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Thomas C, Ayres M, Pye K, Yassin D, Howell SJ, Alderson S. Process, structural, and outcome quality indicators to support perioperative opioid stewardship: a rapid review. Perioper Med (Lond) 2023; 12:34. [PMID: 37430326 DOI: 10.1186/s13741-023-00312-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 05/19/2023] [Indexed: 07/12/2023] Open
Abstract
Opioids are effective analgesics but can cause harm. Opioid stewardship is key to ensuring that opioids are used effectively and safely. There is no agreed set of quality indicators relating to the use of opioids perioperatively. This work is part of the Yorkshire Cancer Research Bowel Cancer Quality Improvement programme and aims to develop useful quality indicators for the improvement of care and patient outcomes at all stages of the perioperative journey.A rapid review was performed to identify original research and reviews in which quality indicators for perioperative opioid use are described. A data tool was developed to enable reliable and reproducible extraction of opioid quality indicators.A review of 628 abstracts and 118 full-text publications was undertaken. Opioid quality indicators were identified from 47 full-text publications. In total, 128 structure, process and outcome quality indicators were extracted. Duplicates were merged, with the final extraction of 24 discrete indicators. These indicators are based on five topics: patient education, clinician education, pre-operative optimization, procedure, and patient-specific prescribing and de-prescribing and opioid-related adverse drug events.The quality indicators are presented as a toolkit to contribute to practical opioid stewardship. Process indicators were most commonly identified and contribute most to quality improvement. Fewer quality indicators relating to intraoperative and immediate recovery stages of the patient journey were identified. An expert clinician panel will be convened to agree which of the quality indicators identified will be most valuable in our region for the management of patients undergoing surgery for bowel cancer.
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Affiliation(s)
- C Thomas
- Department of Anaesthesia, St. James' University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, LS9 7TF, UK.
| | - M Ayres
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - K Pye
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - D Yassin
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - S J Howell
- Leeds Institute of Health Research, University of Leeds, Leeds, UK
| | - S Alderson
- Primary Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Nie Z, Cui X, Zhang R, Li Z, Lu B, Li S, Cao T, Zhuang P. Effectiveness of Patient-Controlled Intravenous Analgesia (PCIA) with Sufentanil Background Infusion for Post-Cesarean Analgesia: A Randomized Controlled Trial. J Pain Res 2022; 15:1355-1364. [PMID: 35573842 PMCID: PMC9091317 DOI: 10.2147/jpr.s363743] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/29/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose To investigate the effectiveness of sufentanil patient-controlled intravenous analgesia pump (PCIA) and background infusion in patients of post-cesarean analgesia. Patients and Methods This trial compared two groups of women undergoing cesarean section and receiving PCIA: no background infusion group (n=30), 6-min lockout time, and background infusion group (n=30), 2 mL/h infusion, 10-min lockout time. Both groups with 2 μg/kg sufentanil was diluted to 100 mL with normal saline. VAS scores at rest at 36 h was the primary endpoint. The secondary endpoints were the VAS scores at rest at 6, 12, and 24 h, the total amount of sufentanil consumed, the Ramsay sedation score (RSS) assessed at the same time points, postpartum bleeding within 24 h, the injection/attempt (I/A) ratio, BP and HR, PONV, side effects of sufentanil. Results Compared with the no background infusion group, the background infusion group showed lower VAS pain scores at 6, 12, and 24 h (P<0.01), but no differences at 36 h (95% CI = -0.5-0.8. P>0.05). Attempts, injections, and total sufentanil consumption were significantly different between the two groups (P<0.001), but without difference in I/A. Bleeding was less in the background infusion group at 1 h (P=0.03). The minimal respiration rates were not significantly different between groups. Conclusion Background infusion increased the total consumption of sufentanil within 36 h after cesarean section. Although it did not reduce uterine contraction pain and wound pain at 36 h, it significantly reduced the pain at 6, 12, and 24 h after cesarean section. It improved patient satisfaction and reduced the amount of bleeding after 1 h. Importantly, it did not increase the incidence of hypertension, PONV and respiratory depression.
