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British Journal of Anaesthesia Jan 1999
Topics: Analgesics, Opioid; Humans; Pain, Postoperative; Pirinitramide
PubMed: 10325826
DOI: 10.1093/bja/82.1.3 -
BMC Emergency Medicine Sep 2023BACKGROUND: Treatment of acute pain is an essential element of pre-hospital care for injured and critically ill patients. Clinical studies indicate the need for...
ABSTRAC
BACKGROUND: Treatment of acute pain is an essential element of pre-hospital care for injured and critically ill patients. Clinical studies indicate the need for improvement in the prehospital analgesia.
OBJECTIVE
The aim of this study is to assess the current situation in out of hospital pain management in Germany regarding the substances, indications, dosage and the delegation of the use of analgesics to emergency medical service (EMS) staff.
MATERIAL AND METHODS
A standardized survey of the medical directors of the emergency services (MDES) in Germany was carried out using an online questionnaire. The anonymous results were evaluated using the statistical software SPSS (Chi-squared test, Mann-Whitney-U test).
RESULTS
Seventy-seven MDES responsible for 989 rescue stations and 397 EMS- physician bases in 15 federal states took part in this survey. Morphine (98.7%), Fentanyl (85.7%), Piritramide (61%), Sufentanil (18.2%) and Nalbuphine (14,3%) are provided as opioid analgesics. The non-opioid analgesics (NOA) including Ketamine/Esketamine (98,7%), Metamizole (88.3%), Paracetamol (66,2%), Ibuprofen (24,7%) and COX-2-inhibitors (7,8%) are most commonly available. The antispasmodic Butylscopolamine is available (81,8%) to most rescue stations. Fentanyl is the most commonly provided opioid analgesic for treatment of a traumatic pain (70.1%) and back pain (46.8%), Morphine for visceral colic-like (33.8%) and non-colic pain (53.2%). In cases of acute coronary syndrome is Morphine (85.7%) the leading analgesic substance. Among the non-opioid analgesics is Ketamine/Esketamine (90.9%) most frequently provided to treat traumatic pain, Metamizole for visceral colic-like (70.1%) and non-colic (68.6%) as well as back pain (41.6%). Butylscopolamine is the second most frequently provided medication after Metamizole for "visceral colic-like pain" (55.8%). EMS staff (with or without a request for presence of the EMS physician on site) are permitted to use the following: Morphine (16.9%), Piritramide (13.0%) and Nalbuphine (10.4%), and of NOAs for (Es)Ketamine (74.1%), Paracetamol (53.3%) and Metamizole (35.1%). The dosages of the most important and commonly provided analgesic substances permitted to independent treatment by the paramedics are often below the recommended range for adults (RDE). The majority of medical directors (78.4%) of the emergency services consider the independent application of analgesics by paramedics sensible. The reason for the relatively rare authorization of opioids for use by paramedics is mainly due to legal (in)certainty (53.2%).
CONCLUSION
Effective analgesics are available for EMS staff in Germany, the approach to improvement lies in the area of application. For this purpose, the adaptations of the legal framework as well as the creation of a guideline for prehospital analgesia are useful.
Topics: Adult; Humans; Ketamine; Analgesics, Non-Narcotic; Dipyrone; Acetaminophen; Nalbuphine; Pirinitramide; Butylscopolammonium Bromide; Physician Executives; Analgesics; Analgesics, Opioid; Fentanyl; Germany; Acute Pain; Morphine Derivatives
PubMed: 37710177
DOI: 10.1186/s12873-023-00878-8 -
The Cochrane Database of Systematic... Feb 2014Postoperative pain may lead to adverse effects on the body, which might result in an increase in morbidity. Its management therefore poses a unique challenge for the... (Review)
Review
BACKGROUND
Postoperative pain may lead to adverse effects on the body, which might result in an increase in morbidity. Its management therefore poses a unique challenge for the clinician. Major shoulder surgery is associated with severe postoperative pain, and different modalities are available to manage such pain, including opioid and non-opioid analgesics, local anaesthetics infiltrated into and around the shoulder joint and regional anaesthesia. All of these techniques, alone or in combination, have been used to treat the postoperative pain of major shoulder surgery but with varying success.
