Poorly controlled postoperative pain is strongly associated with the development of chronic pain. We aimed to investigate the effect of topical morphine (in 1 of 3 doses: 5, 10, or 15 mg) on acute and chronic neuropathic pain after modified radical mastectomy for cancer breast. Methods: In this registered clinical trial (ClinicalTrials.gov identifier: NCT02462577), 90 patients were allocated to receive 10 mL plain bupivacaine 0.5% plus either 5, 10, or 15 mg morphine (designated by the group namesMorphine5,Morphine10, andMorphine15, respectively). The combination was diluted by saline 0.9% to 20 mL and irrigated in the wound before skin closure. Groups were compared for the following: time to first postoperative analgesia; intravenous patient-controlled analgesia (PCA) morphine consumption; pain scores; hemodynamics; sedation; adverse events in first postoperative 48 hours; and Leeds Assessment of Neuropathic Symptoms and Signs scores in first and third postoperative months. Results: No patient in theMorphine15 group requested postoperative PCA morphine versus 19 and 8 in the Morphine5 andMorphine10 groups, respectively (P 0.002). Time to first analgesic request and total consumption of PCA morphine analgesia were 7.31 ± 3.12 hours versus 14.00 ± 3.54 hours (P 0.000) and 1.42 ± 0.50 mg versus 1.00 ± 0.00 mg (P = 0.371) in the Morphine5 and Morphine10 groups, respectively. Lowest scores on visual analog pain scale at rest (P 0.001) and visual analog pain scale during movement (P 0.01) were recorded in the Morphine15 group, followed by Morphine10 then Morphine5 group. Lowest Leeds Assessment of Neuropathic Symptoms and Signs scores were recorded in the Morphine15 group in the first month (1.10 ± 0.37 vs 5.76 ± 3.26 and 4.73 ± 2.87, P 0.0001) and third postoperative month (4.40 ± 1.77 vs 6.33 ± 3.21 and 5.43 ± 2.67, P 0.006) compared with Morphine5 and Morphine10 groups, respectively. No patient in the Morphine15 group developed chronic pain versus 4 and 2 in Morphine5 and Morphine10 groups, respectively. Conclusions: Topicalmorphine controlled acute postmastectomy pain in a dose-dependent manner and reduced the incidence and severity of chronic postmastectomy pain syndrome. (Reg Anesth Pain Med 2016;41: 704–710) The skin over my incision feels as if it has been rubbed off with a metal brush. I can’t bear the touch of clothes or even the sheet. My upper arm feels as if all the skin has been peeled off. Some days, it hurts just to breathe

Poorly controlled postoperative pain is strongly associated with the development of chronic pain. We aimed to investigate the effect of topical morphine (in 1 of 3 doses: 5, 10, or 15 mg) on acute and chronic neuropathic pain after modified radical mastectomy for cancer breast. Methods: In this registered clinical trial (ClinicalTrials.gov identifier: NCT02462577), 90 patients were allocated to receive 10 mL plain bupivacaine 0.5% plus either 5, 10, or 15 mg morphine (designated by the group namesMorphine5,Morphine10, andMorphine15, respectively). The combination was diluted by saline 0.9% to 20 mL and irrigated in the wound before skin closure. Groups were compared for the following: time to first postoperative analgesia; intravenous patient-controlled analgesia (PCA) morphine consumption; pain scores; hemodynamics; sedation; adverse events in first postoperative 48 hours; and Leeds Assessment of Neuropathic Symptoms and Signs scores in first and third postoperative months. Results: No patient in theMorphine15 group requested postoperative PCA morphine versus 19 and 8 in the Morphine5 andMorphine10 groups, respectively (P 0.002). Time to first analgesic request and total consumption of PCA morphine analgesia were 7.31 ± 3.12 hours versus 14.00 ± 3.54 hours (P 0.000) and 1.42 ± 0.50 mg versus 1.00 ± 0.00 mg (P = 0.371) in the Morphine5 and Morphine10 groups, respectively. Lowest scores on visual analog pain scale at rest (P 0.001) and visual analog pain scale during movement (P 0.01) were recorded in the Morphine15 group, followed by Morphine10 then Morphine5 group. Lowest Leeds Assessment of Neuropathic Symptoms and Signs scores were recorded in the Morphine15 group in the first month (1.10 ± 0.37 vs 5.76 ± 3.26 and 4.73 ± 2.87, P 0.0001) and third postoperative month (4.40 ± 1.77 vs 6.33 ± 3.21 and 5.43 ± 2.67, P 0.006) compared with Morphine5 and Morphine10 groups, respectively. No patient in the Morphine15 group developed chronic pain versus 4 and 2 in Morphine5 and Morphine10 groups, respectively. Conclusions: Topicalmorphine controlled acute postmastectomy pain in a dose-dependent manner and reduced the incidence and severity of chronic postmastectomy pain syndrome. (Reg Anesth Pain Med 2016;41: 704–710) The skin over my incision feels as if it has been rubbed off with a metal brush. I can’t bear the touch of clothes or even the sheet. My upper arm feels as if all the skin has been peeled off. Some days, it hurts just to breathe