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Affiliation(s)
- Zhongbiao Nie
- Pharmaceutical Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030012, People’s Republic of China
| | - Xianmei Cui
- Obstetrics Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030012, People’s Republic of China
| | - Ran Zhang
- Nephrology Department, Affiliated Hospital of Shanxi University of Traditional Chinese Medicine, Taiyuan, 030036, People’s Republic of China
| | - Zhihong Li
- Pharmaceutical Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030012, People’s Republic of China
| | - Bin Lu
- Anesthesiology Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030012, People’s Republic of China
| | - Suxian Li
- Pharmaceutical Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030012, People’s Republic of China
| | - Tao Cao
- Obstetrics Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030012, People’s Republic of China
| | - Ping Zhuang
- Anesthesiology Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030012, People’s Republic of China
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Ling YH, Tai YH, Wu HL, Fu WL, Tsou MY, Chang KY. Evaluating the association of preoperative parecoxib with acute pain trajectories after video-assisted thoracoscopic surgery: a single-centre cohort study in Taiwan. BMJ Open 2021; 11:e038985. [PMID: 33579761 PMCID: PMC7883868 DOI: 10.1136/bmjopen-2020-038985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE The efficacy of parecoxib as pre-emptive analgesia still remains controversial. This study aimed to investigate how pre-emptive analgesia with parecoxib affected postoperative pain trajectories over time in patients undergoing thoracic surgery. DESIGN Retrospective cohort study. SETTING A single medical centre in Taiwan. PARTICIPANTS We collected 515 patients undergoing video-assisted thoracoscopic surgery at a tertiary medical centre between September 2016 and August 2017. INTERVENTIONS Pre-emptive parecoxib before surgery. PRIMARY AND SECONDARY OUTCOME MEASURES Daily numeric rating pain scores in the first postoperative week. RESULTS A total of 196 (38.1%) of the recruited patients received parecoxib preoperatively. The latent curve analysis revealed that woman, higher body weight and postoperative use of parecoxib were associated with increased baseline level of pain scores over time (p=0.035, 0.005 and 0.048, respectively) but epidural analgesia and preoperative use of parecoxib were inclined to decrease it (both p<0.001). Regarding the decreasing trends of changes in daily pain scores, older age and epidural analgesia tended to steepen the slope (p=0.014 and <0.001, respectively). Preoperative use of parecoxib were also related to decreased frequency of rescue morphine medication (HR=0.4; 95% CI 0.25 to 0.65). CONCLUSIONS Pre-emptive analgesia with parecoxib was associated with decreased baseline pain scores but had no connection with pain decreasing trends over time. Latent curve analysis provided insights into the dynamic relationships among the analgesic modalities, patient characteristics and postoperative pain trajectories.
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Affiliation(s)
- Yu-Hsiang Ling
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ying-Hsuan Tai
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsiang-Ling Wu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wei-Lun Fu
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Mei-Yung Tsou
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kuang-Yi Chang
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
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Hylén M, Akerman E, Idvall E, Alm-Roijer C. Patients´ experiences of pain in the intensive care - The delicate balance of control. J Adv Nurs 2020; 76:2660-2669. [PMID: 32808692 DOI: 10.1111/jan.14503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/12/2020] [Accepted: 07/14/2020] [Indexed: 01/10/2023]
Abstract
AIM To explore the patients´ experiences of pain when being cared for in the intensive care. DESIGN An exploratory, qualitative design was chosen. METHOD Interviews were performed with patients (October 2015-March 2017) within a week of post-intensive care (N = 16). Thematic analysis was used as method for analysis. RESULTS The findings generated two themes - a lack of control and to struggle for control. Pain was described as overwhelming, both in body and mind and generating the experience of a lack of control, with feelings of incapacitation, isolation, and having their needs unmet. Feeling in control of the pain and thus in control of the situation was experienced as a constant struggle. Well-planned care, finding ways to handle the pain and good communication were all helpful in this struggle. CONCLUSION The participants recalled their experience of pain in the ICU and control seems to be crucial for how pain is experienced. They experienced a lack of control due to not only the pain but also the treatment, which can be avoided by the nurse continuously evaluating and individualising the care. Balanced care, meeting the patients' needs and good communication helps the patient feel more in control when experiencing pain. IMPACT The experience of pain is dependent on control for the intensive care patient. The nurse may help them gain control and thereby handle the experience of pain through including the patient, striving for better communication and implementing individualised care that continuously assesses and treats pain.