OBJECTIVES
The objective of this review was to compare the analgesic efficacy of continuous interscalene brachial plexus block (ISBPB) with parenteral opioid analgesia for pain relief after major shoulder surgery.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 12), MEDLINE (1950 to December 2012), EMBASE (1980 to December 2012), Web of Science (1954 to December 2012), CINAHL (1982 to December 2012) and bibliographies of published studies.
SELECTION CRITERIA
We included randomized controlled trials assessing the effectiveness of continuous ISBPB compared with different forms of parenteral opioid analgesia in relieving pain in adult participants undergoing elective major shoulder surgery.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed trial quality and extracted outcome data.
MAIN RESULTS
We included two randomized controlled trials (147 participants). A total of 17 participants were excluded from one trial because of complications related to continuous ISBPB (16) or parenteral opioid analgesia (one). Thus we have information on 130 participants (66 in the continuous ISBPB group and 64 in the parenteral opioid group). The studies were clinically heterogeneous. No meta-analysis was undertaken. However, results of the two included studies showed better pain relief with continuous ISBPB following major shoulder surgery and a lower incidence of complications when interscalene block is performed under ultrasound guidance rather than without it.
AUTHORS' CONCLUSIONS
Because of the small number of studies (two) relevant to the subject and the high risk of bias of the selected studies, no reasonable conclusion can be drawn.
Topics: Analgesics, Opioid; Anesthesia, Local; Brachial Plexus; Humans; Nerve Block; Pain, Postoperative; Pirinitramide; Randomized Controlled Trials as Topic; Shoulder; Sufentanil
PubMed: 24492959
DOI: 10.1002/14651858.CD007080.pub2 -
Clinical Oral Investigations May 2022The aim of this prospective, randomized, double-blind, controlled clinical study was to evaluate the analgesic effect of ibuprofen versus diclofenac plus orphenadrine on... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVES
The aim of this prospective, randomized, double-blind, controlled clinical study was to evaluate the analgesic effect of ibuprofen versus diclofenac plus orphenadrine on postoperative pain in orthognathic surgery.
MATERIAL AND METHODS
Patients who underwent orthognathic surgery were randomized into two groups to receive intravenously either 600 mg of ibuprofen (I-group) or 75 mg diclofenac plus 30 mg orphenadrine (D-group), both of which were given twice daily. Additionally, both groups were given metamizole 500 mg. Rescue pain medication consisted of acetaminophen 1000 mg and piritramide 7.5 mg as needed. To assess the pain intensity, the primary end point was the numeric rating scale (NRS) recorded over the course of the hospital stay three times daily for 3 days.
RESULTS
One hundred nine patients were enrolled (age range, 18 to 61 years) between May 2019 and November 2020. Forty-eight bilateral sagittal split osteotomies (BSSO) and 51 bimaxillary osteotomies (BIMAX) were performed. Surgical subgroup analysis found a significant higher mean NRS (2.73 vs.1.23) in the BIMAX D-group vs. I-group (p = 0.015) on the third postoperative day. Additionally, as the patient's body mass index (BMI) increased, the mean NRS (r = 0.517, p = 0.001) also increased. No differences were found between age, gender, length of hospital stay, weight, operating times, number of patients with complete pain relief, acetaminophen or piritramide intake, and NRS values. No adverse events were observed.
CONCLUSION
The results of this study demonstrate that ibuprofen administration and lower BMI were associated with less pain for patients who underwent bimaxillary osteotomy on the third postoperative day. Therefore, surgeons may prefer ibuprofen for more effective pain relief after orthognathic surgery.
CLINICAL RELEVANCE
Ibuprofen differs from diclofenac plus orphenadrine in class and is a powerful analgetic after orthognathic surgery.
Topics: Acetaminophen; Adolescent; Adult; Diclofenac; Double-Blind Method; Humans; Ibuprofen; Middle Aged; Orphenadrine; Orthognathic Surgery; Pain, Postoperative; Pirinitramide; Prospective Studies; Young Adult
PubMed: 35103836
DOI: 10.1007/s00784-022-04381-5 -
Biomedical Papers of the Medical... Mar 2022The aim of this study was to compare the efficacy, consumption and safety after piritramide administered either intramuscularly (IM) on demand or via patient-controlled...
