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Dogan M, Hirschfeld G, Blankenburg M, Frühwald M, Ahnert R, Braun S, Marschall U, Pfenning I, Zernikow B, Wager J. Effectiveness of a Psychosocial Aftercare Program for Youth Aged 8 to 17 Years With Severe Chronic Pain: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2127024. [PMID: 34570203 PMCID: PMC8477265 DOI: 10.1001/jamanetworkopen.2021.27024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Severe chronic pediatric pain causes individual suffering and significantly affects social functioning and psychological well-being. For children with high pain severity, intensive interdisciplinary pain treatment (IIPT) is a well-established treatment. However, across specialized centers, it is not sufficient for all patients. OBJECTIVE To evaluate the effectiveness of a psychosocial aftercare (PAC) program for pediatric patients with severe chronic pain followed up for 6 months after discharge from IIPT. DESIGN, SETTING, AND PARTICIPANTS This multicenter randomized clinical trial with 4 assessment points (pre-IIPT, immediately post-IIPT, 3 months, and 6 months) was conducted at 3 pediatric specialized tertiary care pain centers in Germany between September 11, 2018, and March 31, 2020. Included patients were aged 8 to 17 with a severe chronic pain condition who had been admitted for IIPT. Data were analyzed from June 8 to September 4, 2020. INTERVENTIONS Patients and their families were randomly assigned to 1 of 2 study groups at inpatient IIPT admission. Both groups received standardized 3- to 4-week IIPT. After IIPT discharge, the intervention group received PAC and the control group received usual care. PAC involved ongoing contact with a social worker for as long as the family requested the support, up to a maximum of 6 months. MAIN OUTCOMES AND MEASURES The primary outcome measure was pain at 6 months, measured using the Chronic Pain Grading (CPG), an instrument based on an algorithm indicating severity of the chronic pain disorder. Secondary outcomes included other pain-related and emotional parameters. RESULTS A total of 419 patients were randomized (mean [SD] age, 14.3 [2.1] years; 303 [72.3%] girls; 116 [27.7%] boys), with 218 assigned to usual care and 201 assigned to PAC. At baseline in both groups, the median (IQR) CPG was 3 (2-4). Superiority of PAC compared with usual care was demonstrated at 6 months (median [IQR] CPG: usual care, 2 [2-3]; PAC, 1 [1-2]; r = 0.30; 95% CI, 0.17-0.41). Additionally, PAC significantly improved emotional parameters (eg, significant time × group interaction: b = -8.84; P < .001). CONCLUSIONS AND RELEVANCE This randomized clinical trial found that PAC improved pain-related and emotional parameters during the intervention 6 months after discharge from IIPT. Future research is needed to investigate the intervention's long-term effects. TRIAL REGISTRATION German Clinical Trials Register ID: DRKS00015230.
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Affiliation(s)
- Meltem Dogan
- German Paediatric Pain Centre, Children’s and Adolescents’ Hospital, Datteln, Germany
- Department of Children’s Pain Therapy and Paediatric Palliative Care, Faculty of Health, Witten/Herdecke University School of Medicine, Witten, Germany
| | - Gerrit Hirschfeld
- Faculty of Business and Health, University of Applied Sciences Bielefeld, Bielefeld, Germany
| | - Markus Blankenburg
- German Paediatric Pain Centre, Children’s and Adolescents’ Hospital, Datteln, Germany
- Paediatric Pain Center Baden-Württemberg, Department of Pediatric Neurology, Olgahospital Stuttgart, Stuttgart, Germany
| | - Michael Frühwald
- University Children’s Hospital Augsburg, Swabian Children’s Pain Center, Augsburg, Germany
| | - Rosemarie Ahnert
- University Children’s Hospital Augsburg, Swabian Children’s Pain Center, Augsburg, Germany
| | - Sarah Braun
- Paediatric Pain Center Baden-Württemberg, Department of Pediatric Neurology, Olgahospital Stuttgart, Stuttgart, Germany
| | - Ursula Marschall
- Department of Medicine and Health Services Research, BARMER Health Insurance, Wuppertal, Germany
| | - Ingo Pfenning
- Techniker Krankenkasse, Techniker Health Insurance, Hamburg, Germany
| | - Boris Zernikow
- German Paediatric Pain Centre, Children’s and Adolescents’ Hospital, Datteln, Germany
- Department of Children’s Pain Therapy and Paediatric Palliative Care, Faculty of Health, Witten/Herdecke University School of Medicine, Witten, Germany
| | - Julia Wager
- German Paediatric Pain Centre, Children’s and Adolescents’ Hospital, Datteln, Germany
- Department of Children’s Pain Therapy and Paediatric Palliative Care, Faculty of Health, Witten/Herdecke University School of Medicine, Witten, Germany
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Tan PY, Quah DDBS, Chan DXH. Survey of physician comfort and attitudes on perioperative opioid prescription in patients with chronic pain. PROCEEDINGS OF SINGAPORE HEALTHCARE 2021. [DOI: 10.1177/20101058211008197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: This study examines current practices, experiences, beliefs, concerns regarding negative outcomes and confidence of non-pain specialty anaesthetists regarding prescribing opioids to chronic pain patients. Design: An electronic cross-sectional survey was conducted by physicians from the Division of Anaesthesiology, excluding pain specialists, at the Singapore General Hospital. Methods: An online survey was conducted, investigating: (a) sociodemographic and practice characteristics; (b) current opioid prescribing practices; (c) experiences and beliefs towards prescribing opioid analgesics for chronic non-malignant pain; (d) confidence and comfort when prescribing opioids; and (e) educational and training needs in chronic pain management. Results: A total of 123 anaesthetists (80.9%) responded to the survey. It was noted that only 38.2% of respondents were comfortable managing patients with chronic pain. The majority (86.2%) felt that anaesthetists should be the primary doctors in the management of postoperative pain in chronic pain patients, and 61% believed that chronic pain trained specialist anaesthetists should be responsible; 92.7% of respondents agreed that patients who are educated about their pain tend to do better. Most importantly, 96.7% of respondents feel that they will benefit from more education regarding pain management in chronic pain patients. Conclusions: The majority of non-pain specialist anaesthetists recognise the importance of education regarding pain management for non-malignant chronic pain patients. Many feel that they are not confident in managing these patients and will benefit from continuing medical education and self-assessment courses to improve their confidence. These results could be used to enrich current pain management courses.