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Affiliation(s)
- Mia Hylén
- Department of Care Science, Faculty of Health and Society, Malmo University, Malmo, Sweden.,Department of Intensive and Perioperative Care, Skane University Hospital, Malmo, Sweden
| | - Eva Akerman
- Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden.,General Intensive Care Unit, Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Ewa Idvall
- Department of Care Science, Faculty of Health and Society, Malmo University, Malmo, Sweden
| | - Carin Alm-Roijer
- Department of Care Science, Faculty of Health and Society, Malmo University, Malmo, Sweden
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Lee Y, Kim K. Factors Related to the Consumption of Patient-Controlled Postoperative Analgesics in Korea: A Retrospective Study. Pain Manag Nurs 2019; 21:449-455. [PMID: 31859054 DOI: 10.1016/j.pmn.2019.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 02/27/2019] [Accepted: 09/17/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pain is the most common symptom among inpatients, and patient-controlled analgesia (PCA) is one of the effective pain management methods for postoperative patients. AIMS This study aimed to identify the predictors of analgesic consumption in patients using postoperative PCA. DESIGN As part of a descriptive and retrospective study, data were collected from the nursing records of 662 patients who underwent postoperative intravenous PCA for three days after surgery at one medical institution. Stepwise multiple regression analyses were conducted to select significant variables that could predict total analgesic consumption. RESULTS The results demonstrated that surgical sites, physical characteristics, donation surgery, and postoperative pain significantly influenced total analgesic consumption (POD 3, R2 = 53%, p < .001). CONCLUSION The present findings provide valuable information for the effective postoperative administration of intravenous PCA and may contribute to the development of customized patient-centered pain management intervention by nurses through more accurate predictions of analgesic consumption based on individual characteristics, the surgical site, and the type of surgery-especially organ donation surgery. This study could contribute to improving preventive interventions by general nurses as well as pain control nurses by enabling more accurate predictions of patients' pain and consumption of self-controlled analgesic agents based on personal characteristics and surgical characteristics.
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Affiliation(s)
- Yoonyoung Lee
- Department of Nursing, Suncheon National University, Suncheon-si, Jollanamdo, Republic of Korea
| | - Kisook Kim
- College of Nursing, Chung-Ang University, Seoul, Republic of Korea.
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Chen PY, Samy W, Aaron Ying CL. Comparing cost and effectiveness of IVPCA morphine with perioperative multimodal analgesia of oral etoricoxib and oxycontin: A retrospective study. J Orthop 2019; 16:585-589. [PMID: 31660027 PMCID: PMC6806655 DOI: 10.1016/j.jor.2019.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 06/05/2019] [Indexed: 11/23/2022] Open
Abstract
Introduction Good pain control modality for post total knee replacement promotes patient's comfort and facilitates functional recovery, which may prevent post-operative complications; and shorten hospital stay. Therefore, manage pain efficiently and effectively have financial implications to the hospital. This retrospective study analyzed the clinical outcomes and costs of the intravenous (IV) patient-controlled analgesia (PCA) with a new perioperative multimodal analgesia (PMA) of using etoricoxib and oxycontin. Methods This retrospective study analyzed a total of 102 inpatients, 53 received both IVPCA and regular oral analgesics from September 2016 to February 2017, while 49 received preemptive oral etoricoxib before surgery and duly together with oxycontin and paracetamol after surgery from September 2017 to February 2018. Pain scores as the primary outcome were measured by Numeric Rating Scale (0–10) at rest (NRS-R) and on movement (NRS-M). They were analyzed by one-way analysis of covariance (ANCOVA). Other outcomes included side effects from analgesics, range of motion (ROMo), patient satisfaction, length of hospital stay and costs of medications. Results Patients in PMA group achieved better outcomes than PCA group. NRS-M of PMA group shown lower mean pain score and (standard error) than PCA group (2.96 [0.31] vs 4.26 [0.29]; p = 0.003), side effects from analgesics (18% vs 45%), ROM≥ 90° (55.1% vs 30.2%), patient satisfaction (8.97 vs 7.5 out of 10; p = 0.005), and length of hospital stay (6 days vs 8 days; p < 0.001). Moreover, the medication cost of PMA was 59.9% lower than PCA regimen. Conclusions This PMA approach achieved better outcomes and saved hospital costs.
