Both intra-articular morphine and clonidine produce analgesia. This study was designed to compare the analgesic effects of the two drugs, used separately and in combination. We studied 90 patients undergoing arthroscopy of the knee under general anaesthesia. Patients were allocated randomly to receive 20 ml of intra-articular isotonic saline solution containing morphine 2 mg, clonidine 150 micrograms or both. Pain was assessed on an visual analogue scale after operation and time for rescue medication was measured. There was no difference in VAS scores between the three groups and the time for rescue analgesic was comparable. We conclude that intra-articular morphine and clonidine have comparable analgesic effects in the doses used. The combination of both drugs did not seem to increase analgesia.
Introduction
Despite the pain associated with inflatable penile prosthesis (IPP) implantation, there has been a lack of standardized, nonopioid pain control regimens described to date.
Aim
To assess the effectiveness of a multimodal analgesic regimen in patients undergoing implantation of an IPP compared with patients treated with an opioid-only regimen.
Methods
A large, multicenter patient cohort undergoing IPP implantation whose pain was managed using a multimodal analgesia (MMA) protocol (preoperative and postoperative acetaminophen, meloxicam orcelecoxib, and gabapentin and intraoperative dorsal and pudendal nerve blocks) was compared with a matched cohort of patients managed via an opioid-only protocol. Both groups were compared with respect to visual analog score (VAS) and opioid usage (total morphine equivalents [TME]) in the post-anesthesia care unit (PACU), postoperative day 0 (POD0) and postoperative day 1 (POD1), and in the immediate postdischarge period. Narcotic usage on discharge and follow-up were assessed and compared.
Main Outcome Measure
Postoperative pain scores and narcotic usage are the main outcome measures.
Results
203 patients were eligible for final analysis: 103 (50.7%) patients receiving MMA medication and 100 (49.3%) patients receiving opioids only. The VAS was significantly lower in the multimodal group in PACU (median 0.0 vs 2.0, P = .001), POD0 (median 3.0 vs 4.0, P = .001), and POD1 (median 3.0 vs 4.3, P = .04). Patients in the multimodal group also used fewer narcotics in PACU (median 0.0 vs 4.0 TME, P = .001), POD0 (median 7.5 vs 12.5 TME, P < .001), and POD1 (median 7.5 vs 13.5 TME, P = .01). Despite being discharged with fewer narcotics (median 20.0 vs 30.0 tablets, P < .001), a smaller proportion of patients in the MMA cohort required narcotic refills (10.7% vs 28.0%, P = .001). There were no narcotic- or MMA medication–related side effects in the entire cohort.
Clinical Implications
MMA confers significant improvement in pain management while also providing a significant reduction in narcotic usage in patients undergoing implantation of IPP.
Strength & Limitations
This is the 1st large multi-institutional assessment of a multimodal analgesic regimen in urologic prosthetic surgery. The analgesic regimen targets several pain pathways that provide excellent pain control throughout the recovery process. Limitations include retrospective design and lack of standardization of the nonsteroidal anti-inflammatory drug type within the multimodal analgesic regimen.
Conclusion
The use of a MMA protocol significantly reduces postoperative pain measures in penile implant recipients and further reduces both inpatient and outpatient narcotic usage without any discernable side effects.
Human reasoning is often biased by intuitive heuristics. A central question is whether the bias results from a failure to detect that the intuitions conflict with traditional normative considerations or from a failure to discard the tempting intuitions. The present study addressed this unresolved debate by using people's decision confidence as a nonverbal index of conflict detection. Participants were asked to indicate how confident they were after solving classic base-rate (Experiment 1) and conjunction fallacy (Experiment 2) problems in which a cued intuitive response could be inconsistent or consistent with the traditional correct response. Results indicated that reasoners showed a clear confidence decrease when they gave an intuitive response that conflicted with the normative response. Contrary to popular belief, this establishes that people seem to acknowledge that their intuitive answers are not fully warranted. Experiment 3 established that younger reasoners did not yet show the confidence decrease, which points to the role of improved bias awareness in our reasoning development. Implications for the long standing debate on human rationality are discussed.
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