Page 184 Acute Pain Management

4. Epidural neostigmine combined with an opioid reduces the dose of epidural opioid that is
required for analgesia (U) (Level I).
5. Epidural ketamine (without preservative) added to opioid‐based epidural analgesia
regimens improves pain relief without reducing side effects (U) (Level I).

6. Intrathecal midazolam combined with a local anaesthetic prolongs the time to first
analgesia and reduces postoperative nausea and vomiting (N) (Level I).
7. Following Caesarean section, intrathecal morphine provides improved analgesia compared
with placebo (N) (Level I) and more prolonged analgesia compared with more lipophilic
opioids (N) (Level II).
8. Intrathecal clonidine added to intrathecal morphine improves and prolongs analgesia (N)
(Level II).
9. Epidural clonidine reduces postoperative systemic opioid requirements (N) (Level II).
10. Epidural adrenaline (epinephrine) in combination with a local anaesthetic improves the
quality of postoperative thoracic epidural analgesia (U) (Level II).
11. In obstetrics, epidural neostigmine improves postoperative analgesia without increasing
the incidence of adverse events (N) (Level II).
12. Addition of either clonidine or dexmedetomidine to intrathecal bupivacaine increases the
speed of onset and duration of motor and sensory block without additional side effects (N)
CHAPTER 5 5.4 ANTI-INFLAMMATORY DRUGS
(Level II).

5.4.1
Neuraxial Corticosteroids
Use of epidural methylprednisolone resulted in no difference in morphine requirements or
pain scores following thoracotomy compared with epidural saline (Blanloeil et al, 2001 Level II).
Following lumbar disc surgery, the combination of wound infiltration with bupivacaine and
epidural/ perineural methylprednisolone improved analgesia and decreased opioid
consumption compared with placebo (Mirzai et al, 2002 Level II; Jirarattanaphochai et al, 2007
Level II). However, epidural administration of either drug on its own was not superior to
placebo (Loffinia et al, 2007 Level II). Preoperative single dose epidural administration of
dexamethasone, with or without bupivacaine, was shown to reduce postoperative pain and
morphine consumption following laparoscopic cholecystectomy (Thomas & Beevi, 2006 Level II).
Peripheral sites
Intra‐articular corticosteroid injections would be expected to have an analgesic effect in
inflammatory arthropathies. Following knee joint arthroscopy, intra‐articular steroids were
more effective than placebo in reducing pain, analgesic consumption and duration of
immobilisation either alone (Wang et al, 1998 Level II), in conjunction with opioids (Kizilkaya et al,
2004 Level II; Kizilkaya et al, 2005 Level II) and/or local anaesthetics (Rasmussen et al, 2002 Level II).
Dexamethasone on its own was less effective than pethidine or fentanyl (Saryazdi et al, 2006
Level II). There may be a higher risk of septic arthritis with intra‐articular steroids (Armstrong et
al, 1992 Level IV). Subacromial injections of corticosteroids have been shown to be effective in
treating rotator cuff tendonitis for up to 9 months, and were superior to oral NSAIDs (NNT 2.5;
CI 1 to 9]) (Arroll & Goodyear‐Smith, 2005 Level I).

136 Acute Pain Management: Scientific Evidence