Iliohypogastric-ilioinguinal peripheral nerve block for post-Cesarean delivery analgesia decreases morphine use but not opioid-related side effects. Pain relief in labour using transcutaneous electrical nerve stimulation (TENS). A TENS/TENS placebo controlled study in two parity groups. Transcutaneous nerve stimulation (TENS) during the first stage of labour: a randomized clinical trial. Comparison of the effectiveness of bilateral ilioinguinal nerve block and wound infiltration for postoperative analgesia after caesarean section. An evaluation of transcutaneous electrical nerve stimulation for pain relief in labour. Abdominal nerve blockade for postoperative analgesia after caesarean section. Transcutaneous electrical nerve stimulation following appendicectomy: the placebo effect. Multimodal analgesia before thoracic surgery does not reduce postoperative pain. Analysis of peak magnitude and duration of analgesia produced by local anesthetics injected into sympathetic ganglia of complex regional pain syndrome patients. A comparison between local anaesthetic dorsal nerve block and caudal bupivacaine with ketamine for paediatric circumcision.
To examine if ilioinguinal-iliohypogastric nerve block could reduce the need for post-Cesarean delivery morphine analgesia and thus reduce the incidence of opioid related adverse-effects.
                A multi-level technique for performing the nerve block with bupivacaine was developed and then utilized in this two-part study. Part one was a retrospective assessment of Cesarean delivery patients with and without ilioinguinal-iliohypogastric blocks to determine if the technique reduced patient controlled analgesia morphine use and thus would warrant further study. The second phase was a randomized double-blind placebo-controlled trial to compare post-Cesarean morphine use and the appearance of opioid-related side effects between the anesthetic and placebo-injected groups.
                Both phases demonstrated that our method of ilioinguinal-iliohypogastric nerve block significantly reduced the amount of iv morphine used by patients during the 24 hr following Cesarean delivery. In the retrospective assessment, morphine use was 49 +/- 30 mg in the block group vs 79 +/- 25 mg in the no block group (P = 0.0063). For the prospective trial, patients who received nerve blocks with bupivacaine had a similar result, self-administering 48 +/- 27 mg of morphine over 24 hr compared to 67 +/- 28 mg administered by patients who received infiltrations of saline. However, despite the significant decrease in morphine use, there was no reduction in opioid-related adverse effects: the incidences of nausea were 41% and 46% (P = 0.70) and for itching were 79% and 63% (P = 0.25) in the placebo and nerve block groups, respectively.
                A multi-level ilioinguinal-iliohypogastric nerve block technique can reduce the amount of systemic morphine required to control post-Cesarean delivery pain but this reduction was not associated with a reduction of opioid related adverse effects in our study group. The analgesic effects of transcutaneous electrical nerve stimulation (TENS) in labour and effects on outcome were investigated in a double-blind TENS/TENS placebo controlled trial in 100 primigravidae and 50 women in their third labour. There were no differences between the TENS and the TENS placebo users in terms of pain concept or relief, and only 12 and 13% of primigravidae and 48 and 39% of the para 2 women completed labour without requiring other analgesia in their respective groups. The primigravidae who used either TENS or TENS placebo alone had shorter labours than those who required further analgesia. Although the outcome of labour for mother and infant were similar in the two groups, there was a higher operative delivery rate in women who also had epidural analgesia. There were highly significant differences between the TENS and the TENS placebo users in terms of favourable and unfavourable comments by the mothers and the midwives at 1 and 24 h after delivery. The evident consumer satisfaction for TENS suggests TENS has a part to play in analgesia in labour but the equivocal findings in terms of factors associated with pain relief points to the need for apparatus more specifically designed to cope with the special characteristics of the pain of labour. Our objective was to study the efficacy of transcutaneous electrical nerve stimulation (TENS) in reducing pain during the first stage of labour. Using a prospective randomized placebo-controlled, double blind clinical trial, a patient-controlled analgesia system was used to measure differences in outcome. Trials took place in a labour unit at the St. Antonius Hospital, Nieuwegein, The Netherlands, during a period of 18 months. Forty-six patients, during the first stage of labour, were treated with TENS, and 48 with a placebo apparatus. Main outcome measures were pain relief, amount of administered analgesics, obstetrical and neonatal outcome, and side effects. No significant differences occurred between groups in the number of requests for pethidine/promethazine. The foetal outcome in both groups was the same. TENS and placebo were considered equally effective by both patients and staff. In conclusion, TENS was not more effective than a placebo apparatus in relieving pain during the first stage of labour. No adverse side-effects occurred. We have studied the effects of