Diclofenac 75mg. and 30 mg. orfenadine (Neodolpasse) versus placebo and piroxicam in postoperative analgesia after arthroscopy

PURPOSE OF THE STUDY: Arthroscopy is often performed in an out-patient department or as one-day surgery. Opioids often used as postoperative analgesics may have unwanted side effects that may postpone the patient's discharge from hospital. This study was designed to evaluate a substitute for the most frequently used opioid pethidine. For pain relief, non-steroid anti-inflammatory drugs are recommended, but they offer a limited choice for parenteral administration. We used a new agent (Neodolpasse) based on diclophenac and orphenadine, and compared its efficacy with piroxicam and placebo. METHODS: A total of 119 patients scheduled for knee joint arthroscopy were included in this prospective study. In a randomized, double-blind manner, they received piroxicam (P), Neodolpasse (combining 75 mg diclophenac and 30 mg orphenadine; N) or placebo (C). The number of patients in groups P, N and C were 44, 35 and 40, respectively. The effect of therapy was evaluated on the basis of the following criteria: duration of post-operative analgesia until a request for another analgesic, pain intensity (0-10 VAS), side effects and the patient's satisfaction with analgesia. The efficacy was evaluated for 24 hours after arthroscopy; premedication and analgesia induction and administration followed the same anesthetic protocol in all groups. The ethic committee approved the study and patients gave their informed consent. The results were statistically evaluated using the ANOVA analysis of variance completed by a multiple comparison of levels of significance according to Bonferroni. The presence of side and unwanted effects was analyzed by the chi-square of Fisher's exact test. A p value les than 0.05 was regarded as statistically significant. RESULTS: There were significant differences in the number of patients not requiring further analgesic medication after arthroscopy (P 52.3% vs. C (11.7%) p < 0.05, N (68.6%) vs. C p < 0.001), lower average postoperative pain (0 to 10-point scale, P 2.4 vs. C 2.9 p < 0.05, N 1.5 vs. C p < 0.05) and fewer side effects (N vs. both P and C, p < 0.05). DISCUSSION: The combination of diclophenac with orphenadine for intravenous application has only recently been available in the Czech Republic. The addition of a central muscle relaxant / relaxants to a peripheral analgesic has a better effect than diclophenac alone. This may also account for a longer duration of analgesia in comparison with piroxicam reported to have significantly longer analgesic effects. The new medication also had fewer side effects. It was interesting to record that even the patients who had more pain and shorter postoperative analgesia were satisfied with the therapy provided. CONCLUSIONS: The main result of this study is the finding that Neodolpasse significantly reduces the intensity of postoperative pain and increases the duration of postoperative analgesia after knee joint arthroscopy.

Intrathecal baclofen therapy over 10 years.
Rawlins PK.
Neuroscience Implant Program at Via Christi Regional Medical Center, Wichita, KS, USA. patrice_rawlins@via-christi.org
Intrathecal baclofen (ITB) therapy has evolved into a standard treatment for severe spasticity. After this therapy had been provided for 10 years, a retrospective chart review on 50 patients, representing a total 2,922 patient months of ITB service, was done. These patients suffered severe spasticity from a number of disease processes including multiple sclerosis, cerebral palsy, and brain injury. The average dosage for the total group was 463 micrograms per day (microg/day), and 32% used a simple infusion mode. Pump refills occurred every 3 months for 58% of the group. Three evolving trends in ITB therapy were identified from clinical trial to current management: (a) higher catheter tip placement, (b) use of more complex infusion modes, and (c) a decreased complication rate.

Pharmacologic management of spasticity following stroke.

Montefiore Medical Center--The Jack D Weiler Hospital of the Albert Einstein College of Medicine, 1825 Eastchester Rd, Bronx, NY 10461, USA.

Commonly used muscle relaxant / relaxants therapies for acute low back pain: a review of Carisoprodol ( Soma ), Cyclobenzaprine, Flexeril hydrochloride, and Metaxalone ( Skelaxin ).

