A 31-year-old patient of post-surgical recurrent buccal carcinoma (post-chemo and radiotherapy) on multimodal analgesia with methadone, paracetamol and gabapentin presented to pain clinic with occasional bleeding from tumor area and incidental hypercalcemia. The hypercalcemia was attributed to adrenal insufficiency due to methadone, with no other obvious reasons identified for hypercalcemia or adrenal insufficiency. The patient was managed with the change of opioid, regular aseptic wound dressings and management of hypercalcemia with hydration, calcitonin and steroid therapy. Hypercalcemia in a cancer patient can have multiple other causes like hypercalcemia of malignancy and primary or secondary parathyroid carcinoma. A strong clinical suspicion and appropriate battery of tests may be required to arrive at the diagnosis. Prompt management, including identification and management of the primary pathology along with aggressive hydration with hormonal therapy, may prove to be life-saving.

Once used only as third-line therapy for chronic pain management, methadone is now being used as first- and second-line therapy in palliative care. The risks and stigma associated with methadone use are known, but difficulties with dosing methadone and lack of an established conversion protocol from other opiates have limited the access for patient populations who could potentially benefit from this medication. For palliative care patients, the benefits of methadone can far outweigh its risks. This article provides an overview and specific recommendations on the use of parenteral methadone in pain and palliative care, with a focus on the transition from hospital to home/hospice care. The goal of this consensus guideline is to assist clinicians who are providing chronic pain management in acute care hospital and nonhospital settings (i.e., hospice, long-term care facilities, and community) for patients with life-limiting illnesses, where the goals of care are focused on comfort (i.e., palliative care). The recommendations in this article intend to promote a standard of care involving the use of intravenous methadone with the aim of reaching a broader population of patients for whom this drug would provide important benefits.

Background and objective: Epidural analgesia with bupivacaine plus either sufentanil or fentanyl is widely used during labour, but it is not clear which opioid is to be preferred. The study compared these opioids at equianalgesic doses in terms of analgesia, onset time and side-effects.

Methods: Ninety females in active labour were entered into the randomized, double-blind trial. A test dose of bupivacaine was given into the epidural space. Parturients in Group S received sufentanil 8 mL as a bolus dose, followed by an infusion at a rate of 5 mL h−1 of a mixture containing sufentanil 1 µg mL−1 and bupivacaine 1 mg mL−1. Patients in Group F received fentanyl 8 mL as a bolus, followed by an infusion at 5 mL h−1 of a solution containing fentanyl 3.5 µg mL−1 and bupivacaine 1 mg mL−1. Additional boluses of 5 mL were of the relevant solution were given if necessary.

Results: In a ratio of 1.0 : 3.5 (sufentanil 1 µg versus fentanyl 3.5 µg), both groups reported the same analgesia with the same onset time. The onset time to obtain 50% of the initial visual analogue score was 10 and 11 min for Groups S and F, respectively. Mean visual analogue scores in Groups S and F respectively declined from 77 and 82 before epidural blockade, to 29 and 27 during the first stage of labour, and to 69 and 59 respectively during the second stage. Overall satisfaction among parturients was high (98 and 96%), particularly during the first stage (98 and 98%), and also to a large degree during the second stage of labour (74 and 79%). Furthermore, only a few extra bolus doses were required (mean 0.9 and 1.2, Groups S and F, respectively). All the females could stand on their own, and almost all (81% Group S; 79% Group F) could walk 20 m without help. There were no serious adverse effects. Moderate side-effects occurred equally often with the possible exception of less nausea and vomiting in the fentanyl group.

Conclusions: Epidural analgesia for ambulatory parturients with bupivacaine plus either sufentanil or fentanyl (ratio 1.0 : 3.5) provides good analgesia with a low frequency of modest side-effects. No clinical differences were found between the opioids.

