postoperative; Respiratory Insufficiency; Surgical Procedures, Operative

Topics: Analgesia, Epidural; Bupivacaine; Heroin; Humans; Pain, Postoperative

Two incidence have occurred in our hospital when a patient-controlled analgesia pump has accidentally delivered the whole contents of the syringe of diamorphine (60 mg) over a period of approximately 1 h. Electrical corruption of the pumps' program has been identified as the probable cause. All pumps of this type have been modified to prevent such occurrences.

Topics: Aged; Analgesia, Patient-Controlled; Equipment Failure; Female; Heroin; Humans; Male; Middle Aged; Pain, Postoperative; Product Surveillance, Postmarketing; Respiratory Insufficiency

We report the use of extradural diamorphine for postoperative analgesia as a nurse-based service on selected surgical wards in a district general hospital. Eight hundred patients received lumbar or thoracic extradural diamorphine analgesia for postoperative or traumatic pain. Diamorphine was administered in bolus form by suitably trained nursing staff. Satisfactory analgesia, recorded on a verbal rating scale at the conclusion of the service, was achieved in 94.6% of patients. The technique was considered by medical and nursing staff to be a safe and acceptable method of analgesia. Respiratory depression, defined as a ventilatory frequency of less than 10 b.p.m., occurred in seven patients (incidence of 0.9%). All occurred in the theatre recovery area or in the intensive care unit. Retrospectively, each was predictable and all responded to naloxone 0.4 mg.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Analgesia, Epidural; England; Female; Heroin; Hospitals, District; Hospitals, General; Humans; Male; Middle Aged; Naloxone; Nursing Audit; Nursing Service, Hospital; Pain, Postoperative; Respiratory Insufficiency

The benefits, risks and resource implications of providing an Acute Pain Service were assessed during the first year of the service. Six hundred and sixty patients recovering from major surgery were treated with patient-controlled analgesia (510 patients) or extradural infusion analgesia (150 patients). The results of a prospective outcome study showed that pain control was good: more than 60% of patients scored their pain as mild during the first 24 h. Only 10% of patients complained of severe postoperative pain. Eight patients developed potentially serious complications including respiratory depression and hypotension; the diagnosis and management of these problems on general wards is discussed. Retrospective analysis of the incidence of postoperative chest infection in surgical patients showed a marked reduction during the first year of the service (1.3% in 1988, 0.4% in 1989-90 (P less than 0.01].

Topics: Acute Disease; Adolescent; Adult; Aged; Analgesia, Epidural; Analgesia, Patient-Controlled; Bupivacaine; Evaluation Studies as Topic; Female; Heroin; Humans; Male; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative; Patient Care Team; Patient Satisfaction; Postoperative Complications; Prospective Studies; Retrospective Studies

A case is presented in which myoclonus occurred after epidural diamorphine infusion. Reports of this phenomenon following other epidural drugs and possible mechanisms are discussed.

Topics: Aged; Analgesia, Epidural; Female; Heroin; Humans; Myoclonus; Pain, Postoperative; Postoperative Period

Patient-controlled analgesia was introduced in a district general hospital in order to improve postoperative pain control. Techniques of management were developed with effectiveness, safety and practicality as the main objectives. An analysis of the first 1000 patients to use the system is presented. Problems were encountered with slow respiratory rate, monitoring, equipment function and ward management. Identification of specific hazards and management problems led to improvements in system safety. Patient-controlled analgesia has become the standard technique for postoperative pain control after major surgery in this hospital.

Topics: Adult; Aged; Aged, 80 and over; Analgesia; Female; Heroin; Hospitals, General; Humans; Infusion Pumps; Male; Middle Aged; Pain, Postoperative; Respiration; Self Administration

A patient with advanced multiple sclerosis was successfully managed for a sigmoid colectomy using spinal anaesthesia. Effective postoperative analgesia was achieved with intrathecal diamorphine administered through an indwelling intrathecal catheter, and wound infiltration with 0.25% bupivacaine.

Topics: Adult; Anesthesia, Spinal; Heroin; Humans; Injections, Spinal; Intestinal Obstruction; Male; Multiple Sclerosis; Pain, Postoperative; Sigmoid Diseases

Topics: Heroin; Humans; Injections, Spinal; Pain, Postoperative

The effect of the administration of diamorphine 10 mg epidurally on the metabolic response to cholecystectomy was investigated and compared with a control group of patients given intravenous papaveretum. There were no significant differences in blood glucose, lactate and pyruvate, and plasma nonesterified fatty acid values between the epidural diamorphine group and the control group. Plasma cortisol concentrations were significantly lower in the epidural diamorphine group postoperatively and this was associated with a marked improvement in pain relief. We conclude that epidural opiates do not directly influence the metabolic response to surgery, but decrease the cortisol response postoperatively secondary to improved analgesia.

Topics: Blood Glucose; Cholecystectomy; Epidural Space; Fatty Acids, Nonesterified; Female; Heroin; Humans; Hydrocortisone; Lactates; Lactic Acid; Male; Metabolism; Middle Aged; Opium; Pain, Postoperative; Pyruvates; Pyruvic Acid

Two cases of severe respiratory depression complicating epidural diamorphine administration are reported. In both cases, the dura had been punctured. The risk of epidural opiate administration in association with a breach in the dura is reiterated.