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Affiliation(s)
- Pik Yu Chen
- Department of Anaesthesia and Intensive Care, 4/F, Main Clinical Block and Trauma Centre, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong
| | - Winnie Samy
- Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong, 4/F, Main Clinical Block and Trauma Centre, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong
| | - Chee Lun Aaron Ying
- Department of Anaesthesia and Intensive Care, 4/F, Main Clinical Block and Trauma Centre, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong
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Risk Factors for Moderate to Severe Pain during the First 24 Hours after Laparoscopic Bariatric Surgery While Receiving Intravenous Patient-Controlled Analgesia. Anesthesiol Res Pract 2019; 2019:6593736. [PMID: 31687018 PMCID: PMC6794962 DOI: 10.1155/2019/6593736] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 06/25/2019] [Accepted: 08/09/2019] [Indexed: 12/31/2022] Open
Abstract
Objective To investigate the incidence of and risk factors for moderate to severe pain during the first 24 hours after laparoscopic bariatric surgery. Materials and Methods This retrospective study included morbidly obese patients who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass at a single institution between June 2016 and July 2018. Demographic, clinical, operative, and postoperative pain data from the postanesthesia care unit (PACU) and ward were analyzed. Intravenous patient-controlled analgesia (IV-PCA) was commenced before PACU discharge. Results Ninety-seven patients were included. The mean age was 38.60 ± 12.27 years, and the mean BMI was 45.04 ± 8.42 kg/m2, and 69% were female. The incidence of moderate to severe pain was 75%. Moderate to severe pain during the first 24 hours was associated with young age, female sex, postoperative administration of NSAIDs, first pain score greater than 3 on arrival at the PACU, and inadequate pain control at PACU discharge. A multivariate analysis revealed that inadequate pain control at PACU discharge was the only factor independently associated with moderate to severe pain during the first 24 hours postoperatively (p=0.011). From PACU discharge to the end of postoperative day 3, moderate to severe pain at the end of each 24-hour period was a significant predictor of moderate to severe pain in the subsequent 24-hour period (p=0.011, p < 0.001, and p=0.004, respectively). Conclusions Moderate to severe pain was experienced by 75% of patients undergoing laparoscopic bariatric surgery and receiving IV-PCA after PACU discharge. Inadequate pain control at PACU discharge was the only independent risk factor for moderate to severe pain during the first 24 hours postoperatively.
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Predicting Procedure-specific Morphine Consumption of Intravenous Patient-controlled Analgesia With Random-effect Model Approach. Clin J Pain 2019; 35:43-49. [DOI: 10.1097/ajp.0000000000000647] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chan JJI, Thong SY, Tan MGE. Factors affecting postoperative pain and delay in discharge from the post-anaesthesia care unit: A descriptive correlational study. PROCEEDINGS OF SINGAPORE HEALTHCARE 2017. [DOI: 10.1177/2010105817738794] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Pain occurring in the post-anaesthesia care unit (PACU) is common, distressing to patients and remains a management challenge for staff. This study aims to identify the factors affecting pain severity and delay in discharge of patients from the PACU. Methods: Data from 590 consecutive postoperative patients in the PACU was collected over one month in 2012 at the Singapore General Hospital. Patient demographics, surgical, intraoperative anaesthetic and recovery data were collected. The primary outcome measured was postoperative pain score and secondary outcome was a delay in discharge. Univariate and multivariate logistic regression were performed to determine preoperative and intraoperative variables that may be associated with pain and delayed discharge. Results: The majority (67.6%) of patients reported no to mild pain while 32.3% reported moderate to severe pain; 65.4% of patients had delayed discharge and 28.3% of these were a result of uncontrolled pain. Factors associated with moderate to severe postoperative pain included younger age, same day admissions, duration of operation >2 h, abdominal, upper limb and spine surgeries and use of general anaesthesia. Factors associated with delay in discharge included higher body mass index, abdominal, spine and superficial surgeries, use of general anaesthesia, moderate to severe pain score and use of nurse controlled analgesia. Conclusions: This study identifies predictive factors for postoperative pain and delay in discharge from the PACU. Knowledge of these factors may help in better clinical judgment for postoperative pain management and can lead to quality improvement measures for patient management and work flow in the PACU.