Background and objective: We assessed the analgesic efficacy of postoperative epidural infusions of ropivacaine 0.1 and 0.2% combined with sufentanil 1 μg mL−1 in a prospective, randomized, double-blinded study.

Methods: Twenty-two ASA I—III patients undergoing elective total-knee replacement were included. Lumbar epidural blockade using ropivacaine 0.75% was combined with either propofol sedation or general anaesthesia for surgery. After surgery, the epidural infusion was commenced. Eleven patients in each group received either an epidural infusion of ropivacaine 0.1% with 1 μg mL−1 sufentanil (Group 1) or ropivacaine 0.2% with 1 μg mL−1 sufentanil (Group 2) at a rate of 5–9 mL h−1. All patients had access to intravenous pirinatrimide (piritramide) via a patient-controlled analgesia (PCA) device.

Results: Motor block was negligible for the study duration in both groups. There was no significant difference with the 100 mm visual analogue scale (VAS) scores, with the consumption of rescue analgesia or with patient satisfaction. Patients in Group 1 experienced significantly less nausea (P < 0.05) than those in Group 2. Both treatment regimens provided effective postoperative analgesia with only a minimal use of supplemental opioid PCA.

Conclusions: We recommend the use of ropivacaine 0.1% with 1 μg mL−1 sufentanil for postoperative analgesia after total knee replacement as it provides efficient pain relief with no motor block of the lower limbs. In addition, compared with 0.2% ropivacaine with sufentanil, the mixture reduces local anaesthetic consumption without compromise in patient satisfaction or VAS scores. Patients even experience less nausea.

Background and objective: The effect of anaesthesia and surgery on gastric emptying is not constant, and this has not been previously studied in patients undergoing thoracotomy for lung resection with a bupivacaine-fentanyl epidural infusion for analgesia. There are important implications in this group of patients with regards to the recommencement of important oral medication as well as the risks of aspiration of gastric contents. The study examined gastric emptying in these patients until the second postoperative day.

Methods: In a prospective repeated measures study, the effect of fentanyl-bupivacaine epidural analgesia at the mid-thoracic level on gastric emptying was assessed in 11 patients undergoing thoracotomy for lung resection. Gastric emptying was measured using a paracetamol absorption technique. Patients acted as their preoperative controls and were assessed 4 h postoperatively and on the second postoperative day.

Results: The mean (SEM) maximum plasma paracetamol concentration was 204.6 (20.4) μmol L−1 before operation, 61 (9.5) μmol L−1 4 h postoperatively and 114.3 (22.6) μmol L−l on the second postoperative day. Mean (SEM) paracetamol absorption at 120 min was 15 638 (1441) μmol min L−l preoperatively, 5731 (821) μmol min L−l4 h postoperatively and 9325 (1759) μmol min L−l on the second postoperative day. Postoperative values were significantly (P < 0.005) less than the preoperative values.

Conclusions: After thoracotomy, gastric emptying was delayed until at least the second postoperative day in patients receiving mid-thoracic fentanyl-bupivacaine epidural analgesia.

Background and objective: The α2-adrenoceptor agonist clonidine has potent central antinociceptive properties. The study was designed to investigate the effects of the combined subarachnoid administration of clonidine and prilocaine on spinal block and postoperative analgesia for the transurethral resection of tumours in the urinary bladder.

Methods: The controlled, prospective, double-blind study enrolled 40 patients scheduled for elective transurethral resection of bladder tumours under spinal anaesthesia with prilocaine. Patients were randomly assigned to receive an intrathecal injection of prilocaine 75 mg alone (control group) or in combination with clonidine 75 µg. We assessed haemodynamic changes (non-invasive arterial pressure, heart rate), pulse oximetry, the upper level of block, the onset and duration of sensory and motor block, postoperative analgesia and any adverse effects.