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Affiliation(s)
- Pei Yu Tan
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
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Jung KT, So KY, Kim SU, Kim SH. The Optimizing Background Infusion Mode Decreases Intravenous Patient-Controlled Analgesic Volume and Opioid Consumption Compared to Fixed-Rate Background Infusion in Patients Undergoing Laparoscopic Cholecystectomy: A Prospective, Randomized, Controlled, Double-Blind Study. ACTA ACUST UNITED AC 2021; 57:medicina57010042. [PMID: 33419086 PMCID: PMC7825461 DOI: 10.3390/medicina57010042] [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] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/02/2021] [Accepted: 01/04/2021] [Indexed: 02/06/2023]
Abstract
Background and objectives: The fixed-rate continuous background infusion mode with bolus dosing is a common modality for intravenous patient-controlled analgesia (PCA). However, some patients suffer from inadequate analgesia or opioid-related adverse effects due to the biphasic pattern of postoperative pain. Therefore, we investigated the postoperative analgesic efficacy of PCA using an optimizing background infusion mode (OBIM) where the background injection rate varies depending on the patient’s bolus demand. Materials and Methods: We prospectively enrolled 204 patients who underwent laparoscopic cholecystectomy in a randomized, controlled, double-blind study. Patients were allocated to either the optimizing (group OBIM) or the traditional background infusion group (group TBIM). The numeric rating scale (NRS) score for pain was evaluated at admission to and discharge from the recovery room, as well as at the 6th, 24th, and 48th postoperative hours. Data on bolus demand count, total infused volume, and background infusion rate were downloaded from the PCA device at 30-min intervals until the 48th postoperative hour. Results: The NRS score was not significantly different between groups throughout the postoperative period (p = 0.621), decreasing with time in both groups (p < 0.001). The bolus demand count was not significantly different between groups throughout (p = 0.756). The mean total cumulative infused PCA volume was lower in group OBIM (84.0 (95% confidence interval: 78.9−89.1) mL) than in group TBIM (102 (97.8−106.0) mL; p < 0.001). The total cumulative opioid dose in fentanyl equivalents, after converting sufentanil to fentanyl using an equipotential dose ratio, was lower in group OBIM (714.1 (647.4−780.9) μg) than in group TBIM (963.7 (870.5−1056.9) μg); p < 0.001). The background infusion rate was significantly different between groups throughout the study period (p < 0.001); it was higher in group OBIM than in group TBIM before the 12th postoperative hour and lower from the 18th to the 48th postoperative hour. Conclusions: The OBIM combined with bolus dosing reduces the cumulative PCA volume and opioid consumption compared to the TBIM combined with bolus dosing, while yielding comparable postoperative analgesia and bolus demand in patients undergoing laparoscopic cholecystectomy.
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Affiliation(s)
- Ki Tae Jung
- Department of Anesthesiology and Pain Medicine, School of Medicine, Chosun University, 309 Pilmun-daero, Dong-gu, Gwangju 61452, Korea; (K.T.J.); (K.Y.S.)
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, 365 Pilmun-daero, Dong-gu, Gwangju 61453, Korea;
| | - Keum Young So
- Department of Anesthesiology and Pain Medicine, School of Medicine, Chosun University, 309 Pilmun-daero, Dong-gu, Gwangju 61452, Korea; (K.T.J.); (K.Y.S.)
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, 365 Pilmun-daero, Dong-gu, Gwangju 61453, Korea;
| | - Seung Un Kim
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, 365 Pilmun-daero, Dong-gu, Gwangju 61453, Korea;
| | - Sang Hun Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Chosun University, 309 Pilmun-daero, Dong-gu, Gwangju 61452, Korea; (K.T.J.); (K.Y.S.)
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, 365 Pilmun-daero, Dong-gu, Gwangju 61453, Korea;
- Correspondence: ; Tel.: +82-62-2203223
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Erlenwein J, Emons MI, Petzke F, Quintel M, Staboulidou I, Przemeck M. The effectiveness of an oral opioid rescue medication algorithm for postoperative pain management compared to PCIA : A cohort analysis. Anaesthesist 2020; 69:639-648. [PMID: 32617631 PMCID: PMC7458942 DOI: 10.1007/s00101-020-00806-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 05/11/2020] [Accepted: 05/27/2020] [Indexed: 11/17/2022]
Abstract
Background Standard protocols or algorithms are considered essential to ensure adequate analgesia. Germany has widely adopted postoperative protocols for pain management including oral opioids for rescue medication, but the effectiveness of such protocols has only been evaluated longitudinally in a before and after setting. The aim of this cohort analysis was to compare the effectiveness of an oral opioid rescue medication algorithm for postoperative management of pain to the gold standard of patient-controlled intravenous analgesia (PCIA). Material and methods This study compared cohorts of patients of two prospective observational studies undergoing elective total hip replacement. After surgery patients received piritramide to achieve a pain score of ≤3 on the numeric rating scale (NRS 0–10). A protocol was started consisting of oral long-acting oxycodone and ibuprofen (basic analgesia). Cohort 1 (C1, 126 patients) additionally received an oral opioid rescue medication (hydromorphone) when reporting pain >3 on the NRS. Cohort 2 (C2, 88 patients) was provided with an opioid by PCIA (piritramide) for opioid rescue medication. Primary endpoints were pain intensity at rest, during movement, and maximum pain intensity within the first 24 h postoperative. Secondary endpoints were opioid consumption, functional outcome and patient satisfaction with pain management. Results Pain during movement and maximum pain intensity were higher in C1 compared to C2: pain on movement median 1st–3rd quartile: 6 (3.75–8) vs. 5 (3–7), p = 0.023; maximum pain intensity: 7 (5–9) vs. 5 (3–8), p = 0.008. There were no differences in pain intensity at rest or between women and men in either group. The mean opioid consumption in all patients (combined PACU, baseline, and rescue medication; mean ± SD mg ME) was 126.6 ± 51.8 mg oral ME (median 120 (87.47–154.25) mg ME). Total opioid consumption was lower in C1 than C2 (117 ± 46 mg vs 140 ± 56 mg, p = 0.002) due to differences in rescue opioids (C1: 57 ± 37 mg ME, C2: 73 ± 43 mg ME, p = 0.006, Z = −2.730). Basic analgesia opioid use was comparable (C1: 54 ± 31 mg ME, C2: 60 ± 36 mg ME, p = 0.288, Z = −1.063). There were no differences in respect to the addition of non-opioids and reported quality of mobilization, sleep, frequency of nausea and vomiting, or general satisfaction with pain management. Conclusion In this study PCIA provided a better reduction of pain intensity, when compared to a standardized protocol with oral opioid rescue medication. This effect was associated with increased opioid consumption. There were no differences in frequencies of opioid side effects. This study was a retrospective analysis of two cohorts of a major project. As with all retrospective studies, our analysis has several limitations to consider. Data can only represent the observation of clinical practice. It cannot reflect the quality of a statement of a randomized controlled trial. Observational studies do not permit conclusions on causal relationships.