bilateral ilioinguinal nerve block and wound infiltration with 0.5% bupivacaine on postoperative pain and analgesic requirements in 62 patients undergoing Caesarean section under general anaesthesia. A control group received no local anaesthetic supplementation. Both ilioinguinal block and wound infiltration reduced significantly the pain scores and analgesic requirements in the immediate postoperative period (P < 0.05). The differences in pain scores and analgesic requirements between the study groups were not statistically significant (P > 0.05). The effectiveness of transcutaneous nerve stimulation (TENS) for pain relief in labour was evaluated by randomizing 280 patients in early labour into 2 groups. Inoperative sham machines were applied to patients in the control group and active units to those in the test group. Neither patients nor attending labour ward staff were aware of which group the patient was in. The intensity of low back pain and abdominal pain was assessed by the patient each hour on a visual analogue pain scale. Each patient served as her own control by switching off the machine for 2 contractions every hour and then recording the intensity of pain. The amount of conventional analgesia each patient received was recorded by labour ward staff. There was no difference in the intensity of pain recorded by each group. Nor was there any difference between the 2 groups in the change of pain experienced when the machine was switched off. Moreover there was no difference in the amount of other analgesia required. Some differences were found when those with little low back pain were excluded from the study. We conclude that TENS is ineffective as a routine method of pain relief in labour. It is likely to benefit only those with severe back pain and then only to a modest degree. A prospective study of blocking T10-L1 with local anaesthetic, bilaterally in 30 patients undergoing caesarean section under general anaesthesia has been shown to provide effective postoperative analgesia thus requiring significantly less narcotics (mean 66.6 mg of pethidine) compared to the 30 patients in the control group (mean 163 mg of pethidine). A cocktail of 0.5% of bupivacaine with adrenaline and xylocaine 1% produced analgesia for the duration ranging from 8 to 12 hours (mean 8.4 hours). Patients with abdominal field block were awake, alert and comfortable during the immediate postoperative period. They were pain-free sufficiently to put the babies to the breast early and frequently. A controlled trial was undertaken to compare the efficacy of transcutaneous electrical nerve stimulation (TENS) with standard intramuscular opiate analgesia in the management of postoperative pain following appendicectomy. Consecutive patients undergoing emergency appendicectomy were randomised into control, sham TENS and active TENS groups. There was a significant decrease in pain severity and analgesic intake in both active and sham TENS groups when compared with the control group (P less than 0.01). No difference was demonstrated in pain severity between active and sham TENS groups but the active TENS group required slightly less analgesia. These results suggest that the major benefit of TENS in the postappendicectomy patient is due to its 'placebo effect' and its use in this situation cannot be recommended. Several reports have suggested that preoperative nociceptive block may reduce postoperative pain, analgesic requirements, or both, beyond the anticipated duration of action of the analgesic agents. We have investigated, in a double-blind, placebo-controlled study, pre-emptive analgesia and the respiratory effects of preoperative administration of a multimodal antinociceptive regimen. Thirty patients undergoing thoracotomy were allocated randomly to two groups. Before surgery, the treatment group (n = 15) received morphine 0.15 mg kg-1 i.m. with perphenazine 0.03 mg kg-1 i.m. and a rectal suppository of indomethacin 100 mg, while the placebo group (n = 15) received midazolam 0.05 mg kg-1 i.m. and a placebo rectal suppository. After induction of anaesthesia, the treatment group received intercostal nerve block with 0.5% bupivacaine and adrenaline 1:200,000 (3 ml) in the interspace of the incision and in the two spaces above and two spaces below. The placebo group received identical injections but with normal saline only. The treatment group consumed significantly less morphine by patient-controlled analgesia in the first 6 h after operation, but the total dose of morphine consumed on days 2 and 3 after surgery was significantly greater in the treatment group. There were no differences between the groups in postoperative VAS scores (at rest or after movement), PaCO2 values or postoperative spirometry. However, pain thresholds to pressure applied at the side of the chest contralateral to the site of incision decreased significantly from preoperative values on days 1 and 2 after surgery in both groups. The results of this study do not support the preoperative use of this combined regimen for post-thoracotomy pain. Pain-relieving effects of lidocaine/bupivicaine local anesthetic (LA) and saline (S) block of sympathetic ganglia (stellate block, 4 patients; lumbar sympathetic block, 3 patients) were compared in 7 complex regional pain syndrome (CRPS) patients on a double-blind crossover basis to evaluate the diagnostic and therapeutic value of local anesthetic sympathetic blocks.