Analgesic effects of piritramide in acute postoperative pain - comparison of intramuscular administration with patient-controlled intravenous analgesia and impact of OPRM1 and ABCB1 polymorphisms.
AIMS
The aim of this study was to compare the efficacy, consumption and safety after piritramide administered either intramuscularly (IM) on demand or via patient-controlled intravenous analgesia (PCA) and to examine the impact of OPRM1 and ABCB1 gene polymorphisms on the drug efficacy/safety in both regimens.
METHODS
One hundred and four patients scheduled for elective inguinal hernioplasty received piritramide with PCA or IM for postoperative pain management. We evaluated piritramide consumption, pain intensity using visual analogue scale (VAS) and adverse effects.
RESULTS
Median (IQR) piritramide consumption was 18.5 (13.5-31.2) and 15.0 (15.0-15.0) mg in the PCA and IM groups, respectively (P=0.0092). The respective values of area under the VAS-time curve were 40 and 280 mm.h (P=0.0027). Opioid-induced adverse effects were more frequent in the PCA than in the IM group. Variant OPRM1 allele was associated with decreased pain relief, increased opioid consumption and increased incidence of adverse effects, while ABCB1 polymorphisms showed no impact on the observed parameters.
CONCLUSIONS
We observed higher piritramide consumption, better pain relief and slightly worse safety profile in the PCA group compared with IM administration. Variant OPRM1 118G allele carriers required higher opioid dosing and suffered from more adverse effects, however, the differences between genotypes have been less pronounced in the PCA patients likely due to improved pain management via PCA.
Topics: ATP Binding Cassette Transporter, Subfamily B; Analgesia, Patient-Controlled; Analgesics, Opioid; Humans; Pain, Postoperative; Pirinitramide; Polymorphism, Genetic; Receptors, Opioid, mu
PubMed: 33252118
DOI: 10.5507/bp.2020.053 -
British Journal of Anaesthesia Aug 2003Successful management of postoperative pain requires that adequate analgesia is achieved without excessive adverse effects. Opioid-induced nausea and vomiting is known... (Clinical Trial)
Clinical Trial Randomized Controlled Trial
BACKGROUND
Successful management of postoperative pain requires that adequate analgesia is achieved without excessive adverse effects. Opioid-induced nausea and vomiting is known to impair patients' satisfaction, but there are no studies providing sufficient power to test the hypothesis that the incidence of opioid-induced nausea and vomiting differs between micro -opioid receptor agonists. Thus, we tested the hypothesis that the incidence of vomiting and nausea differs between morphine and piritramide.
METHODS
In a prospective, randomized, double-blind fashion, we administered either morphine (n=250) or piritramide (n=250) by patient-controlled analgesia (PCA) for postoperative pain relief. We used a bolus dose of 1.5 mg with a lockout time of 10 min. Incidence and intensity (numerical rating scale) of postoperative nausea, vomiting, pain, patient satisfaction (score 0-10), side-effects (score 0-3) and drug consumption were measured.
RESULTS
Mean drug consumption did not differ between the piritramide and morphine groups (30.8 (SD 22.4) mg day(-1) vs 28.4 (21.8) mg day(-1)) during the first postoperative day and there were no significant differences in the overall incidence of nausea (30% vs 27%) and vomiting (19% vs 15%). Intensity of nausea correlated inversely (P=0.01) with morphine consumption but not with piritramide consumption. Pain scores both at rest (2.2 (1.9) vs 2.6 (2)) and during movement (4.4 (2.2) vs 4.9 (2.3)) were slightly but significantly less with morphine.
CONCLUSIONS
Opioid-induced emesis was observed in about one-third of the patients using morphine and piritramide for PCA and the incidence of vomiting was one-half of that. Potential differences in the incidence of vomiting during PCA therapy between these micro-opioid receptor agonists can be excluded.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Analgesia, Patient-Controlled; Analgesics, Opioid; Double-Blind Method; Drug Administration Schedule; Female; Humans; Male; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative; Pirinitramide; Postoperative Care; Postoperative Nausea and Vomiting; Prospective Studies
PubMed: 12878621
DOI: 10.1093/bja/aeg165 -
The Cochrane Database of Systematic... Jan 2019Laparoscopy is a common procedure used to diagnose and treat various gynaecological conditions. Shoulder-tip pain (STP) as a result of the laparoscopy occurs in up to... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Laparoscopy is a common procedure used to diagnose and treat various gynaecological conditions. Shoulder-tip pain (STP) as a result of the laparoscopy occurs in up to 80% of women, with potential for significant morbidity, delayed discharge and readmission. Interventions at the time of gynaecological laparoscopy have been developed in an attempt to reduce the incidence and severity of STP.