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Affiliation(s)
- J Erlenwein
- Department of Anesthesiology, University Hospital, Georg August University of Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany.
| | - M I Emons
- Department of Anesthesiology, University Hospital, Georg August University of Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - F Petzke
- Department of Anesthesiology, University Hospital, Georg August University of Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - M Quintel
- Department of Anesthesiology, University Hospital, Georg August University of Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - I Staboulidou
- Fetal Medicine Center Hannover, Podbielskistraße 122, 30177, Hannover, Germany
| | - M Przemeck
- Department of Anesthesiology and Intensive Care, Annastift, Hannover, Anna-von-Borries-Straße 1-7, 30625, Hannover, Germany
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Andrews R, Greasley S, Knight S, Sireau S, Jordan A, Bell A, White P. Collaboration for clinical innovation: a nursing and engineering alliance for better patient care. J Res Nurs 2020; 25:291-304. [PMID: 34394638 DOI: 10.1177/1744987120918263] [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] [Indexed: 11/15/2022] Open
Abstract
Background There is significant need and enormous potential for innovation in clinical settings. However, for various reasons, this potential is rarely realised. Aims This paper aims to present a collaborative approach to innovation between clinicians and engineers, using two nursing case studies as examples. Suggestions are offered to improve facilitation of innovation in healthcare settings. Methods An engineering design process was applied to develop novel medical devices in response to unmet clinical needs identified by nurses. This process includes problem exploration, definition of project scope, concept generation, detailed design, manufacture, prototype evaluation and iterative design improvements. Results Two case studies are presented to showcase the results of this multidisciplinary approach to innovation. Both projects resulted in novel medical devices being put into clinical use safely and effectively. Conclusions Collaboration between nurses and engineers facilitates rapid iteration of novel solutions to unmet clinical needs. Both professions have similar approaches to problem-solving, complemented by specialist knowledge in their contrasting areas of expertise, making for a highly capable multidisciplinary team.
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Affiliation(s)
- Rachael Andrews
- Clinical Scientist, Clinical Engineering Innovation, Cambridge University Hospitals NHS Foundation Trust, UK
| | - Sarah Greasley
- Clinical Scientist, Clinical Engineering Innovation, Cambridge University Hospitals NHS Foundation Trust, UK
| | - Sarah Knight
- Clinical Engineer, Clinical Engineering Innovation, Cambridge University Hospitals NHS Foundation Trust, UK
| | - Sonya Sireau
- Clinical Scientist & Head of Section, Clinical Engineering Innovation, Cambridge University Hospitals NHS Foundation Trust, UK
| | - Andrea Jordan
- Lead Clinical Nurse Specialist, Paediatric Surgery, Cambridge University Hospitals NHS Foundation Trust, UK
| | - Andrew Bell
- Charge Nurse, Pain Service, Cambridge University Hospitals NHS Foundation Trust, UK
| | - Paul White
- Consultant Clinical Scientist & Head of Department, Clinical Engineering, Cambridge University Hospitals NHS Foundation Trust, UK
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6
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Lee SH, Baek CW, Kang H, Park YH, Choi GJ, Jung YH, Woo YC. A comparison of 2 intravenous patient-controlled analgesia modes after spinal fusion surgery: Constant-rate background infusion versus variable-rate feedback infusion, a randomized controlled trial. Medicine (Baltimore) 2019; 98:e14753. [PMID: 30855472 PMCID: PMC6417619 DOI: 10.1097/md.0000000000014753] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Conventional intravenous patient-controlled analgesia (PCA), which usually involves constant-rate background infusion plus demand dosing, may cause adverse effects or insufficient analgesia. When variable-rate feedback infusion plus demand dosing mode is used, the infusion rate can be changed according to the patient's needs. METHODS In this prospective randomized double-blind study, 78 adults who were undergoing spinal fusion surgery were randomly allocated to either the constant-rate background infusion plus demand dosing group (group C) or the variable-rate feedback infusion plus demand dosing group (group V). The number of demands, volume delivered, numerical rating scale (NRS) score, adverse effects and the use of rescue analgesics were examined at 30 minutes after the operation in the post-anesthesia care unit, and at 6, 12, 24, and 48 hours. RESULTS The number of demands was significantly lower in group V than in group C at 12-24 hours (4.59 ± 4.31 vs 9.21 ± 6.79 times, P = .001) and over the total period. The volume delivered via PCA was significantly lower in group V than in group C at 12 to 24 hours (13.96 ± 13.45 vs 21.19 ± 8.66 mL, P = .006), 24 to 48 hours (13.39 ± 12.44 vs 33.6 ± 12.49 mL, P = .000), and over the total period. NRS scores, administration of rescue analgesics, and postoperative nausea and vomiting showed no between-group differences. CONCLUSIONS Variable-rate feedback infusion plus the demand dosing mode can control postoperative pain more efficiently, with lower dosages of analgesics, than constant-rate background infusion plus demand dosing in patients who undergo spinal fusion surgery.
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Pitre L, Garbee D, Tipton J, Schiavo J, Pitt A. Effects of preoperative intrathecal morphine on postoperative intravenous morphine dosage: a systematic review protocol. JBI DATABASE OF SYSTEMATIC REVIEWS AND IMPLEMENTATION REPORTS 2018; 16:867-870. [PMID: 29634512 DOI: 10.11124/jbisrir-2016-003209] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
REVIEW QUESTION/OBJECTIVE The purpose of this systematic review is to describe the effect of preoperative intrathecal morphine (ITM) on postoperative intravenous (IV) morphine dosage during the first postoperative day. This systematic review will compare the postoperative IV morphine dosage of patients receiving ITM plus morphine morphine-based patient-controlled analgesia (PCA), to patients receiving PCA morphine without ITM. This will establish the magnitude of the postoperative morphine sparing effect of ITM.This review aims to answer the following specific question: In adult abdominal and thoracic surgery patients undergoing general anesthesia (GA), what is the effect of ITM plus PCA morphine, compared to PCA morphine alone, on total IV morphine dosage (in milligrams) during the first 24 hours after surgery?