BACKGROUND: Low back pain is a leading reason for primary care visits. Many treatment options are available, but some lack scientific support. OBJECTIVE: The aim of this review was to discuss the etiology of low back pain and the relative risks and benefits of muscle relaxants / relaxant commonly prescribed for the management of back pain. METHODS: We searched Intercontinental Marketing Services data for January 2003 through January 2004 to determine the most commonly prescribed agents for the management of musculoskeletal pain. Carisoprodol ( Soma ), Cyclobenzaprine, Flexeril hydrochloride, and Metaxalone ( Skelaxin ) represented >45% of all such prescriptions. Cochrane Library, MEDLINE, and EMBASE databases were searched (time frame: 1960 through January 2004; search terms: back pain, Carisoprodol ( Soma ), Cyclobenzaprine, Flexeril, Metaxalone ( Skelaxin ), muscle relaxants, and pharmacotherapy) and reference lists of identified articles were hand-searched. RESULTS: Three trials of Carisoprodol ( Soma ) (N = 197) were located in the Cochrane Library database. Two double-blind, randomized, placebo-controlled trials evaluating the safety and efficacy of Cyclobenzaprine, Flexeril hydrochloride (N = 1405) were identified in the literature. Three double-blind, placebo-controlled trials were identified for Metaxalone ( Skelaxin ) (N = 428) in 2 reports. The types of adverse events seen with these agents involved the central nervous system, including drowsiness/sedation, fatigue, and dizziness. However, the efficacy of Cyclobenzaprine, Flexeril hydrochloride was shown to be independent of its sedative effects, which were dose related. The potential for abuse with Carisoprodol ( Soma ) is of growing concern. CONCLUSIONS: Analgesic pain management for low back pain due to muscle spasm may be combined with a muscle relaxant. Cyclobenzaprine, Flexeril hydrochloride has the most recent and largest clinical trials demonstrating its benefit, but Carisoprodol ( Soma ) and Metaxalone ( Skelaxin ) also appear to be effective. However, Carisoprodol ( Soma )'s usefulness is mitigated by its potential for abuse.

Cardiomyopathy developed in the postoperative period in a patient with amyotrophic lateral sclerosis

Department of Intensive and Critical Care Medicine, Dokkyo University School of Medicine, Tochigi 321-0207. A 75-year-old woman with amyotrophic lateral sclerosis (ALS) underwent surgical gastrostomy and repair of incisional hernia. Anesthesia was induced with propofol and high concentrations of sevoflurane. Tracheal intubation was performed without muscle relaxants. Anesthesia was maintained with sevoflurane and thoracic epidural anesthesia (bupivacaine and fentanyl). Surgery, emergence and extubation were completed uneventfully. She was transferred to ICU for postoperative observation. On the 2 nd POD, however, she was re-intubated due to sudden dyspnea and desaturation caused by failed sputum exhaustion. Simultaneously, her ECG showed ischemic change in leads I, III, aVF, and V3-6. Left ventriculogram showed an "Ampulla" or so called "Takotsubo" shape with intact coronary angiogram. After medication with nitroglycerin and diltiazem, her ECG returned to normal. She showed no deterioration of neurological symptoms. No respiratory and cardiac events were reported until her discharge from hospital. We conclude that an extreme care is required in patient with ALS to avoid perioperative complications.

Propofol decreases waste anesthetic gas exposure during pediatric bronchoscopy.

OBJECTIVE: This study compared the anesthetic gas exposure and operating conditions during insufflation anesthesia with halothane-alone versus halothane-propofol in children undergoing direct laryngobronchoscopy. STUDY DESIGN: Forty-six children were enrolled in this randomized prospective study, with institutional review board approval and informed consent. METHODS: All children were anesthetized by halothane mask induction and anesthesia was maintained using spontaneous ventilation with insufflation. No muscle relaxants / relaxant or opioids were used. In the halothane group, halothane was titrated as needed. In the propofol group, halothane was decreased to 1% inspired concentration and the propofol was titrated as needed to maintain spontaneous ventilation and a still patient. Trace anesthetic gases, hemodynamic stability, and operating conditions were measured. RESULTS: The groups were similar in age, weight, and bronchoscopy time. There was significantly less gas exposure in the propofol group (25 +/- 33 parts per million) versus the halothane group (66 +/- 97 ppm; P <.02). There was a trend toward earlier emergence in the halothane group (33 +/- 13 minutes) versus the propofol group (41 +/- 17 minutes). Postoperative stridor was common, occurring in 30% of children. CONCLUSIONS: Insufflation anesthesia with spontaneous respiration provides excellent surgical conditions for laryngobronchoscopy. The addition of propofol resulted in fewer airway complications (P =.047). Although the addition of propofol significantly decreased anesthetic gas exposure in the operating room, both techniques resulted in operating room pollution that exceeded the maximum levels of 2 ppm per hour recommended by the US National Institute for Occupational Safety and Health (NIOSH).