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Affiliation(s)
- Jason Ju In Chan
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Sze Ying Thong
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Michelle Geoh Ean Tan
- Pain Management Centre and Department of Anaesthesiology, Singapore General Hospital, Singapore
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Serial Analgesic Consumptions and Predictors of Intravenous Patient-controlled Analgesia with Cluster Analysis. Clin J Pain 2017; 32:488-94. [PMID: 26710218 PMCID: PMC4894765 DOI: 10.1097/ajp.0000000000000312] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objectives: To elucidate the dynamics of analgesic consumption regarding intravenous patient controlled analgesia (IVPCA) during postoperative period is rather complex partly due to between-patient variation and partly due to within-patient variation. A statistical method was proposed to classify serial analgesic consumption into different classifications that were further taken as the multiple outcomes on which to explore the associated predictors. Methods: We retrospectively included 3284 patients administrated by IVPCA for 3 days after surgery. A repeated measurement design corresponding to serial analgesic consumption variables defined as six-hour total analgesic consumptions was adopted. After determining the numbers of clusters, serial analgesic consumptions were classified into several homogeneous subgroups. Factors associated with new classifications were identified and quantified with a multinominal logistic regression model. Results: Three distinct analgesic classifications were aggregated, including “high”, ”middle” and “low” level of analgesic consumption of IVPCA. The mean analgesic consumptions on 12 successive analgesic consumptions at 6-hour interval of each classification consistently revealed a decreasing trend. As the trends were almost parallel with time, this suggests the time-invariant proportionality of analgesic consumption between the levels of analgesic consumption of IVPCA. Patient’s characteristics, like age, gender, weight, height, and cancer status, were significant factors associated with analgesic classifications. Surgical sites had great impacts on analgesic classifications. Discussion: The serial analgesic consumptions were simplified into 3 analgesic consumptions classifications. The identified predictors are useful to recognize patient’s analgesic classifications before using IVPCA. This study explored a new approach to analysing dynamic changes of postoperative analgesic consumptions.
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Chan ACS, Qiu Q, Choi SW, Wong SSC, Chan ACY, Irwin MG, Cheung CW. Effects of Intra-Operative Total Intravenous Anaesthesia with Propofol versus Inhalational Anaesthesia with Sevoflurane on Post-Operative Pain in Liver Surgery: A Retrospective Case-Control Study. PLoS One 2016; 11:e0149753. [PMID: 26901037 PMCID: PMC4763721 DOI: 10.1371/journal.pone.0149753] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 02/04/2016] [Indexed: 12/11/2022] Open
Abstract
Background Patients receiving total intravenous anesthesia (TIVA) with propofol have been shown to experience less postoperative pain. We evaluated the post-operative analgesic effects of propofol compared with sevoflurane maintenance of anesthesia in liver surgery. This study was registered at ClinicalTrials.gov (NCT02179437). Methods In this retrospective study, records of patients who underwent liver surgery between 2010 and 2013 were reviewed. Ninety-five patients anesthetized with propofol TIVA were matched with 95 patients anesthetized with sevoflurane. Numeric pain rating scale (NRS) pain scores, postoperative morphine consumption, side effects and patients’ satisfaction with pain relief were evaluated. Results The TIVA group reported lower NRS pain scores during coughing on postoperative days 1 and 2 but not 3 (p = 0.0127, p = 0.0472, p = 0.4556 respectively). They also consumed significantly less daily (p = 0.001 on day 1, p = 0.0231 on day 2, p = 0.0004 on day 3), accumulative (p = 0.001 on day 1, p<0.0001 on day 2 and p = 0.0064 on day 3) and total morphine (p = 0.03) when compared with the sevoflurane group. There were no differences in total duration of intravenous patient controlled analgesia (PCA) morphine use and patient satisfaction. No difference was found in reported side effects. Conclusion Patients anesthetized with propofol TIVA reported less pain during coughing and consumed less daily, accumulative and total morphine after liver surgery.
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Affiliation(s)
| | - Qiu Qiu
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, The University of Hong Kong, Hong Kong, China
| | - Siu Wai Choi
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, The University of Hong Kong, Hong Kong, China
| | - Stanley Sau Ching Wong
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, The University of Hong Kong, Hong Kong, China
| | | | - Michael G Irwin
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, The University of Hong Kong, Hong Kong, China
| | - Chi Wai Cheung
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, The University of Hong Kong, Hong Kong, China
- * E-mail:
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GOVIND P, BHAKTA P, DUREJA GP, GUPTA A, VENKATARAJU A. Acute pain service: the journey in a developing country setting. Acta Anaesthesiol Scand 2015; 59:98-106. [PMID: 25349071 DOI: 10.1111/aas.12434] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 09/24/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND In India, acute pain service (APS) is in nascent stage because of lesser importance given to pain management. After establishing an APS in our hospital, we conducted a prospective audit (2008-2011) with an aim to regularly assess the efficacy of techniques on pain scores, muscle power, and adverse effects. METHODS The audit was undertaken in three phases. An assessment of the existing system and recommendation to modify the APS was undertaken in phase I. In phase II, an APS team was constituted and audits were conducted at six monthly intervals for formation of the protocol. Subsequently in phase III, yearly audits were undertaken that led to the development of a final APS. RESULTS There was a steady increase in the number of patients availing APS in intravenous patient-controlled analgesia (IVPCA), epidural analgesia (EA), and continuous peripheral nerve block (CPNB). At the same time, the average visual analogue score (VAS) decreased significantly as the year progressed. While the VAS score did not differ significantly between EA and CPNB, it was less compared with IVPCA. Introduction of regional analgesic techniques played a major role in improving the pain scores. CONCLUSION Implementation of APS resulted in reduced pain scores in our surgical patients. Proper planning, role allocation, formation, and adherence to protocols as well as undertaking regular audit resulted in improving the quality of APS.