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Affiliation(s)
- Luke Pitre
- Louisiana Centre for Promotion of Optimal Health Outcomes: a Joanna Briggs Institute Center of Excellence
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8
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Anderson B. The Use of Remifentanil as the Primary Agent for Analgesia in Parturients. Crit Care Nurs Clin North Am 2017; 29:495-517. [DOI: 10.1016/j.cnc.2017.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Loss-of-function polymorphisms in the organic cation transporter OCT1 are associated with reduced postoperative tramadol consumption. Pain 2017; 157:2467-2475. [PMID: 27541716 DOI: 10.1097/j.pain.0000000000000662] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The organic cation transporter OCT1 (SLC22A1) mediates uptake and metabolism of the active tramadol metabolite (+)O-desmethyltramadol in the liver. In this study, the influence of OCT1 genetic polymorphisms on pharmacokinetics and analgesic efficacy of tramadol in patients recovering from surgery was analyzed in addition to the CYP2D6 genotype. Postoperative patients who received tramadol through patient-controlled analgesia were enrolled. Genotypes resulting in 0, 1, or 2 active OCT1 alleles were determined as well as CYP2D6 genotypes. The primary endpoint was the 24-hour postoperative tramadol consumption in patients with 0 vs at least 1 active OCT1 allele. Secondary endpoint was the OCT1-dependent plasma concentration (areas under the concentration-time curves) of the active tramadol metabolite (+)O-desmethyltramadol. Of 205 patients, 19, 82, and 104 carried 0, 1, and 2 active OCT1 alleles, respectively. Cumulative tramadol consumption through patient-controlled analgesia was lowest in patients with 0 active OCT1 allele compared with the group of patients with 1 or 2 active alleles (343 ± 235 vs 484 ± 276 mg; P = 0.03). Multiple regression revealed that the number of active OCT1 alleles (P = 0.014), CYP2D6 (P = 0.001), pain scores (P < 0.001), and the extent of surgery (0.034) had a significant influence on tramadol consumption. Plasma areas under the concentration-time curves of (+)O-desmethyltramadol were 111.8 (95% confidence interval: 63.4-160.1), 80.2 (65.1-95.3), and 64.5 (51.9-77.2) h·ng·mL in carriers of 0, 1, or 2 active OCT1 alleles (P = 0.03). Loss of OCT1 function resulted in reduced tramadol consumption and increased plasma concentrations of (+)O-desmethyltramadol in patients recovering from surgery. Therefore, analyzing OCT1 next to CYP2D6 genotype might further improve future genotype-dependent dose recommendations for tramadol.
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Kim MH, Shim YH, Kim MS, Shin YS, Lee HJ, Lee JS. The efficacy of elastomeric patient-control module when connected to a balloon pump for postoperative epidural analgesia: A randomized, noninferiority trial. Medicine (Baltimore) 2017; 96:e5828. [PMID: 28079812 PMCID: PMC5266174 DOI: 10.1097/md.0000000000005828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
When considering the principles of a pain control strategy by patients, reliable administration of additional bolus doses is important for providing the adequate analgesia and improving patient satisfaction. We compared the efficacy of elastomeric patient-control module (PCM) with conventional PCM providing epidural analgesia postoperatively.A noninferiority comparison was used. Eighty-six patients scheduled for open upper abdominal surgery were randomized to use either an elastomeric or conventional PCM connected to balloon pump. After successful epidural catheter insertion at T6-8 level, fentanyl (15-20 μg/kg) in 0.3% ropivacaine 100 mL was administered at basal rate 2 mL/h with bolus 2 mL and lock-out time 15 minutes. The primary outcome was the verbal numerical rating score for pain.The 95% confidence intervals for differences in pain scores during the first 48 hours postoperatively were <1, indicating noninferiority of the elastomeric PCM. The duration of pump reservoir exhaustion was shorter for the elastomeric PCM (mean [SD], 33 hours [8 hours] vs 40 hours [8 hours], P = 0.0003). There were no differences in the frequency of PCM use, additional analgesics, or adverse events between groups.The elastomeric PCM was as effective as conventional PCM with and exhibited a similar safety profile.
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Affiliation(s)
- Myung Hwa Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital
| | - Yon Hee Shim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul
| | - Min-Soo Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital
| | - Yang-Sik Shin
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Centre, CHA University, Seongnam, Republic of Korea
| | - Hyun Joo Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital
| | - Jeong Soo Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul
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Messerer B, Grögl G, Stromer W, Jaksch W. [Pediatric perioperative systemic pain therapy: Austrian interdisciplinary recommendations on pediatric perioperative pain management]. Schmerz 2015; 28:43-64. [PMID: 24550026 DOI: 10.1007/s00482-013-1384-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Many analgesics used in adult medicine are not licensed for pediatric use. Licensing limitations do not, however, justify that children are deprived of a sufficient pain therapy particularly in perioperative pain therapy. The treatment is principally oriented to the strength of the pain. Due to the degree of pain caused, intramuscular and subcutaneous injections should be avoided generally. NON-OPIOIDS The basis of systemic pain therapy for children are non-opioids and primarily non-steroidal anti-inflammatory drugs (NSAIDs). They should be used prophylactically. The NSAIDs are clearly more effective than paracetamol for acute posttraumatic and postoperative pain and additionally allow economization of opioids. Severe side effects are rare in children but administration should be carefully considered especially in cases of hepatic and renal dysfunction or coagulation disorders. Paracetamol should only be taken in pregnancy and by children when there are appropriate indications because a possible causal connection with bronchial asthma exists. To ensure a safe dosing the age, body weight, duration of therapy, maximum daily dose and dosing intervals must be taken into account. Dipyrone is used in children for treatment of visceral pain and cholic. According to the current state of knowledge the rare but severe side effect of agranulocytosis does not justify a general rejection for short-term perioperative administration. OPIOIDS In cases of insufficient analgesia with non-opioid analgesics, the complementary use of opioids is also appropriate for children of all age groups. They are the medication of choice for episodes of medium to strong pain and are administered in a titrated form oriented to effectiveness. If severe pain is expected to last for more than 24 h, patient-controlled anesthesia should be implemented but requires a comprehensive surveillance by nursing personnel. KETAMINE Ketamine is used as an adjuvant in postoperative pain therapy and is recommended for use in pediatric sedation and analgosedation.
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Affiliation(s)
- B Messerer
- Universitätsklinik für Anästhesiologie und Intensivmedizin, Medizinische Universität Graz, LKH-Universitätsklinikum Graz, Auenbruggerplatz 29, 8036, Graz, Österreich,
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Fleet J, Belan I, Jones MJ, Ullah S, Cyna AM. A comparison of fentanyl with pethidine for pain relief during childbirth: a randomised controlled trial. BJOG 2015; 122:983-92. [DOI: 10.1111/1471-0528.13249] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2014] [Indexed: 11/26/2022]
Affiliation(s)
- J Fleet
- School of Nursing & Midwifery; Flinders University; Adelaide SA Australia
| | - I Belan
- School of Nursing & Midwifery; Flinders University; Adelaide SA Australia
| | - MJ Jones
- School of Nursing & Midwifery; Flinders University; Adelaide SA Australia
| | - S Ullah
- School of Nursing & Midwifery; Flinders University; Adelaide SA Australia
- Flinders Centre for Epidemiology and Biostatistics; School of Medicine; Flinders University; Adelaide SA Australia
| | - AM Cyna
- Women's & Children's Hospital; North Adelaide SA Australia
- The University of Adelaide; Adelaide SA Australia
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Overcoming barriers to effective pain management: the use of professionally directed small group discussions. Pain Manag Nurs 2014; 16:121-7. [PMID: 25439127 DOI: 10.1016/j.pmn.2014.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 05/12/2014] [Accepted: 05/14/2014] [Indexed: 11/20/2022]
Abstract
Inadequate assessment and management of pain among critical care patients can lead to ineffective care delivery and an increased length of stay. Nurses' lack of knowledge regarding appropriate assessment and treatment, as well as negative biases toward specific patient populations, can lead to poor pain control. Our aim was to evaluate the effectiveness of professionally directed small group discussions on critical care nurses' knowledge and biases related to pain management. A quasi-experiment was conducted at a 383-bed Magnet(®) redesignated hospital in the southeastern United States. Critical care nurses (N = 32) participated in the study. A modified Brockopp and Warden Pain Knowledge Questionnaire was administered before and after the small group sessions. These sessions were 45 minutes in length, consisted of two to six nurses per group, and focused on effective pain management strategies. Results indicated that mean knowledge scores differed significantly and in a positive direction after intervention [preintervention mean = 18.28, standard deviation = 2.33; postintervention mean = 22.16, standard deviation = 1.70; t(31) = -8.87, p < .001]. Post-bias scores (amount of time and energy nurses would spend attending to patients' pain) were significantly higher for 6 of 15 patient populations. The strongest bias against treating patients' pain was toward unconscious and mechanically ventilated individuals. After the implementation of professionally directed small group discussions with critical care nurses, knowledge levels related to pain management increased and biases toward specific patient populations decreased.