OBJECTIVES
To determine the effectiveness and safety of methods for reducing the incidence and severity of shoulder-tip pain (STP) following gynaecological laparoscopy.
SEARCH METHODS
We searched the following databases: Cochrane Gynaecology and Fertility (CGF) Specialised Register, the Cochrane Central Register of Studies Online (CRSO), MEDLINE, Embase, PsycINFO and CINAHL from inception to 8 August 2018. We also searched the reference lists of relevant articles and registers of ongoing trials.
SELECTION CRITERIA
Randomised controlled trials (RCTs) of interventions used during or immediately after gynaecological laparoscopy to reduce the incidence or severity of STP.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures expected by Cochrane. Primary outcomes: incidence or severity of STP and adverse events of the interventions; secondary outcomes: analgesia usage, delay in discharge, readmission rates, quality-of-life scores and healthcare costs.
MAIN RESULTS
We included 32 studies (3284 women). Laparoscopic procedures in these studies varied from diagnostic procedures to complex operations. The quality of the evidence ranged from very low to moderate. The main limitations were risk of bias, imprecision and inconsistency.Specific technique versus "standard" technique for releasing the pneumoperitoneumUse of a specific technique of releasing the pneumoperitoneum (pulmonary recruitment manoeuvre, extended assisted ventilation or actively aspirating intra-abdominal gas) reduced the severity of STP at 24 hours (standardised mean difference (SMD) -0.66, 95% confidence interval (CI) -0.82 to -0.50; 5 RCTs; 670 participants; I = 0%, low-quality evidence) and reduced analgesia usage (SMD -0.53, 95% CI -0.70 to -0.35; 4 RCTs; 570 participants; I = 91%, low-quality evidence). There appeared to be little or no difference in the incidence of STP at 24 hours (odds ratio (OR) 0.87, 95% CI 0.41 to 1.82; 1 RCT; 118 participants; low-quality evidence).No adverse events occurred in the only study assessing this outcome.Fluid instillation versus no fluid instillationFluid instillation is probably associated with a reduction in STP incidence (OR 0.38, 95% CI 0.22 to 0.66; 2 RCTs; 220 participants; I = 0%, moderate-quality evidence) and severity (mean difference (MD) (0 to 10 visual analogue scale (VAS) scale) -2.27, 95% CI -3.06 to -1.48; 2 RCTs; 220 participants; I = 29%, moderate-quality evidence) at 24 hours, and may reduce analgesia usage (MD -12.02, 95% CI -23.97 to -0.06; 2 RCTs; 205 participants, low-quality evidence).No study measured adverse events.Intraperitoneal drain versus no intraperitoneal drainUsing an intraperitoneal drain may reduce the incidence of STP at 24 hours (OR 0.30, 95% CI 0.20 to 0.46; 3 RCTs; 417 participants; I = 90%, low-quality evidence) and may reduce analgesia use within 48 hours post-operatively (SMD -1.84, 95% CI -2.14 to -1.54; 2 RCTs; 253 participants; I = 90%). We are uncertain whether it reduces the severity of STP at 24 hours, as the evidence was very low quality (MD (0 to 10 VAS scale) -1.85, 95% CI -2.15 to -1.55; 3 RCTs; 320 participants; I = 70%).No study measured adverse events.Subdiaphragmatic intraperitoneal local anaesthetic versus control (no fluid instillation, normal saline or Ringer's lactate)There is probably little or no difference between the groups in incidence of STP (OR 0.72, 95% CI 0.42 to 1.23; 4 RCTs; 336 participants; I = 0%; moderate-quality evidence) and there may be no difference