Poorly controlled postoperative pain is strongly associated with the development of chronic pain. We aimed to investigate the effect of topical morphine (in 1 of 3 doses: 5, 10, or 15 mg) on acute and chronic neuropathic pain after modified radical mastectomy for cancer breast. Methods: In this registered clinical trial (ClinicalTrials.gov identifier: NCT02462577), 90 patients were allocated to receive 10 mL plain bupivacaine 0.5% plus either 5, 10, or 15 mg morphine (designated by the group namesMorphine5,Morphine10, andMorphine15, respectively). The combination was diluted by saline 0.9% to 20 mL and irrigated in the wound before skin closure. Groups were compared for the following: time to first postoperative analgesia; intravenous patient-controlled analgesia (PCA) morphine consumption; pain scores; hemodynamics; sedation; adverse events in first postoperative 48 hours; and Leeds Assessment of Neuropathic Symptoms and Signs scores in first and third postoperative months. Results: No patient in theMorphine15 group requested postoperative PCA morphine versus 19 and 8 in the Morphine5 andMorphine10 groups, respectively (P 0.002). Time to first analgesic request and total consumption of PCA morphine analgesia were 7.31 ± 3.12 hours versus 14.00 ± 3.54 hours (P 0.000) and 1.42 ± 0.50 mg versus 1.00 ± 0.00 mg (P = 0.371) in the Morphine5 and Morphine10 groups, respectively. Lowest scores on visual analog pain scale at rest (P 0.001) and visual analog pain scale during movement (P 0.01) were recorded in the Morphine15 group, followed by Morphine10 then Morphine5 group. Lowest Leeds Assessment of Neuropathic Symptoms and Signs scores were recorded in the Morphine15 group in the first month (1.10 ± 0.37 vs 5.76 ± 3.26 and 4.73 ± 2.87, P 0.0001) and third postoperative month (4.40 ± 1.77 vs 6.33 ± 3.21 and 5.43 ± 2.67, P 0.006) compared with Morphine5 and Morphine10 groups, respectively. No patient in the Morphine15 group developed chronic pain versus 4 and 2 in Morphine5 and Morphine10 groups, respectively. Conclusions: Topicalmorphine controlled acute postmastectomy pain in a dose-dependent manner and reduced the incidence and severity of chronic postmastectomy pain syndrome. (Reg Anesth Pain Med 2016;41: 704–710) The skin over my incision feels as if it has been rubbed off with a metal brush. I can’t bear the touch of clothes or even the sheet. My upper arm feels as if all the skin has been peeled off. Some days, it hurts just to breathe

Objective. To compare the analgesic effect of combined intrathecal morphine and dexmedetomidine with either drug alone for postoperative analgesia in patients undergoing major abdominal cancer surgery. Methods. Ninety patients were allocated to receive intrathecal 10mg bupivacaine 0.5% (bupivacaine group, n530), 10mg bupivacaine 0.5% and 0.5mg morphine (Morphine Group, n530), or 10mg bupivacaine 0.5%, 0.5mg morphine and 5 mg dexmedetomidine (morphine-Dex group, n530). The groups were compared with time to first postoperative analgesia, iv patient-controlled analgesia (PCA) morphine consumption, pain scores, hemodynamics, sedation, and adverse events in the first 48h postoperative. Results. The time to first use of morphine PCA was longer in morphine (22.1365.21h, P50.000) and morphine-Dex (23.4664.69h, P50.000) groups compared with bupivacaine group (0.5060.09h). Dexmedetomidine addition increased the duration of intrathecal morphine (ITM) analgesia by 1.33 h (P50.485). Morphine consumption was less in morphine (10.8362.96 mg, P50.000) and morphine- Dex (11.0063.32 mg, P50.000) groups than in bupivacaine group (27.564.30 mg), with a nonsignificant difference between morphine and morphine- Dex groups (P50.375). Morphine and morphine-Dex groups showed lower pain scores (P 0.001). Intraoperative blood pressure and heart rate were lower in morphine and morphine-Dex groups (P 0.05) with no significant difference between groups in postoperative hemodynamics. Patients in bupivacaine group showed a higher incidence of postoperative nausea (P 0.03) and vomiting (P 0.01), while patients in morphine and morphine-Dex groups had a higher incidence of pruritus (P 0.02). Conclusions. Our results do not support improved analgesia with the combination of intrathecal morphine and dexmedetomidine, despite the absence of significant adverse effects.