Experience with removing Palmaz stents with a rigid bronchoscope.
Tsai HL, Liu C, Chen PT, Soong WJ, Chang WK, Chin T, Wei CF.
Division of Pediatric Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.
BACKGROUND: The Palmaz stent can relieve congenital malacia or stenosis of airway, but reports on the indications and results of stent removal are rare. The authors report their experience in removing Palmaz stents and discuss the indications for removal. METHODS: Thirteen stents in 12 patients were removed by a rigid bronchoscope for various reasons. The indications were expected recovery (n = 5), severe granulations and expected recovery (n = 2), stent collapse (n = 2), and stent migration and/or fracture (n = 4). RESULTS: The course after removal was smooth in 9 patients and complicated in 3. The indications for stent removal in these 3 complicated cases were all expected recovery. One of the 3 complicated cases needed emergent cardiopulmonary bypass and tracheostomy for a collapsed stent that occluded airway, 1 failed for intractable bleeding, and 1 failed for intense vagal reflex causing cardiac arrest. At 6 months of follow-up, satisfactory results were seen in all but one case that needed further procedures for an iatrogenic tracheoesophageal fistula. CONCLUSIONS: Most Palmaz stents can be removed smoothly with a rigid bronchoscope; however, lethal complications can happen. The authors suggest that indications for stent removal should be intractable airway symptoms caused by the stent rather than expected recovery. muscle relaxants / relaxant should be avoided during anesthesia to maintain spontaneous breathing, and cardiopulmonary bypass should be on standby.


F-18 fluorodeoxyglucose positron emission tomographic imaging in a patient with persistent hiccups.

Department of Nuclear Medicine, Warren Grant Magnuson Clinical Center, National Institutes of Health, Bethesda, Maryland 20892, USA.

Prolonged paralysis related to mivacurium: a case study.
Kendrick K.
PACU and Day Surgery, Children's Healthcare of Atlanta at Egleston, 1405 Clifton Road NE, Atlanta, GA 30322, USA. kathy.kendrick@choa.org
Pseudocholinesterase deficiency is usually identified when an anesthetized patient has prolonged paralysis after receiving neuromuscular blocking agents dependent on pseudocholinesterase enzymes for hydrolysis. This rare complication, most frequently associated with succinylcholine, can occur with the use of mivacurium, one of the newer nondepolarizing muscle relaxants / relaxant also hydrolyzed by pseudocholinesterase. Prolonged paralysis has occurred 3 times in the past 2 years at this pediatric hospital after administration of mivacurium. The following case study describes causality and interventions for a patient with prolonged paralysis after receiving mivacurium.


Electrophysiological assessment of the effect of intrathecal baclofen in dystonic children.

OBJECTIVE: To evaluate the effect of intrathecal baclofen in a group of dystonic children using electrophysiological procedures previously validated in spastic children. METHODS: Seven children (aged 2-16 years) with dystonia of various aetiologies (dyskinetic cerebral palsy, pantothenate kinase-associated neurodegeneration and Aicardi-Goutieres syndrome) underwent transcranial magnetic stimulation, H-reflex and flexor reflex studies before and after intrathecal injection of baclofen. The Barry-Albright Dystonia Scale (BADS) was used for clinical evaluation of dystonia. RESULTS: Motor-evoked potentials, present in 2 of 5 patients before baclofen, were preserved after injection. Before baclofen, H reflex was present in 6 of 7 patients (mean H(max)/M(max:) 0.45+/-0.21). It was markedly reduced after the injection (mean H(max)/M(max:) 0.09+/-0.11) (P<0.001). Area of flexor reflex significantly decreased after baclofen (P=0.047), while threshold significantly increased (P=0.01). No significant clinical improvement of the BADS scores was observed (P=0.058). CONCLUSIONS: These electrophysiological procedures, previously demonstrated to quantify the action of intrathecal baclofen in spastic adults and children, also appear sensitive in dystonic children. The electrophysiological changes are consistent with primarily spinal sites of action of baclofen. They appear more sensitive than clinical evaluation.