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Valdez CA, Leif RN, Mayer BP. An efficient, optimized synthesis of fentanyl and related analogs. PLoS One 2014; 9:e108250. [PMID: 25233364 PMCID: PMC4169472 DOI: 10.1371/journal.pone.0108250] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 08/26/2014] [Indexed: 11/18/2022] Open
Abstract
The alternate and optimized syntheses of the parent opioid fentanyl and its analogs are described. The routes presented exhibit high-yielding transformations leading to these powerful analgesics after optimization studies were carried out for each synthetic step. The general three-step strategy produced a panel of four fentanyls in excellent yields (73–78%) along with their more commonly encountered hydrochloride and citric acid salts. The following strategy offers the opportunity for the gram-scale, efficient production of this interesting class of opioid alkaloids.
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Affiliation(s)
- Carlos A. Valdez
- Physical and Life Sciences Directorate, Lawrence Livermore National Laboratory, Livermore, California, United States of America
- Forensic Science Center, Lawrence Livermore National Laboratory, Livermore, California, United States of America
| | - Roald N. Leif
- Physical and Life Sciences Directorate, Lawrence Livermore National Laboratory, Livermore, California, United States of America
- Forensic Science Center, Lawrence Livermore National Laboratory, Livermore, California, United States of America
| | - Brian P. Mayer
- Physical and Life Sciences Directorate, Lawrence Livermore National Laboratory, Livermore, California, United States of America
- Forensic Science Center, Lawrence Livermore National Laboratory, Livermore, California, United States of America
- * E-mail:
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Bech RD, Ovesen O, Lindholm P, Overgaard S. Local anesthetic wound infiltration for pain management after periacetabular osteotomy. A randomized, placebo-controlled, double-blind clinical trial with 53 patients. Acta Orthop 2014; 85:141-6. [PMID: 24650022 PMCID: PMC3967255 DOI: 10.3109/17453674.2014.899840] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE To our knowledge, there is no evidence to support the use of local infiltration analgesia (LIA) for postoperative pain relief after periacetabular osteotomy (PAO). We investigated the effect of wound infiltration with a long-acting local anesthetic (ropivacaine) for postoperative analgesia after PAO. PATIENTS AND METHODS We performed a randomized, double-blind, placebo-controlled trial (ClinicalTrials.gov: NCT00815503) in 53 patients undergoing PAO to evaluate the effect of local anesthetic infiltration on postoperative pain and on postoperative opioid consumption. All subjects received intraoperative infiltration followed by 5 postoperative injections in 10-hour intervals through a multi-holed catheter placed at the surgical site. 26 patients received ropivacaine and 27 received saline. The intervention period was 2 days and the observational period was 4 days. All subjects received patient-controlled opioid analgesia without any restrictions on the total daily dose. Pain was assessed at specific postoperative time points and the daily opioid usage was registered. RESULTS Infiltration with 75 mL (150 mg) of ropivacaine did not reduce postoperative pain or opioid requirements during the first 4 days. INTERPRETATION The clinical importance of ropivacaine as single component in postoperative treatment of pain is questionable, and we are planning further studies to explore the potential of LIA in larger volume-and also a multimodal regimen-to treat pain in this category of patients.
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Affiliation(s)
- Rune D Bech
- Department of Orthopaedics and Traumatology, Odense University Hospital and University of Southern Denmark, Odense, Denmark.
| | - Ole Ovesen
- Department of Orthopaedics and Traumatology, Odense University Hospital and University of Southern Denmark, Odense, Denmark.
| | - Peter Lindholm
- Department of Anaesthesiology and Intensive Care, Odense University Hospital and University of Southern Denmark, Odense, Denmark.
| | - Søren Overgaard
- Department of Orthopaedics and Traumatology, Odense University Hospital and University of Southern Denmark, Odense, Denmark.
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Indermun S, Choonara YE, Kumar P, Du Toit LC, Modi G, Luttge R, Pillay V. Patient-Controlled Analgesia: Therapeutic Interventions Using Transdermal Electro-Activated and Electro-Modulated Drug Delivery. J Pharm Sci 2014; 103:353-66. [DOI: 10.1002/jps.23829] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 11/28/2013] [Accepted: 12/03/2013] [Indexed: 01/14/2023]
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Yi Y, Kang S, Hwang B. Drug overdose due to malfunction of a patient-controlled analgesia machine -A case report-. Korean J Anesthesiol 2013; 64:272-5. [PMID: 23560197 PMCID: PMC3611081 DOI: 10.4097/kjae.2013.64.3.272] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Revised: 04/20/2012] [Accepted: 05/23/2012] [Indexed: 11/10/2022] Open
Abstract
Patient-controlled analgesia (PCA) provides excellent pain control and high stability, thereby minimizing the incidence of adverse effects. However, one of our patients experienced respiratory depression and hypotension within 30 minutes of initiation of PCA therapy. We discovered that machine malfunction caused continuous activation of the PCA button, resulting in a drug overdose. The PCA machine was sent to the manufacturer, who found an electrical short in the PCA button. All PCA units of the same make and model were immediately removed from hospitals and replaced with redesigned units without defects in the PCA button. We have used the improved machines without any problems. The purpose of this report is to raise awareness of this type of malfunction in PCA units in order to help prevent adverse events in the future.