Objective. To compare the analgesic effect of combined intrathecal morphine and dexmedetomidine with either drug alone for postoperative analgesia in patients undergoing major abdominal cancer surgery. Methods. Ninety patients were allocated to receive intrathecal 10mg bupivacaine 0.5% (bupivacaine group, n530), 10mg bupivacaine 0.5% and 0.5mg morphine (Morphine Group, n530), or 10mg bupivacaine 0.5%, 0.5mg morphine and 5 mg dexmedetomidine (morphine-Dex group, n530). The groups were compared with time to first postoperative analgesia, iv patient-controlled analgesia (PCA) morphine consumption, pain scores, hemodynamics, sedation, and adverse events in the first 48h postoperative. Results. The time to first use of morphine PCA was longer in morphine (22.1365.21h, P50.000) and morphine-Dex (23.4664.69h, P50.000) groups compared with bupivacaine group (0.5060.09h). Dexmedetomidine addition increased the duration of intrathecal morphine (ITM) analgesia by 1.33 h (P50.485). Morphine consumption was less in morphine (10.8362.96 mg, P50.000) and morphine- Dex (11.0063.32 mg, P50.000) groups than in bupivacaine group (27.564.30 mg), with a nonsignificant difference between morphine and morphine- Dex groups (P50.375). Morphine and morphine-Dex groups showed lower pain scores (P 0.001). Intraoperative blood pressure and heart rate were lower in morphine and morphine-Dex groups (P 0.05) with no significant difference between groups in postoperative hemodynamics. Patients in bupivacaine group showed a higher incidence of postoperative nausea (P 0.03) and vomiting (P 0.01), while patients in morphine and morphine-Dex groups had a higher incidence of pruritus (P 0.02). Conclusions. Our results do not support improved analgesia with the combination of intrathecal morphine and dexmedetomidine, despite the absence of significant adverse effects.

Objective. To compare the analgesic effect of combined intrathecal morphine and dexmedetomidine with either drug alone for postoperative analgesia in patients undergoing major abdominal cancer surgery. Methods. Ninety patients were allocated to receive intrathecal 10mg bupivacaine 0.5% (bupivacaine group, n530), 10mg bupivacaine 0.5% and 0.5mg morphine (Morphine Group, n530), or 10mg bupivacaine 0.5%, 0.5mg morphine and 5 mg dexmedetomidine (morphine-Dex group, n530). The groups were compared with time to first postoperative analgesia, iv patient-controlled analgesia (PCA) morphine consumption, pain scores, hemodynamics, sedation, and adverse events in the first 48h postoperative. Results. The time to first use of morphine PCA was longer in morphine (22.1365.21h, P50.000) and morphine-Dex (23.4664.69h, P50.000) groups compared with bupivacaine group (0.5060.09h). Dexmedetomidine addition increased the duration of intrathecal morphine (ITM) analgesia by 1.33 h (P50.485). Morphine consumption was less in morphine (10.8362.96 mg, P50.000) and morphine- Dex (11.0063.32 mg, P50.000) groups than in bupivacaine group (27.564.30 mg), with a nonsignificant difference between morphine and morphine- Dex groups (P50.375). Morphine and morphine-Dex groups showed lower pain scores (P 0.001). Intraoperative blood pressure and heart rate were lower in morphine and morphine-Dex groups (P 0.05) with no significant difference between groups in postoperative hemodynamics. Patients in bupivacaine group showed a higher incidence of postoperative nausea (P 0.03) and vomiting (P 0.01), while patients in morphine and morphine-Dex groups had a higher incidence of pruritus (P 0.02). Conclusions. Our results do not support improved analgesia with the combination of intrathecal morphine and dexmedetomidine, despite the absence of significant adverse effects.