Results: There were no statistically significant differences in demographic data, heart rate, onset time or the levels of sensory or motor block. Analgesia lasted significantly longer in the clonidine group (498.4 ± 226.9 versus 187.2 ± 103.1 min; P < 0.05). The duration of motor block was longer in the clonidine group (165.5 ± 30.6 min) than in the control group (139.7 ± 40.4 min; P < 0.05) and the duration of sensory block was also longer in the clonidine group (157.3 ± 24.5 min) than in the control group (137.2 ± 31.2 min; P < 0.05). Fewer patients in the recovery room needed metamizol (dipyrone) in the clonidine group (5%) than in the control group (50%). Arterial pressure decreased significantly in the clonidine group 75-135 min after the block.

Conclusions: The addition of clonidine 75 µg to prilocaine 75 mg for subarachnoid anaesthesia increased the duration of sensory and motor block and reduced the need for additional postoperative analgesics by providing excellent analgesia for about 8 h during recovery from transurethral resection of bladder tumours.

Background and objective: Induction of general anaesthesia in combination with positive-pressure ventilation is often associated with a significant decrease of arterial pressure. A decreased preload may contribute to this phenomenon. The aim was to investigate whether a change in cardiac filling occurs following the induction of general anaesthesia with sufentanil under typical clinical conditions.

Methods: Fifteen patients scheduled for elective coronary bypass grafting were studied immediately before surgery. In addition to standard monitors, a transpulmonary double-indicator dilution technique measured in vivo intrathoracic blood volume, global end-diastolic volume and total circulating blood volume. For induction of anaesthesia 2 μg kg−1 sufentanil was given. Measurements were performed awake and after the induction of anaesthesia, intubation and mechanical ventilation of the lungs.

Results: To maintain arterial pressure during the induction period within −20% of baseline pressure, on average 22 ± 6 mL kg−1 crystalloids and 8 ± 6 mL kg−1 colloids were given. Despite these amounts of fluid, cardiac filling was decreased, whereas circulating blood volume increased significantly. Both central venous pressure and pulmonary capillary wedge pressure increased.

Conclusions: Induction of general anaesthesia with positive-pressure ventilation is regularly associated with a blood volume shift from intra- to extrathoracic compartments. Even in low-dose opioid monoanaesthesia with sufentanil – often regarded as relatively inert in haemodynamic terms – the phenomenon could be demonstrated as the primary cause of the often-observed decrease of arterial pressure. It seems, therefore, rationally justified to restore cardiac filling by generous administration of intravenous fluids, at least in patients with unaffected cardiac pump function. During induction of anaesthesia, central venous pressure and pulmonary capillary wedge pressure do not reliably indicate cardiac filling.

Background and objective: Comparison of the effectiveness of tramadol with meperidine given intravenously to emergency patients with suspected renal colic.

Methods: A double-blind, randomized clinical trial was performed in the Emergency Department of a tertiary-care university hospital. Consecutive patients with suspected renal colic (n =47) were randomized to receive intravenously an initial dose of tramadol 50 mg (n = 23) or meperidine 50 mg (n = 24). After 30 min, additional doses of meperidine 50 mg were given intravenously as a rescue medication in an open fashion. Pain relief was assessed using a 10 cm visual analogue scale, the primary outcomes being pain relief at 15 and 30 min after the analgesics. Secondary outcomes were the frequency of rescue meperidine use and the development of side-effects.

Results: Visual analogue scale pain scores after 15 and 30 min decreased in both tramadol and meperidine groups (P < 0.05). However, pain relief was better in the meperidine group at the 15 and 30 min evaluations (P < 0.05). Only 11 patients (48%), initially receiving meperidine, needed more meperidine compared with 16 patients (67%) initially receiving tramadol. Both drugs were well tolerated with no adverse effects occurring in either group.

Conclusions: Meperidine 50 mg was superior to tramadol 50 mg for acute pain relief in patients with suspected renal colic when given intravenously. Because many patients in both groups received supplemental meperidine and the response to tramadol alone cannot be predicted, clinicians may want to choose higher doses of meperidine alone or other alternative combinations.