in STP severity (MD -1.13, 95% CI -2.52 to 0.26; 1 RCT; 50 participants; low-quality evidence), both measured at 24 hours. However, the intervention may reduce post-operative analgesia use (SMD-0.57, 95% CI -0.94 to -0.21; 2 RCTs; 129 participants; I = 51%, low-quality evidence).No adverse events occurred in any study.Local anaesthetic into peritoneal cavity (not subdiaphragmatic) versus normal salineLocal anaesthetic into the peritoneal cavity may reduce the incidence of STP at 4 to 8 hours post-operatively (OR 0.23, 95% CI 0.06 to 0.93; 2 RCTs; 157 participants; I = 56%; low-quality evidence). Our other outcomes of interest were not assessed.Warmed, or warmed and humidified CO versus unwarmed and unhumidified COThere may be no difference between these interventions in incidence of STP at 24 to 48 hours (OR 0.81 95% CI 0.45 to 1.49; 2 RCTs; 194 participants; I = 12%; low-quality evidence) or in analgesia usage within 48 hours (MD -4.97 mg morphine, 95% CI -11.25 to 1.31; 1 RCT; 95 participants; low-quality evidence); there is probably little or no difference in STP severity at 24 hours (MD (0 to 10 VAS scale) 0.11, 95% CI -0.75 to 0.97; 2 RCTs; 157 participants; I = 50%; moderate-quality evidence).No study measured adverse events.Gasless laparoscopy versus CO insufflationGasless laparoscopy may be associated with increased severity of STP within 72 hours post-operatively when compared with standard treatment (MD 3.8 (0 to 30 VAS scale), 95% CI 0.76 to 6.84; 1 RCT; 54 participants, low-quality evidence), and there may be no difference in the risk of adverse events (OR 2.56, 95% CI 0.25 to 26.28; 1 RCT; 54 participants; low-quality evidence).No study measured the incidence of STP.
AUTHORS' CONCLUSIONS
There is low to moderate-quality evidence that the following interventions are associated with a reduction in the incidence or severity, or both, of STP, or a reduction in analgesia requirements for women undergoing gynaecological laparoscopy: a specific technique for releasing the pneumoperitoneum; intraperitoneal fluid instillation; an intraperitoneal drain; and local anaesthetic applied to the peritoneal cavity (not subdiaphragmatic).There is low to moderate-quality evidence that subdiaphragmatic intraperitoneal local anaesthetic and warmed and humidified insufflating gas may not make a difference to the incidence or severity of STP.There is low-quality evidence that gasless laparoscopy may increase the severity of STP, compared with standard treatment.Few studies reported data on adverse events. Some potentially useful interventions have not been studied by RCTs of gynaecological laparoscopy.
Topics: Acetaminophen; Analgesics; Anti-Inflammatory Agents, Non-Steroidal; Carbon Dioxide; Diclofenac; Drainage; Female; Gynecologic Surgical Procedures; Gynecological Examination; Humans; Incidence; Insufflation; Laparoscopy; Meperidine; Pain Measurement; Pain, Procedural; Pirinitramide; Pneumoperitoneum; Randomized Controlled Trials as Topic; Shoulder Pain
PubMed: 30699235
DOI: 10.1002/14651858.CD011101.pub2 -
Medicina (Kaunas, Lithuania) Apr 2023: The pupillary pain index (PPI) allows the evaluation of intraoperative nociception by measuring pupillary reaction after a localized electrical stimulus. It was the... (Observational Study)
Observational Study
Pupillary Pain Index Predicts Postoperative Pain but Not the Effect of Peripheral Regional Anaesthesia in Patients Undergoing Total Hip or Total Knee Arthroplasty: An Observational Study.