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Affiliation(s)
- P. GOVIND
- Department of Anaesthesia and Pain Management; Indian Spinal Injury Centre; New Delhi India
| | - P. BHAKTA
- Our Lady of Lourdes Hospital; Drogheda Ireland
| | - G. P. DUREJA
- Department of Anaesthesia and Pain Management; Indian Spinal Injury Centre; New Delhi India
| | - A. GUPTA
- Department of Anaesthesia and Pain Management; Indian Spinal Injury Centre; New Delhi India
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Cheung CW, Qiu Q, Ying ACL, Choi SW, Law WL, Irwin MG. The effects of intra-operative dexmedetomidine on postoperative pain, side-effects and recovery in colorectal surgery. Anaesthesia 2014; 69:1214-21. [PMID: 24915800 DOI: 10.1111/anae.12759] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2014] [Indexed: 12/15/2022]
Abstract
In this double-blind, randomised study, 100 patients undergoing open or conventional laparoscopic colorectal surgery received an intra-operative loading dose of dexmedetomidine 1 μg.kg(-1) followed by an infusion of 0.5 μg.kg(-1) .h(-1) , or a bolus and infusion of saline 0.9% of equivalent volume. Forty-six patients in the dexmedetomidine group and 50 in the saline group completed the study. The area under the curve of numerical rating scores for pain at rest for 1-48 h postoperatively was significantly lower in the patients receiving dexmedetomidine (p = 0.041). There was no difference in morphine consumption, duration of recovery ward or hospital stay. From the data obtained in this study, we calculated a number needed to treat for effective pain relief of 4. Intra-operative dexmedetomidine in colorectal surgery resulted in a reduction in resting pain scores, but there was no morphine-sparing effect or improvement in patients' recovery outcome measures.
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Affiliation(s)
- C W Cheung
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, The University of Hong Kong, Hong Kong, China
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Over-expression of endothelin-1 in astrocytes, but not endothelial cells, ameliorates inflammatory pain response after formalin injection. Life Sci 2012; 91:618-22. [DOI: 10.1016/j.lfs.2012.06.038] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Revised: 06/24/2012] [Accepted: 06/28/2012] [Indexed: 10/28/2022]
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15
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Cheung CW, Ng KFJ, Liu J, Yuen MYV, Ho MHA, Irwin MG. Analgesic and sedative effects of intranasal dexmedetomidine in third molar surgery under local anaesthesia. Br J Anaesth 2011; 107:430-7. [PMID: 21685111 DOI: 10.1093/bja/aer164] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Dexmedetomidine (DEX) is an alpha 2-adrenoreceptor agonist, which induces sedation and analgesia. This study aimed to determine whether intranasal DEX offered perioperative sedation and better postoperative analgesia. METHODS Patients having unilateral third molar surgery under local anaesthesia were recruited and allocated to receive either intranasal DEX 1 µg kg(-1) (Group D) or same volume of saline (Group P) 45 min before surgery. Patient-controlled sedation with propofol was offered as a rescue sedative. Perioperative sedation, postoperative pain relief and analgesic consumption, vital signs, adverse events, postoperative recovery, and satisfaction in sedation and analgesia were assessed. RESULTS Thirty patients from each group were studied. Areas under curve (AUC) of postoperative numerical rating scale (NRS) pain scores 1-12 h at rest and during mouth opening were significantly lower in Group D (P=0.003 and 0.009, respectively). AUC BIS values and OAA/S sedation scores were significantly lower before surgery and at the recovery area (all P<0.01) with significantly less intra-operative propofol used in group D (P<0.01). In group D, heart rate was significantly lower at recovery period (P=0.005) while systolic blood pressure in different periods of the study (all P<0.01), but the decreases did not require treatment. More patients from placebo group experienced dizziness (P=0.026) but no serious adverse event was found. No difference was found in postoperative psychomotor recovery and satisfaction in pain relief and sedation. CONCLUSIONS Patients receiving intranasal DEX for unilateral third molar surgery with local anaesthesia were more sedated perioperatively with better postoperative pain relief. No delay in psychomotor recovery was seen.
