MD, MSCI, Deepti Agarwal, MDand Honorio T. Benzon, MDAbstractBACKGROUND:Preventive analgesia using non-opioid analgesic strategies is recognized as apathway to improve postoperative pain control while minimizing opioid-relatedside effects. Ketorolac is a nonsteroidal antiinflammatory drug frequently usedto treat postoperative pain. However, the optimal dose and route ofadministration for systemic single dose ketorolac to prevent postoperative painis not well defined. We performed a quantitative systematic review to evaluatethe efficacy of a single dose of perioperative ketorolac on postoperativeanalgesia.METHODS: Wefollowed the PRISMA statement guidelines. A wide search was performed toidentify randomized controlled trials that evaluated the effects of a singledose of systemic ketorolac on postoperative pain and opioid consumption.Meta-analysis was performed using a random-effects model. Effects of ketorolacdose were evaluated by pooling studies into 30- and 60-mg dosage groups.Asymmetry of funnel plots was examined using Egger regression. The presence ofheterogeneity was assessed by subgroup analysis according to the route ofsystemic administration (IV versus IM) and the time of drug administration(preincision versus postincision).RESULTS:Thirteen randomized clinical trials with 782 subjects were included. Theweighted mean difference (95% confidence interval [CI]) of combined effectsshowed a difference for ketorolac over placebo for early pain at rest of 0.64(1.11 to 0.18) but not at late pain at rest, 0.29 (0.88 to 0.29) summarypoint (010 scale). Opioid consumption was decreased by the 60-mg dose, with amean (95% CI) IV morphine equivalent consumption of 1.64 mg (2.90 to 0.37mg). The opioid-sparing effects of ketorolac compared with placebo were greaterwhen the drug was administered IM compared with when the drug was administeredIV, with a mean difference (95% CI) IV morphine equivalent consumption of 2.13mg (4.1 to 0.21 mg). Postoperative nausea and vomiting were reduced by the60-mg dose, with an odds ratio (95% CI) of 0.49 (0.290.81).CONCLUSIONS: Single dose systemic ketorolac is aneffective adjunct in multimodal regimens to reduce postoperative pain.Improved postoperative analgesia achieved with ketorolac was also accompaniedby a reduction in postoperative nausea and vomiting. The 60-mg doseoffers significant benefits but there is a lack of current evidence that the30-mg dose offers significant benefits on postoperative pain outcomes.________________________________________________________________________A Review of the Impact of PhenylephrineAdministration on Maternal Hemodynamics and Maternal and Neonatal Outcomes inWomen Undergoing Cesarean Delivery Under Spinal Anesthesiahttp://www.anesthesia-analgesia.org/content/114/2/377Ashraf S.Habib, MBBCh, MSc, MHS, FRCAAbstractPhenylephrineis effective for the management of spinal anesthesia-induced hypotension inparturients undergoing cesarean delivery under spinal anesthesia. Whileephedrine was previously considered the vasopressor of choice in obstetricpatients, phenylephrine is increasingly being used. This is largely due tostudies suggesting improved fetal acid-base status with the use ofphenylephrine as well as the low incidence of hypotension and its related sideeffects with prophylactic phenylephrine regimens. This review highlights theeffects of phenylephrine compared with ephedrine on maternal hemodynamics(arterial blood pressure, heart rate, and cardiac output), and occurrence of intraoperativenausea and vomiting. The impact of the administration of phenylephrine as abolus for the treatment of established hypotension compared with itsadministration as a prophylactic infusion is discussed. This article alsoreviews the impact of phenylephrine compared with ephedrine on uteroplacentalperfusion, and fetal outcomes such as neonatal acid-base status and Apgarscores. The optimum dosing regimen for phenylephrine administration is alsodiscussed.________________________________________________________________________Plasma methemoglobin as a potential biomarkerof anemic stress in humanshttp://www.springerlink.com/content/h22h6594054j7w27/Gregory M.T. Hare,