To assess the blood-sparing efficacy of tranexamic acid (TA) administered orally or via a variable IV infusion, 80 healthy patients undergoing elective total knee replacement were studied according to a prospective, controlled, randomized, single-blinded study design. Patients were allocated to one of four treatment groups. In group TA-long, 30 min before deflation of the limb tourniquet, an IV bolus dose of TA 15 mg/kg was administered over 30 min. Thereafter, a constant IV infusion of 10 mg . kg(-1) . h(-1) was administered until 12 h after final deflation of the limb tourniquet. In group TA-short, a similar regimen was followed; however, the constant IV infusion was discontinued 2 h after final deflation of the limb tourniquet (time of discharge from the postanesthesia care unit). Thereafter, oral TA 1 g was administered after 6 and 12 h. In group TA-oral, 60 min before surgery an oral dose of TA 1 g was administered. After surgery, a similar dose of TA was administered every 6 h for the next 18 h. In the control group, TA was not administered. At patient discharge, postoperative allogeneic blood administration was significantly more in group Control when compared with each of the three TA treatment groups. Because oral drug administration is simple and does not require specific infusion equipment, the authors suggest that oral TA is a superior blood-sparing strategy compared with IV drug administration.

To assess the efficacy and safety of wound instillation of ropivacaine, when administered via a patient-controlled elastometric pump, 50 term parturients undergoing cesarean delivery were enrolled into this prospective, placebo-controlled, double-blinded study. In all cases, a standard spinal anesthetic was administered. After the surgery, a multihole 20-gauge epidural catheter (B. Braun, Melsungen, Germany) was placed above the fascia such that the tip was sited at the point that demarcated 50% of the length of the surgical wound. Thereafter, the catheter was connected to the elastometric pump. According to a computer-generated randomization schedule, the pump was filled with either ropivacaine 0.2% (Ropivacaine Group) or an equal volume of sterile water (Control Group). Postoperatively, patient-controlled analgesia was administered via the elastometric pump. During the first 6 postoperative hours, a coinvestigator administered "rescue" morphine (2 mg, IV). Thereafter, "rescue" dipyrone (1 g) was administered on patient request. In a subset of 10 patients, blood ropivacaine levels were assessed. Compared with the Control Group, significantly fewer patients in the Ropivacaine Group received "rescue" morphine (92% vs. 48%, respectively) (P<0.01). The total "rescue" morphine administered during the first 6 postoperative hours was 2+/-3 mg vs. 10+/-5 mg (P<0.01) for the Ropivacaine and Control Groups, respectively. Patient-generated resting pain scores were similar between the groups. However, pain scores generated after coughing and leg raise were significantly (P<0.04) less in the Ropivacaine Group. More patients in the Ropivacaine Group than in the Control Group described their analgesia as good or excellent. In the subset of patients (n = 10) studied, unbound ropivacaine blood levels were below the toxic threshold (600 ng/mL). However, blood ropivacaine accumulation was noted. All patients stated that the elastometric pump was easy to use. Ropivacaine wound instillation via an elastometric pump is a simple technique that provides safe and effective analgesia after cesarean delivery.

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pioid analgesics are commonly used during the perioperative period because of their pre-0 dictable anesthetic-sparing and pain-relieving qualities. However, concerns regarding opioid-related side effects (e.g., nausea, vomiting, ileus, biliary spasm, urinary retention, respiratory depression, and the potential for abuse by health care professionals) have stimulated a search for analgesics devoid of these untoward effects. Not surprisingly, the nonsteroidal antiinflammatory drugs (NSAIDs) have become increasingly popular in the perioperative management of pain ( Fig. 1) (1-3).In this review article, we discuss the published literature relating to the clinical use of the NSAIDs for premedication, as adjuvants during general anesthesia and monitored anesthesia care (MoAC), as well as during the postoperative period. Although the perioperative use of NSAIDs has been increasing because of concerns regarding the side effects of opioid analgesics, their efficacy and safety during and after surgery has been questioned recently. Finally, we make recommendations regarding the use of currently available NSAIDs in the management of perioperative pain. Mechanisms of NSAIDs ActionThe tissue response to surgery-induced injury initiates a cascade consisting of nociception, inflammation, and hyperalgesia (4 -6). After a noxious stimulus, peripheral nerves release prostaglandins, substance P, and related nociceptive peptides. The resultant prostaglandin-mediated inflammatory process is characterized by vasodilation and increased vascular permeability, followed by hyperalgesia, an altered functional state of the nervous system with sensitization of nociceptors, and a resultant decrease in the pain threshold (6). Primary hyperalgesia describes the changes in pain threshold within the area of injury, while secondary hyperalgesia refers to changes in the surrounding uninjured tissue as a result of altered central processing of the nociceptive input from the periphery (5). These sensitization processes are followed by expansion of the receptive fields with a decrease in the threshold of the dorsal horn neurons and a disruption of the normal pattern of afferent processing within the central nervous system (CNS). Sensitization is thought to be mediated centrally by activation of N-methyhaspartate (NMDA) receptors in the dorsal horn of the spinal cord (7,8). Consequently, a "wind-up" phenomenon occurs which results in the formation of a positive feed-forward circuit in which afferent sensory input, central sensitization, and sympathetic outflow all contribute to the modulation of the pain response. As a result, a hypersensitivity state may result that can outlast the duration of the initial injury (6).Traditionally, the analgesic properties of the NSAIDs have been attributed to their effects on the peripheral synthesis of prostaglandins (Fig. 2). Inhibition of prostaglandin synthesis by NSAIDs decreases the inflammatory response to surgical trauma and, hence, reduced peripheral nociception and pain perception (9). However, recent in vivo ...

Three different anesthetic techniques were compared in 146 healthy outpatients undergoing ambulatory surgery. In Groups I and II, anesthesia was induced with propofol (1.5-2.0 mg/kg, intravenously [iv]) and maintained with nitrous oxide (N2O) 60% in oxygen and either a propofol infusion, 75-160 micrograms.kg-1.min-1 IV, or sevoflurane, 1%-2% end-tidal, respectively. In Group III, anesthesia was induced and maintained with sevoflurane, 1%-4% end-tidal and N2O 60% in oxygen. In addition to 60% N2O in oxygen at a total gas flow of 3 L/min, all patients received fentanyl, 2-3 micrograms/kg IV, and vecuronium, 0.1 mg/kg IV. IV induction of anesthesia with propofol (90 +/- 53 s and 94 +/- 48 s in Groups I and II, respectively) was significantly faster than inhalation induction with sevoflurane (153 +/- 100 s). There were no significant differences in the incidence of coughing, airway irritation, or laryngospasm during induction of anesthesia. Although the mean arterial blood pressure values were similar in all three groups, the use of sevoflurane was associated with consistently lower heart rate values during the early maintenance period. Early and intermediate recovery times were the same in all three treatment groups. The use of sevoflurane for induction and/or maintenance of anesthesia was associated with a higher incidence of postoperative emetic sequelae compared with propofol. Finally, the times at which patients were considered "fit for discharge" and the actual discharge times were similar in all three groups. Sevoflurane is an acceptable alternative to propofol for induction and maintenance of outpatient anesthesia.

After major abdominal surgery performed through a 20-cm incision, repeated 0.25% bupivacaine wound instillation via an electronic patient-controlled analgesia device and a double-catheter system does not decrease postoperative pain or opioid requirements.