Background: Different adjuvant drugs are currently added to lidocaine for intravenous regional anesthesia (IVRA) to decrease tourniquet and postoperative pain. Objective: The aim of the study was to examine the effect of nalbuphine when added to IVRA. Study Design: Prospective, randomized, double-blind, controlled clinical trial. Setting: Assiut University Hospitals. Methods: One hundred-six adult patients scheduled for unilateral hand surgery under IVRA were randomized into 2 equal groups. The lidocaine-nalbuphine (LN) group received nalbuphine plus lidocaine and the lidocaine (L) group received lidocaine. A tourniquet and postoperative pain were assessed using a visual analogue scale (VAS). The following parameters were measured: onset and recovery time for both sensory and motor blocks, intra- and postoperative analgesic consumption, time to first analgesic request, postoperative nausea and/or vomiting (PONV), hemodynamics, and cortisol levels. Results: Early tourniquet and postoperative pain were significantly lower in the LN group. The onset time for both sensory and motor blocks was significantly shorter in the LN group. In addition, the recovery time for both sensory and motor blocks was longer in the LN group. Intra- and postoperative fentanyl consumption was significantly lower in the LN group with no significance in postoperative diclofenac consumption. The patient first analgesic request was significantly delayed in the LN group (P 0.0001). There were no significant differences between the 2 groups in PONV, hemodynamic parameters abnormalities, medications adverse events or cortisol levels. Limitations: The inclusion of a study group in which the nalbuphine administered systemically could determine whether its beneficial effects were due to its local or systemic action. Conclusions: Nalbuphine decreases early tourniquet and postoperative pain after IVRA and delays the need for analgesic rescue. In addition, nalbuphine accelerates the onset and prolongs the recovery time for both sensory and motor blocks with no significant adverse events. However, it has no effect on postoperative cortisol levels.

Background: Different adjuvant drugs are currently added to lidocaine for intravenous regional anesthesia (IVRA) to decrease tourniquet and postoperative pain. Objective: The aim of the study was to examine the effect of nalbuphine when added to IVRA. Study Design: Prospective, randomized, double-blind, controlled clinical trial. Setting: Assiut University Hospitals. Methods: One hundred-six adult patients scheduled for unilateral hand surgery under IVRA were randomized into 2 equal groups. The lidocaine-nalbuphine (LN) group received nalbuphine plus lidocaine and the lidocaine (L) group received lidocaine. A tourniquet and postoperative pain were assessed using a visual analogue scale (VAS). The following parameters were measured: onset and recovery time for both sensory and motor blocks, intra- and postoperative analgesic consumption, time to first analgesic request, postoperative nausea and/or vomiting (PONV), hemodynamics, and cortisol levels. Results: Early tourniquet and postoperative pain were significantly lower in the LN group. The onset time for both sensory and motor blocks was significantly shorter in the LN group. In addition, the recovery time for both sensory and motor blocks was longer in the LN group. Intra- and postoperative fentanyl consumption was significantly lower in the LN group with no significance in postoperative diclofenac consumption. The patient first analgesic request was significantly delayed in the LN group (P 0.0001). There were no significant differences between the 2 groups in PONV, hemodynamic parameters abnormalities, medications adverse events or cortisol levels. Limitations: The inclusion of a study group in which the nalbuphine administered systemically could determine whether its beneficial effects were due to its local or systemic action. Conclusions: Nalbuphine decreases early tourniquet and postoperative pain after IVRA and delays the need for analgesic rescue. In addition, nalbuphine accelerates the onset and prolongs the recovery time for both sensory and motor blocks with no significant adverse events. However, it has no effect on postoperative cortisol levels.

Background: Different adjuvant drugs are currently added to lidocaine for intravenous regional anesthesia (IVRA) to decrease tourniquet and postoperative pain. Objective: The aim of the study was to examine the effect of nalbuphine when added to IVRA. Study Design: Prospective, randomized, double-blind, controlled clinical trial. Setting: Assiut University Hospitals. Methods: One hundred-six adult patients scheduled for unilateral hand surgery under IVRA were randomized into 2 equal groups. The lidocaine-nalbuphine (LN) group received nalbuphine plus lidocaine and the lidocaine (L) group received lidocaine. A tourniquet and postoperative pain were assessed using a visual analogue scale (VAS). The following parameters were measured: onset and recovery time for both sensory and motor blocks, intra- and postoperative analgesic consumption, time to first analgesic request, postoperative nausea and/or vomiting (PONV), hemodynamics, and cortisol levels. Results: Early tourniquet and postoperative pain were significantly lower in the LN group. The onset time for both sensory and motor blocks was significantly shorter in the LN group. In addition, the recovery time for both sensory and motor blocks was longer in the LN group. Intra- and postoperative fentanyl consumption was significantly lower in the LN group with no significance in postoperative diclofenac consumption. The patient first analgesic request was significantly delayed in the LN group (P 0.0001). There were no significant differences between the 2 groups in PONV, hemodynamic parameters abnormalities, medications adverse events or cortisol levels. Limitations: The inclusion of a study group in which the nalbuphine administered systemically could determine whether its beneficial effects were due to its local or systemic action. Conclusions: Nalbuphine decreases early tourniquet and postoperative pain after IVRA and delays the need for analgesic rescue. In addition, nalbuphine accelerates the onset and prolongs the recovery time for both sensory and motor blocks with no significant adverse events. However, it has no effect on postoperative cortisol levels.

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