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Affiliation(s)
- Yuri Yi
- Department of Anesthesiology and Pain Medicine, Institute of Medical Sciences, Kangwon National University Hospital, School of Medicine, Kangwon National University, Chuncheon, Korea
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An audit of postoperative intravenous patient-controlled analgesia with morphine: Evolution over the last decade. Eur J Pain 2012; 13:464-71. [DOI: 10.1016/j.ejpain.2008.05.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2007] [Revised: 04/24/2008] [Accepted: 05/21/2008] [Indexed: 11/20/2022]
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Schiessl C, Schestag I, Sittl R, Drake R, Zernikow B. Rhythmic pattern of PCA opioid demand in adults with cancer pain. Eur J Pain 2012; 14:372-9. [DOI: 10.1016/j.ejpain.2009.06.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2009] [Revised: 06/23/2009] [Accepted: 06/30/2009] [Indexed: 10/20/2022]
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Ismail S, Afshan G, Monem A, Ahmed A. Postoperative Analgesia Following Caesarean Section: Intravenous Patient Controlled Analgesia Versus Conventional Continuous Infusion. ACTA ACUST UNITED AC 2012. [DOI: 10.4236/ojanes.2012.24028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Esophageal cancer, although considered uncommon in the United States, continues to exhibit increased incidence. Esophageal cancer now ranks seventh among cancers in mortality for men in the United States. Even as treatment continues to advance, the mortality rate remains high, with a 5-year survival rate less than 35%. Esophageal cancer typically is discovered in advanced stages, which reduces the treatment options. When disease is locally advanced, esophagectomy remains the standard for treatment. Surgery remains challenging and complicated. Multiple surgical approaches are available, with the choice determined by tumor location and stage of disease. Recovery is often fraught with complications-both physical and emotional. Nursing care revolves around complex care managing multiple body systems and providing effective education and emotional support for both patients and patients' families. Even after recovery, local recurrence and distant metastases are common. Early diagnosis, surgical advancement, and improvements in postoperative care continue to improve outcomes.
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Organizational Factors Associated With Decreased Mortality Among Veterans Affairs Patients With an ICU Stay. Comput Inform Nurs 2011; 29:496-501. [DOI: 10.1097/ncn.0b013e3182148c47] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kim JJ, Ha MH, Jung SH, Song NW. The efficiency of IV PCA with remifentanil and ketorolac after laparoscopic-assisted vaginal hysterectomy. Korean J Anesthesiol 2011; 61:42-9. [PMID: 21860750 PMCID: PMC3155136 DOI: 10.4097/kjae.2011.61.1.42] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Revised: 01/04/2011] [Accepted: 01/05/2011] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND This randomized, double-blinded clinical study was designed to evaluate the efficiency and safety of remifentanil with ketorolac for IV PCA after laparoscopic-assisted vaginal hysterectomy. METHODS Eighty patients were randomly allocated into four groups. Group R received IV PCA using only remifentanil at a basal rate of 0.025 µg/kg/min and a bolus of 0.375 µg/kg. Group RK1 received IV PCA using remifentanil at a basal rate of 0.015 µg/kg/min and a bolus of 0.225 µg/kg. Group RK2 received IV PCA using remifentanil at a basal rate of 0.0075 µg/kg/min and a bolus of 0.1125 µg/kg. Group F received IV PCA using fentanyl at a basal rate of 0.3 µg/kg/h and a bolus of 0.075 µg/kg. In addition, ketorolac at a basal rate of 0.04 mg/kg/h and a bolus of 0.01 mg/kg was added to Group RK1, RK2, and F. All PCA conditions had a lock out period of 15 minutes. Pulse rate, systolic and diastolic BP, sedation score, visual analogue scale (VAS), and PONV score were recorded at 1, 3, 6, 12, and 24 hours after the operation. Total opioid use and the patients' number for rescue analgesic drug were also collected. RESULTS The groups did not differ in PONV score and hemodynamic changes. The VAS in Group RK2 was high compared with the other groups. In addition, the sedation score was high in Group R. CONCLUSIONS The additional ketorolac administration in remifentanil IV PCA had remifentanil sparing effects and reduced sedation among the side effects. Further studies will be needed to evaluate the precise and adequate dosage of ketorolac.
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Affiliation(s)
- Jung-Jong Kim
- Department of Anesthesiology and Pain Medicine, Maryknoll Hospital Busan, Busan, Korea
| | - Myung-Hwa Ha
- Department of Anesthesiology and Pain Medicine, Maryknoll Hospital Busan, Busan, Korea
| | - Sang-Ho Jung
- Department of Anesthesiology and Pain Medicine, Maryknoll Hospital Busan, Busan, Korea
| | - Nam-Won Song
- Department of Anesthesiology and Pain Medicine, Maryknoll Hospital Busan, Busan, Korea
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Mean analgesic consumption is inappropriate for testing analgesic efficacy in post-operative pain: analysis and alternative suggestion. Eur J Anaesthesiol 2011; 28:427-32. [DOI: 10.1097/eja.0b013e328343c569] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Intravenous patient-controlled analgesia and management of pain in post-surgical elderly with cancer. Surg Oncol 2010; 19:173-7. [DOI: 10.1016/j.suronc.2009.11.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Patient-controlled oral analgesia for postoperative pain management following total knee replacement. Pain Res Manag 2010; 15:11-6. [PMID: 20195553 DOI: 10.1155/2010/528092] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To investigate whether patient-controlled oral analgesia (PCOA) used by individuals receiving a total knee replacement could reduce pain, increase patient satisfaction, reduce opioid use and/or reduce opioid side effects when compared with traditional nurse (RN)-administered oral analgesia. METHODS Patients who underwent an elective total knee replacement at a quaternary care centre (Toronto Western Hospital, Toronto, Ontario) were randomly assigned to either PCOA or RN-administered short-acting oral opioids on postoperative day 2. Subjects in the RN group called the RN to receive their prescribed short-acting opioid. Subjects in the PCOA group kept a single dose of their prescribed oral opioid at their bedside and took this dose when they felt they needed it, to a maximum of one dose every 2 h. Study outcomes, collected on postoperative day 2, included pain (measured by the Brief Pain Inventory - Short Form), patient satisfaction (measured by the Pain Outcome Questionnaire Satisfaction subscale - component II), opioid use (oral morphine equivalents), opioid side effects (nausea, pruritus and/or constipation) and knee measures (maximum passive knee flexion and pain at maximum passive knee flexion, performed on the operative knee). RESULTS Study outcomes were analyzed twice. First, for a subset of 73 subjects who remained in their randomly assigned group (PCOA group, n=36; RN group, n=37), randomized analyses were performed. Second, for the larger sample of 88 subjects who were categorized by their actual method of receiving oral opioids (PCOA group, n=41; RN group, n=47), as-treated analyses were performed. There were no differences in study outcomes between the PCOA and RN groups in either analysis. CONCLUSION PCOA was not superior to RN administration on study outcomes. However, PCOA did not increase opioid use or pain. PCOA remains an important element in the patient-centred care facility.