: The pupillary pain index (PPI) allows the evaluation of intraoperative nociception by measuring pupillary reaction after a localized electrical stimulus. It was the objective of this observational cohort study to investigate the pupillary pain index (PPI) as a method to evaluate the fascia iliaca block (FIB) or adductor canal block (ACB) sensory areas during general anaesthesia in orthopaedic patients with lower-extremity joint replacement surgery. : Orthopaedic patients undergoing hip or knee arthroplasty were included. After anaesthesia induction, patients received an ultrasound-guided single-shot FIB or ACB with 30 mL and 20 mL of 0.375% ropivacaine, respectively. Anaesthesia was maintained with isoflurane or propofol/remifentanil. The first PPI measurements were performed after anaesthesia induction and before block insertion, the second at the end of surgery. Pupillometry scores were evaluated in the area of the femoral or saphenous nerve (target) and C3 dermatome (control). Primary outcomes were differences between PPIs before and after peripheral block insertion as well as the relationship between PPIs and postoperative pain scores; secondary outcomes were the relationship between PPIs and opioid requirements after surgery. : PPI decreased significantly from the first to the second measurement (4.17 ± 2.7 vs. 1.6 ± 1.2, < 0.001 for target; 4.46 ± 2.7 vs. 2.17 ± 2.1, < 0.001 for control). Control and target measurements did not show significant differences. A linear regression analysis showed that early postoperative pain scores could be predicted with intraoperative piritramide with improved prediction after adding PPI scores, PCA opioids and surgery type. Forty-eight-hour pain scores at rest and in movement were correlated with intraoperative piritramide and control PPI after the PNB in movement and with second-postoperative-day opioids and target PPI scores before block insertion, respectively. : While the effect of an FIB and ACB could not be shown with PPI postoperative pain scores due to a large effect of opioids, perioperative PPI was shown to be associated with postoperative pain. These results suggest that preoperative PPI may be used to predict postoperative pain.
Topics: Humans; Arthroplasty, Replacement, Knee; Pirinitramide; Nerve Block; Pain, Postoperative; Analgesics, Opioid; Anesthesia, Conduction
PubMed: 37241058
DOI: 10.3390/medicina59050826 -
Scandinavian Journal of Trauma,... Jan 2023Pain management in the pre-hospital setting remains a particular challenge for paramedics and emergency physicians, especially in children. This study evaluates the...
BACKGROUND
Pain management in the pre-hospital setting remains a particular challenge for paramedics and emergency physicians, especially in children. This study evaluates the pre-hospital use and effect of analgesics in children with trauma or pain due to other reasons.
METHODS
This study is a retrospective analysis of the database of a German air rescue service and was conducted over a period of 9 years (2012-2020) to assess pain in general and whether patients with trauma pain due to other reasons received treatment with analgesics. We included all patients in the registry under the age of 16 years. Patients with a Glasgow Coma Scale of 3 at hospital admission and incomplete records were excluded. The intensity of pain was determined by the emergency physician on scene at arrival and hospital admission in a ten-point rating scale (0 = no pain). Effective pain reduction was analyzed.
RESULTS
Out of 227,458 cases, a total of 22,025 emergency cases involved pediatric patients aged 0-16 years. 20,405 cases were included in the study. 12,000 (58.8%) children had suffered a trauma, 8108 (39.7%) had pain due to other reasons and 297 (1.5%) had both. In total, 4,608 (38.4%) of the children with trauma were assessed having a numerical rating scale (NRS) > 4 at EMS arrival. These patients received mainly ketamine (34.5%) and the opioids fentanyl (38.7%) and piritramide (19.1%). The value on the NRS was significantly lower at admission to hospital (mean 1.9) compared with the EMS arrival (mean 6.9). In 4.9% the NRS at hospital admission was still > 4. 282 patients within the non-trauma group had a pre-hospital NRS of > 4. The pain therapy consisted of opioids (35.8%) and ketamine (2.8%). 28.4% patients in the non-trauma group received no pain medication. In 16.0% the NRS at hospital admission was still > 4.
CONCLUSIONS
German emergency physicians achieved a sufficient pain therapy in pediatric patients with a NRS > 4 after trauma. In case of non-trauma, the pain management by the emergency physicians is restrained and less successful. The most common analgesic medications administered were ketamine and fentanyl, followed by piritramide.
TRIAL REGISTRATION
The study has been retrospectively registered at DRKS (DRKS00026222).
Topics: Humans; Child; Pain Management; Ketamine; Pirinitramide; Critical Illness; Retrospective Studies; Pain; Analgesia; Analgesics; Fentanyl; Analgesics, Opioid; Hospitals; Emergency Medical Services
PubMed: 36709289
DOI: 10.1186/s13049-023-01069-x