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Affiliation(s)
- C W Cheung
- Department of Anaesthesiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong.
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16
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Esteve N, Ribera H, Mora C, Romero O, Garrido P, Verd M. [Treating acute postoperative pain: evaluation of results on the surgical ward]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2011; 58:353-361. [PMID: 21797085 DOI: 10.1016/s0034-9356(11)70084-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To describe management of acute postoperative pain on the surgical ward. To study the relationship between pain and a variety of surgical procedures and approaches. To determine the level of information patients received, their expectations, and their satisfaction with treatment of postoperative pain. PATIENTS AND METHODS Cross-sectional observational study by survey and review of patient records. We studied 234 patients, including all who were hospitalized for more than 24 hours after scheduled or emergency operations. The main variables recorded were pain intensity at rest and during movement, including on the day after surgery, and the surgical procedure and approach. RESULTS The prevalence of pain (>3 on a numerical scale) on the surgical ward was 33% at rest and 66% during movement. The prevalence of intense pain (>6 on the numerical scale) was 1.7% at rest and 7.3% during movement. Factors related to greater pain intensity were timing, that is, the first day after surgery, when 74.4% of patients experienced their most intense pain; type of surgery and approach (P<.004); and expecting to experience moderate or intense pain (P<.001). CONCLUSIONS Recording the prevalence of postoperative pain on a surgical ward provides information about the real situation of acute postoperative pain control. Pain on movement is a principal indicator for detecting groups of patients for whom analgesic protocols could be improved. Type of surgery and approach is a fundamental factor to consider when comparing the results of analgesic protocols.
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Affiliation(s)
- N Esteve
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Universitari Son Espases, Palma de Mallorca.
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Keyte D, Richardson C. Re-thinking pain educational strategies: Pain a new model using e-learning and PBL. NURSE EDUCATION TODAY 2011; 31:117-121. [PMID: 20566232 DOI: 10.1016/j.nedt.2010.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2009] [Revised: 03/01/2010] [Accepted: 05/04/2010] [Indexed: 05/29/2023]
Abstract
Despite some high profile reorganisation including the introduction of acute pain teams, many patients still experience unnecessary pain. Traditional teaching and learning strategies seem to have made little impact in clinical practice. This paper explores the possible reasons for this and identifies the need to help postregistration students transfer (re-contextualise) what they are learning to practice. A new, more flexible pain management module utilising a blended face to face/e-learning approach within a problem-based learning philosophy was introduced to increase knowledge in pain management whilst also attempting to overcome the barriers to knowledge transfer into practice. This is done by challenging attitudes and encouraging students to explore their clinical practice alongside theoretical concepts.
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Affiliation(s)
- Donna Keyte
- University of Manchester, School of Nursing, Midwifery and Social Work, Jean MacFarlane Building, University Place, Oxford Road, Manchester, M13 9PL, UK.
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18
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Siddiqui MRS, Sajid MS, Uncles DR, Cheek L, Baig MK. A meta-analysis on the clinical effectiveness of transversus abdominis plane block. J Clin Anesth 2011; 23:7-14. [DOI: 10.1016/j.jclinane.2010.05.008] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2009] [Revised: 05/13/2010] [Accepted: 05/22/2010] [Indexed: 11/27/2022]
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Difficulties in Controlling Mobilization Pain Using a Standardized Patient-Controlled Analgesia Protocol in Burns. J Burn Care Res 2011; 32:166-71. [DOI: 10.1097/bcr.0b013e31820334e5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Relief from pain is itself a marker of high-quality medical care. Quality assurance in the case of pain management could simply mean successful elimination of pain. Because the means of controlling pain are imperfect, it is essential to consider whether pain interventions actually achieve the primary goal of pain relief and also whether they are safe, cost-effective, and even capable of producing secondary benefits such as early recovery from surgery. Quality assurance and assessment in pain management therefore becomes a complex undertaking that must incorporate into its processes the often-conflicting goals of comfort versus safety versus patients' rights.