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Harding G, Schein JR, Nelson WW, Vallow S, Olson WH, Hewitt DJ, Polomano RC. Development and validation of a new instrument to evaluate the ease of use of patient-controlled analgesic modalities for postoperative patients. J Med Econ 2010; 13:42-54. [PMID: 20001659 DOI: 10.3111/13696990903484637] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To describe the development and psychometric evaluation of a questionnaire assessing the ease of use that patients associate with patient-controlled analgesia (PCA) modalities. METHODS Qualitative interviews were conducted with patients who had experience with intravenous (IV) PCA for postoperative pain management to generate items relevant to the ease of using PCA modalities. The content validity of the resulting questionnaire was examined through follow-up patient interviews, and an expert panel reviewed the questionnaire. Cognitive debriefing interviews were conducted with patients to determine the clarity and content of the instructions, items, and response scales, and the ease of completing the instrument. Psychometric evaluation was performed with patients who had undergone surgery and received IV PCA for postoperative pain management. Item and scale quality and the internal consistency reliability of the questionnaire were assessed. Construct validity was evaluated by examining the relationship between subscales of the questionnaire with patient-reported outcome measures. Known-groups validity was determined by assessing the instrument's ability to differentiate between patients with versus without an IV PCA problem. A potential limitation of this study was the exclusive sampling of patients who had experience with IV PCA. RESULTS The Patient Ease-of-Care (EOC) Questionnaire included 23 items in the following subscales: Confidence with Device, Comfort with Device, Movement, Dosing Confidence, Pain Control, Knowledge/Understanding, and Satisfaction. Coefficient alpha reliability estimates were ≥ 0.66 for Overall EOC (includes all subscales except Satisfaction) and all EOC subscales. Construct validity was supported by the moderate relationship between the Pain Control subscale and measures of pain severity and pain interference; additional evidence of construct validity was provided by correlations of the Confidence with Device subscale, the Satisfaction subscale, and Overall EOC with measures of pain severity, pain interference, and satisfaction. Significant mean score differences were reported between participants with and without IV PCA problems for Overall EOC and for the Comfort with Device, Confidence with Device, Movement, Pain Control, and Satisfaction subscales indicating known-groups validity. CONCLUSIONS Results provide evidence for the reliability and validity of the Patient EOC Questionnaire as a measure of the ease of use that patients associate with PCA systems and may be useful for evaluating emerging PCA modalities.
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Affiliation(s)
- Gale Harding
- Center for Health Outcomes Research, United BioSource Corporation, 7101 Wisconsin Avenue, Bethesda, MD 20814, USA.
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Pennington P, Caminiti S, Schein JR, Hewitt DJ, Nelson WW. Patients' Assessment of the Convenience of Fentanyl HCl Iontophoretic Transdermal System (ITS) Versus Morphine Intravenous Patient-Controlled Analgesia (IV PCA) in the Management of Postoperative Pain After Major Surgery. Pain Manag Nurs 2009; 10:124-33. [DOI: 10.1016/j.pmn.2007.09.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2007] [Revised: 08/06/2007] [Accepted: 09/25/2007] [Indexed: 11/26/2022]
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Abstract
The accurate assessment and effective treatment of acute pain in children in the hospital setting is a high priority. During the past 2 to 3 decades, pediatric pain management has gained tremendous knowledge with respect to the understanding of developmental neurobiology, developmental pharmacology the use of analgesics in children, the use of regional techniques in children, and of the psychological needs of children in pain. A wide range of medications is available to treat a variety of pain types. This article provides an overview of the most common analgesic medications and techniques used to treat acute pain in children.
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Affiliation(s)
- F Wickham Kraemer
- University of Pennsylvania, School of Medicine, Department of Anesthesiology and Critical Care, Philadelphia, PA 19104, USA.
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Schiessl C, Bidmon J, Sittl R, Griessinger N, Schüttler J. [Patient-controlled analgesia (PCA) in outpatients with cancer pain. Analysis of 1,692 treatment days]. Schmerz 2008; 21:35-8, 40-2. [PMID: 16955293 DOI: 10.1007/s00482-006-0500-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION In the home-care setting, cancer pain patients in need of parenteral analgesia have to be switched to patient-controlled analgesia using portable pumps. But there is a paucity on data on the logistic requirements or the success rate of such a cost-intensive therapy performed by specialized home-care services. METHODS In a retrospective study we analyzed data on care intensity, logistics and outcome of 46 consecutive palliative cancer patients with patient-controlled analgesia (PCA) in a home-care setting. RESULTS On days 1, 2, and 3 of PCA the switch to parenteral analgesia resulted in a significant increase of the median daily opioid dose in comparison to the dose just prior to PCA. Concurrently, pain scores were significantly reduced. The median duration of PCA was 25 days (range 2-189 days). On average, each patient was seen by the home-care team every 7.4 days. The median duration of the home visits was 60 min (range, 10-190 min). Of the visits 20% were unscheduled, most of these visits being due to problems regarding analgesia. Most patients died at home. Insufficient analgesia required prefinal hospitalization in only a single case. CONCLUSION If the indications are correct, intravenous PCA for palliative cancer pain patients results in higher opioid consumption and better pain control. Home-care PCA requires a lot of human and financial resources, but pain-related hospitalization can be prevented.
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Affiliation(s)
- C Schiessl
- Schmerzambulanz der Anästhesiologischen Klinik, Universitätsklinikum, Erlangen.
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Zirkadianer Rhythmus des PCA-gesteuerten Opioidverbrauchs bei Kindern mit chemotherapiebedingter Mukositis. Schmerz 2008; 23:7-19. [DOI: 10.1007/s00482-008-0734-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Gagliese L, Gauthier LR, Macpherson AK, Jovellanos M, Chan VWS. Correlates of postoperative pain and intravenous patient-controlled analgesia use in younger and older surgical patients. PAIN MEDICINE 2008; 9:299-314. [PMID: 18366510 DOI: 10.1111/j.1526-4637.2008.00426.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Age-related patterns in postoperative pain are unclear with reports of no age differences and less pain with age. The objective of this study was to identify correlates of pain and intravenous patient-controlled analgesia (i.v. PCA) morphine use in younger and older patients. DESIGN 24 hours after surgery, patients completed measures of pain intensity and pain qualities. Surgical factors, i.v. PCA morphine intake, anticholinergic load, polypharmacy, physical status, previous chronic and postoperative pain, and PCA experience were measured. SETTING Two academic general hospitals. PATIENTS. Two hundred forty-six general surgery patients ranging in age from 18 to 82 years old. RESULTS In older patients, higher pain scores were associated with female gender and previous experience of postoperative PCA. In younger patients, higher pain scores were associated with female gender, previous surgery without PCA, and greater morphine intake. Lower pain was associated with being male, and no previous surgical experience in older patients, and lower morphine intake in younger patients. Morphine intake was higher in patients who were younger, had better physical status, higher anticholinergic load, and experience with PCA. Among younger patients, increased morphine use also was associated with surgical procedure and duration. Higher pain scores were more strongly associated with morphine use among younger than older patients. CONCLUSIONS The correlates of postoperative pain and morphine use may differ with age, and the same factor may have different effects across age groups. Research is needed into the mechanisms of these age-specific profiles.
