title: Preoperative cotreatment with dextromethorphan and ketorolac provides an enhancement of pain relief after laparoscopic-assisted vaginal hysterectomy.
abstract: OBJECTIVE
  Both N-methyl-D-aspartate receptor antagonists and nonsteroidal anti-inflammatory drugs have been demonstrated to produce better postoperative pain relief. The concept of multimodal analgesia has also been used for clinical pain management. The aim of the present study was to examine the analgesic effect of preoperative cotreatment with dextromethorphan (DM) and ketorolac on postoperative pain management after laparoscopic-assisted vaginal hysterectomy (LAVH).
  
  
  METHODS
  Eighty ASA physical status I or II patients scheduled for LAVH were included and randomly assigned to 1 of 4 groups. Patients received intramuscular (IM) chorpheniramine 20 mg+ intravenous (IV) 2 mL of normal saline, IM DM 40 mg+IV 2 mL of normal saline, IM chorpheniramine 20 mg+IV 60 mg (2 mL) of ketorolac, and IM DM 40 mg+IV ketorolac 60 mg as the groups C, DM, Keto, and DM+Keto, respectively. All patients were given a patient-controlled analgesia (PCA) with morphine for pain relief postoperatively. Analgesic effects were evaluated using Visual Analog Scale pain scores at rest and during coughing, time to first PCA request for pain relief, total morphine consumption, bed rest time, and the time to first passage of flatus for 48 hours after surgery.
  
  
  RESULTS
  Patients in DM and Keto groups had significantly better pain relief than patients in group C. Patients in DM+Keto group exhibited the best postoperative pain relief among groups in the following several categories: time to first trigger of PCA, total morphine consumption, the worst Visual Analog Scale, bed rest time, and the time to first passage of flatus, demonstrating an enhanced effect between DM and ketorolac. Neither synergistic nor antagonistic interaction was observed between DM and ketorolac.
  
  
  CONCLUSIONS
  Preoperative treatment with both DM and ketorolac diminish postoperative pain. Our results suggest that the N-methyl-D-aspartate antagonist-DM and the nonsteroidal anti-inflammatory drugs-ketorolac cotreatment provide an enhancement of analgesia for postoperative pain management in patients after LAVH surgery.
authors.affiliation: Department of Anesthesiology, Tri-Service General Hospital and, National Defense Medical Center, no. 325, Section 2, Chenggung Road, Neihu 114, Taipei, Taiwan, Republic of China.
authors.forename: Chueng-He
authors.initials: CH
authors.lastname: Lu
authors.forename: Jah-Yao
authors.initials: JY
authors.lastname: Liu
authors.forename: Meei-Shyuan
authors.initials: MS
authors.lastname: Lee
authors.forename: Cecil O
authors.initials: CO
authors.lastname: Borel
authors.forename: Chun-Chang
authors.initials: CC
authors.lastname: Yeh
authors.forename: Chih-Shung
authors.initials: CS
authors.lastname: Wong
authors.forename: Ching-Tang
authors.initials: CT
authors.lastname: Wu
mesh_terms: D000328:Adult; D000701:Analgesics, Opioid / Q000008:administration & dosage; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000008:administration & dosage; D003915:Dextromethorphan / Q000008:administration & dosage*; D004311:Double-Blind Method; D004338:Drug Combinations; D005260:Female; D006801:Humans; D007045:Hysterectomy, Vaginal / Q000009:adverse effects*; D020910:Ketorolac / Q000008:administration & dosage*; D010535:Laparoscopy / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D010149:Postoperative Pain / Q000175:diagnosis* / Q000209:etiology / Q000517:prevention & control*; D011300:Preoperative Care / Q000379:methods; D016896:Treatment Outcome
chemical_list: D000701:Analgesics, Opioid; D000894:Anti-Inflammatory Agents, Non-Steroidal; D004338:Drug Combinations; D003915:Dextromethorphan; D020910:Ketorolac