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21
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Chan AKM, Cheung CW, Chong YK. Alpha-2 agonists in acute pain management. Expert Opin Pharmacother 2010; 11:2849-68. [DOI: 10.1517/14656566.2010.511613] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Lee A, Chan SKC, Chen PP, Gin T, Lau ASC, Chiu CH. The costs and benefits of extending the role of the acute pain service on clinical outcomes after major elective surgery. Anesth Analg 2010; 111:1042-50. [PMID: 20705784 DOI: 10.1213/ane.0b013e3181ed1317] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Acute pain services have received widespread acceptance and formal support from institutions and organizations, but available evidence on their costs and benefits is scarce. Although there is good agreement on the provision of acute pain services after many major surgical procedures, there are other procedures for which the benefits are unclear. Data are required to justify any expansion of acute pain services. In this randomized, controlled clinical trial we compared the costs and effects of acute pain service care on clinical outcomes with conventional pain management on the ward. Patients included in the trial were considered by their anesthesiologist to have either arm be suitable for the procedure. METHODS Four hundred twenty-three patients undergoing major elective surgery were randomized either to an anesthesiologist-led, nurse-based acute pain service group with patient-controlled analgesia or to a control group with IM or IV boluses of opioid analgesia. Both groups were treated with medications to treat opioid-related adverse effects and received the usual care from health professionals assigned to the ward. The main outcome measures were quality of recovery scores, pain intensity measures, global measure of treatment effectiveness, and overall pain treatment cost. Cost-effectiveness acceptability curves were drawn to detect a difference in the joint cost-effect relationship between groups. RESULTS There was no difference in quality of recovery score on postoperative day 1 between treatment and control groups (mean difference, 0; 95% confidence interval [CI], -0.7 to 0.7; P = 0.94) or in the rate of improvement in quality of recovery score (mean difference, -0.1; 95% CI, -0.4 to 0.1; P = 0.34). The proportion of patients with 1 or more days of highly effective pain management was higher in the acute pain service group than in the control group (86% vs. 75%; P < 0.01). Costs were higher in the acute pain service group (mean difference, US$46; 95% CI, $44 to $48 per patient; P < 0.001). A cost-effectiveness acceptability curve showed that the acute pain service was more cost effective than was control for providing highly effective pain management if the decision maker was willing to pay more than US$546 per patient per 1 day with highly effective treatment. CONCLUSION In extending the role of the acute pain service to a specific group of major surgical procedures, the acute pain service was likely to be cost effective.
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Affiliation(s)
- Anna Lee
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong.
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Epidural Analgesia With Low-concentration Levobupivacaine Combined With Fentanyl Provides Satisfactory Postoperative Analgesia for Colorectal Surgery Patients. ACTA ACUST UNITED AC 2010; 48:68-74. [DOI: 10.1016/s1875-4597(10)60016-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Revised: 01/29/2010] [Accepted: 02/03/2010] [Indexed: 11/20/2022]
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Ahmad I, Thompson A, Frawley M, Hu P, Heffernan A, Power C. Five-year experience of critical incidents associated with patient-controlled analgesia in an Irish University Hospital. Ir J Med Sci 2010; 179:393-7. [PMID: 20495886 DOI: 10.1007/s11845-010-0482-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2009] [Accepted: 03/28/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Patient-controlled analgesia (PCA) is a common and effective means of managing post-operative pain. We sought to identify factors that may lead to critical incidents (CIs) in patient safety when using PCA in our institution. METHODS An observational study of prospectively collected data of patients who received PCA from 2002 to 2006 was performed. All CIs were documented and analysed by staff members of the acute pain service (APS). Cause analysis of CIs was undertaken to determine if measures can be instituted to prevent recurrence of similar events. RESULTS Over eight thousand patients (8,240) received PCA. Twenty-seven CIs were identified. Eighteen were due to programming errors. Other CIs included co-administration of opioids and oversedation. CONCLUSION In our institution, the largest contributory factor to CIs with PCAs was programming error. Strategies to minimize this problem include better education and surveillance.
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Affiliation(s)
- I Ahmad
- Department of Anaesthesia, Adelaide and Meath Hospital, Belgard Road, Tallaght, Dublin 24, Ireland.
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