heroin and Postoperative-Nausea-and-Vomiting

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

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

A continuous infusion of ondansetron was compared with a placebo infusion in 80 patients undergoing major breast reconstructive surgery. All patients received a standard anaesthetic and a bolus dose of ondansetron after induction. They were then randomly allocated to receive an intravenous infusion of ondansetron or a placebo infusion for 24 h in a double-blind fashion. Postoperative analgesia was provided by patient-controlled subcutaneous diamorphine. In the ondansetron group, the severity of nausea, measured by a 10-point verbal rating scale, was reduced (p = 0.01) and fewer patients stated at postoperative interview that nausea and vomiting was a problem (p = 0.01).

Topics: Adolescent; Adult; Aged; Analgesia, Patient-Controlled; Analgesics, Opioid; Antiemetics; Double-Blind Method; Female; Heroin; Humans; Infusions, Intravenous; Mammaplasty; Middle Aged; Ondansetron; Patient Satisfaction; Postoperative Nausea and Vomiting

To assess calculated equivalent doses of intrathecal and epidural opioids for elective Caesarean section in terms of quality and duration of analgesia, and incidence of side effects, we have compared 50 patients, allocated randomly to one of two groups to receive either diamorphine 0.25 mg intrathecally (group 1) or 5 mg epidurally (group 2), in addition to intrathecal bupivacaine 10 mg, using a combined spinal-epidural technique. There was no significant difference in duration of analgesia between groups (group 1 mean 14.6 (SD 5.9) h, group 2 14.2 (6.5) h; mean difference 0.8 h; 95% Cl -2.8-4.5; P = 0.65) or quality of analgesia (VAPS and VRS scores). The degree of pruritus was similar in both groups (80-88%) but the incidence of postoperative nausea and vomiting was significantly higher in the epidural group (24% vs 4%; P < 0.05). Intrathecal diamorphine 0.25 mg produced the same duration and quality of postoperative analgesia as epidural diamorphine 5 mg for elective Caesarean section but with significantly less nausea and vomiting.

Topics: Adult; Analgesia, Epidural; Analgesia, Obstetrical; Analgesics, Opioid; Cesarean Section; Female; Heroin; Humans; Injections, Spinal; Postoperative Nausea and Vomiting; Pregnancy; Pruritus

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

Topics: Adult; Analgesics, Opioid; Anesthesia, Epidural; Anesthesia, Spinal; Female; Heroin; Humans; Placenta, Retained; Postoperative Complications; Postoperative Nausea and Vomiting; Pregnancy

Topics: Adult; Analgesics, Opioid; Anesthesia, Obstetrical; Antiemetics; Cesarean Section; Female; Heroin; Humans; Injections, Spinal; Length of Stay; Ondansetron; Postoperative Complications; Postoperative Nausea and Vomiting; Pregnancy; Pruritus

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

Topics: Analgesics, Opioid; Anesthesia, Obstetrical; Anesthesia, Spinal; Cesarean Section; Female; Heroin; Humans; Postoperative Nausea and Vomiting; Pregnancy

Topics: Analgesics, Opioid; Antiemetics; Heroin; Humans; Midazolam; Postoperative Nausea and Vomiting