                Patients rated their pain on a visual analog scale before and after blocks and were tested for mechanical allodynia one-half hour after blocks. Thereafter, they rated their pain intensity in diaries four times a day for 7 days. Each patient received two blocks, S and LA, and served as his own control.
                Both S and LA injections of sympathetic ganglia produced large reductions in pain intensity in 6 of 7 patients 30 minutes after block. These large reductions were accompanied by the reversal of mechanical allodynia in both S and LA. The mean difference between initial peak reduction in pain intensity produced by saline (68.7%) and active local anesthetic (74.4%) did not approach statistical significance. In striking contrast, the mean duration of pain relief was reliably longer in the case of LA (3 days, 18 hours) as compared with S ( 19.9 hours), a difference that occurred in all 7 patients. In a larger sample of 41 CRPS patients, signs of sympathetic efferent blockade, including Homer' s syndrome or skin surface temperature change, were not predictive of initial peak magnitude of pain relief from sympathetic blockade but were predictive of duration of pain reduction.
                The combination of these results provides evidence that duration of pain relief is affected by injection of local anesthetics into sympathetic ganglia. These results indicate that both magnitude and duration of pain reduction should be closely monitored to provide optimal efficacy in procedures that use local anesthetics to treat CRPS. Ketamine has been shown to prolong analgesia produced by caudal local anaesthetic block and is now in common use. This study compares caudal block using bupivacaine/ketamine with dorsal nerve block of the penis.
                Sixty boys undergoing elective circumcision were given either 0.5 ml x kg-1 of bupivacaine 0.15% with ketamine 0.5 mg x kg-1 (n = 30) or dorsal nerve block of the penis with bupivacaine 0.5% (n = 30) as a supplement to general anaesthesia. Postoperative pain was assessed by parents using a modified objective pain score, and the time taken to first requirement of analgesia was recorded. Motor weakness, time to first micturition, postoperative nausea and vomiting (PONV), eating habits, sleep disturbance and behaviour were also assessed.
                There was no difference between the groups in time to first requirement for analgesia or number of doses of paracetamol given in the first 24 h. Almost half the boys in the caudal group had motor weakness, and there was a significant increase in time to first micturition in that group. There was no difference between the groups in PONV, eating, sleeping or behavioural disturbance.
                Caudal anaesthesia with bupivacaine/ketamine does not confer any advantage over a dorsal nerve block with the doses used in this study. Because of the higher incidence of side-effects and technique failure in the caudal group, dorsal nerve block is perhaps the preferred technique.
Local anaesthetic nerve blocks are more effective than placebo, opioid and non-opioid analgesia for pain management in labour based on RCTs of unclear quality and limited numbers. Side effects are more common after local anaesthetic nerve blocks in comparison with placebo. Different local anaesthetic agents used for pain relief provide similar satisfaction with pain relief. Further high-quality studies are needed to confirm the findings, to assess other outcomes and to compare local anaesthetic nerve blocks with various modalities for pain relief in labour.