Topics: Aged; Dura Mater; Epidural Space; Female; Heroin; Humans; Injections; Male; Pain, Postoperative; Respiratory Insufficiency

Topics: Analgesics, Opioid; Chronic Disease; Cocaine; Fentanyl; Half-Life; Heroin; Humans; Injections, Intramuscular; Methadone; Morphine; Pain, Intractable; Pain, Postoperative

Twenty-two patients were studied before and after major abdominal vascular surgery to determine the effect on ventilation of 5 mg diamorphine given either extradurally or intramuscularly. Diamorphine depressed ventilation maximally at 30 minutes when given by either route. Before operation resting ventilation was reduced by 33% after extradural and 17% after intramuscular diamorphine; PaCO2 increased by an average of 0.5 kPa (either route); ventilation at 7.3 kPa PaCO2 was reduced 40% after extradural and 33% after intramuscular diamorphine. After operation the effect of diamorphine on ventilation was qualitatively similar but resting baseline ventilation was increased from 9.4 to 10.9 litres/minute. The highest individual PaCO2 values were found during the pre-operative study: 6.5 kPa after extradural diamorphine, 6.4 kPa after intramuscular diamorphine. Pain relief was unsatisfactory after intramuscular diamorphine. Four out of six patients requested further analgesia by 3 hours after administration. No patient who received extradural diamorphine required further analgesia for at least 6 hours.

Topics: Adult; Aged; Blood Vessel Prosthesis; Carbon Dioxide; Epidural Space; Heroin; Humans; Injections; Injections, Intramuscular; Middle Aged; Pain, Postoperative; Respiration; Time Factors

Almost one thousand patients underwent either total hip replacement or spinal surgery in which diamorphine 0.5-1.0 mg was injected intrathecally. Approximately one half of the arthroplasty patients and one third of the spinal patients required no other post-operative analgesia. In the remainder, analgesics were not required for 12 hours post-operatively. The benefits of the technique and possible complications are discussed.

Topics: Adult; Female; Heroin; Hip Prosthesis; Humans; Intervertebral Disc; Intraoperative Care; Laminectomy; Male; Middle Aged; Pain, Postoperative; Time Factors

Patients undergoing lumbar laminectomy were given extradural narcotic, either 5 mg morphine sulphate or 5.5 mg heroin (diamorphine hydrochloride); the extradural catheter had been positioned adjacent to the dura under direct vision. Plasma morphine concentrations measured by specific radioimmunoassay showed that peak concentrations occurred significantly earlier with heroin (4.7 +/- 0.6 min, mean +/- SEM) than with morphine (7.6 +/- 0.9 min) and that peak concentrations were significantly higher after heroin 5-10 min after extradural injection. The fraction of extradural heroin crossing the dura was estimated to be 55% of the fraction of morphine crossing the dura. Postoperative fentanyl requirements using demand analgesia were the same with extradural morphine as with extradural heroin (mean, 6.6 micrograms/hr). Clinically significant slowing of respiratory rate occurred only after extradural heroin (three patients).

Topics: Adult; Analgesia; Anesthesia, Epidural; Female; Heroin; Humans; Kinetics; Laminectomy; Male; Morphine; Pain, Postoperative; Radioimmunoassay; Respiration; Time Factors; Vomiting

Catheters were inserted into the extradural space under direct vision at the time of surgery for prolapsed intervertebral disc or lumbar canal stenosis. In the post-operative period, diamorphine (3 mg in 5 ml water) was injected through the catheter when patients requested analgesia. In only four of 49 patients was significant pain relief not achieved after extradural diamorphine injection. In four other patients it was not possible to use this method of analgesia throughout the two post-operative days as planned. As judged by the improved mobility and by grading on a linear analogue pain scale, the quality of analgesia achieved was better than after intramuscular papaveretum (10-20 mg) and extradural diamorphine was requested less frequently. There were no serious side-effects in the patients studied, although the technique was not used in patients over 55 years of age. Extradural diamorphine appeared to be less effective in two patients who had undergone re-explorations.

Topics: Adolescent; Adult; Analgesics, Opioid; Female; Heroin; Humans; Intervertebral Disc Displacement; Laminectomy; Male; Middle Aged; Opium; Pain, Postoperative; Spinal Cord Compression

Sixty-two patients were given morphine 2 mg and 69 patients were given diamorphine 0.5 mg by either the epidural or intrathecal route. All had undergone either total hip replacement or spinal disc surgery. Forty-nine out of 131 patients required no further analgesia. Diamorphine was superior to morphine and the intrathecal route more effective than the epidural. Headache, pruritus, urinary retention and nausea and vomiting were recorded, the incidence of the latter being unacceptably high, particularly when the drugs were administered by the intrathecal route: one patient required resuscitation. It is suggested that previously reported respiratory depression using these techniques is associated with the administration of other analgesics contemporaneously; that dosage should be limited to one-fifth of the estimation intramuscular dose; and that patients should be observed in a recovery ward for 24 hours.

Topics: Aged; Epidural Space; Heroin; Hip Prosthesis; Humans; Injections; Injections, Spinal; Intervertebral Disc; Male; Morphine; Pain, Postoperative

Topics: Heroin; Humans; Morphine; Pain, Postoperative

Topics: Female; Fentanyl; Heroin; Humans; Pain, Postoperative

Topics: Heroin; Humans; Pain, Postoperative