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Affiliation(s)
- Lucia Gagliese
- School of Kinesiology and Health Science, York University, Ontario, Canada.
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Schiessl C, Gravou C, Zernikow B, Sittl R, Griessinger N. Use of patient-controlled analgesia for pain control in dying children. Support Care Cancer 2008; 16:531-6. [PMID: 18274785 DOI: 10.1007/s00520-008-0408-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2007] [Accepted: 01/17/2008] [Indexed: 11/27/2022]
Abstract
BACKGROUND In the last week of life, the daily opioid dose in children is highly variable, making the use of patient-controlled analgesia (PCA) a useful therapy option. Scientific data on the use of PCA in paediatric palliative care are rare. MATERIALS AND METHODS Retrospective chart review over a 7-year period (Jan 1998-Jan 2005) of PCA treated children dying of cancer was used. RESULTS Eight children were on PCA for a median duration of 9 days (range, 1 to 50). The daily median intravenous morphine equivalent dose referenced to body weight increased significantly when PCA was initiated and during the last week of life. In the last week of life, the median daily number of delivered and undelivered bolus requests ranged from 7.5-21 and 0-4.5, respectively. To meet children's individual needs, 39 PCA parametre changes on 22 opportunities were performed. Median daily mean pain scores remained low (range, 0-3; numerical rating scale 0-10) throughout the period. CONCLUSION PCA proved an ideal, dependable and feasible mode of analgesic administration for the individual titration of dose to effect.
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Affiliation(s)
- Christine Schiessl
- Department of Palliative Medicine, University Hospital Cologne, Kerpener Strasse 62, 50924, Cologne, Germany.
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Locked out and still knocking: predictors of excessive demands for postoperative intravenous patient-controlled analgesia. Can J Anaesth 2008; 55:88-99. [DOI: 10.1007/bf03016320] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Postoperative continuous paravertebral anesthetic infusion for pain control in lumbar spinal fusion surgery. Spine (Phila Pa 1976) 2008; 33:210-8. [PMID: 18197109 DOI: 10.1097/brs.0b013e318160447a] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective, case-control study was conducted to analyze postoperative outcomes in patients who received local anesthetic infusion pumps after lumbar spinal fusion procedures. Data were collected prospectively via nursing protocol and third party assessment, and analyzed retrospectively. OBJECTIVE To review the safety and efficacy of continuous infusion of local anesthetic into the subfascial aspects of the wound after lumbar fusion surgery for treatment of postoperative pain, and to determine whether other outcome measures such as postoperative nausea and vomiting, ambulation and length of hospitalization were affected by the presence of the device. SUMMARY OF BACKGROUND DATA Patients who undergo lumbar spine fusion procedures frequently experience significant, debilitating pain related to their surgery. This pain may delay postoperative mobilization, increase length of hospitalization, and require prolonged use of high doses of narcotics. Use of a local anesthetic continuous-infusion pump after surgery may lead to improvements in these outcome variables. METHODS After posterior lumbar spine fusion procedures, 26 consecutive patients received the ON-Q PainBuster, which infused 0.5% marcaine via an elastomeric pump into the subfascial aspects of the wound. Retrospective analysis compared each of these patients with a case-matched control patient. Data included pain scores and opiate use during the first 5 postoperative days (PODs), length of hospital stay, and complications. Variables such as age, American Society of Anesthesiologists (ASA) physical status, and surgical procedure were similar between matched cases. One patient was excluded because of active heroine abuse. RESULTS Patients with the ON-Q PainBuster used 41.2% less narcotics on POD 1, 50.1% less on day 2, and 47.1% less on day 3 compared with the control patients. Differences in opiate usage were not statistically significant on POD 4 (45.5% less) and 5 (50.3% less). A lower average pain score was observed among patients with the ON-Q PainBuster on each POD: 39.1% less pain on POD 1, 34.0% on day 2, 45.1% on day 3, 29.5% on day 4, and 43.6% on day 5. No differences were observed in length of hospital stay or complication rate. CONCLUSION Patients who received the ON-Q PainBuster used less narcotic medications than case-matched patients during the first 3 PODs, and reported lower pain scores during the first 5 PODs. No complications attributable to the device were noted. These results suggest that continuous infusion of local anesthetic into the wound during the immediate postoperative period is a safe and effective technique that results in lower pain scores and narcotic use. Further data may reveal additional benefits such as lower incidence of nausea and vomiting and decreased times to mobility and functional independence.
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Chiaretti A, Genovese O, Antonelli A, Tortorolo L, Ruggiero A, Focarelli B, Di Rocco C. Patient-controlled analgesia with fentanil and midazolam in children with postoperative neurosurgical pain. Childs Nerv Syst 2008; 24:119-24. [PMID: 17639417 DOI: 10.1007/s00381-007-0429-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Pain is the most common discomfort experienced by children undergoing major operations. It is most often not adequately treated because of inexperience and unfounded fears related to the use of opioid drugs. In adults, patient-controlled analgesia (PCA) is widely administered, while in children, its use with opioid drugs is still under evaluation for safety and efficacy. OBJECTIVES The objective of the study is to evaluate the safety and efficacy of an opioid drug (fentanil) administered by PCA associated with a sedative-adjuvant drug (midazolam) administered by continuous infusion in children having undergone major neurosurgical procedures. MATERIALS AND METHODS Sixteen children with moderate to severe postoperative pain were treated with fentanil by PCA (booster doses of 1 microg/kg) plus continuous infusion of midazolam (2 microg/kg per min) by an intravenous route. To evaluate safety and efficacy of this analgesic protocol, different subjective and objective parameters were monitored at 4-h intervals. In addition, patients' satisfaction was assessed by a questionnaire at the end of the treatment. MAIN RESULTS All children experienced a good degree of analgesia and did not require any other analgesic drug during the treatment. Both subjective and objective parameters improved after starting pain-relieving treatment, and no major side effects occurred. The analysis of the answers of the questionnaire administered to the children showed a high grade of satisfaction. CONCLUSIONS PCA with fentanil plus continuous infusion of midazolam is a safe and efficacious method for analgesia in children with moderate to severe postoperative neurosurgical pain. The association of midazolam to fentanil also contributes to control anxiety and stress in this subset of patients and does not show any important side effects.
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Affiliation(s)
- Antonio Chiaretti
- Pediatric Intensive Care Unit, A. Gemelli Hospital, Catholic University of Rome, Largo A. Gemelli, 8, 00168, Rome, Italy.
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Abstract
Go beyond the push-button approach to patient-controlled analgesia and learn what it takes to keep him both safe and pain-free.
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Schiessl C, Sittl R, Griessinger N, Lutter N, Schuettler J. Intravenous morphine consumption in outpatients with cancer during their last week of life--an analysis based on patient-controlled analgesia data. Support Care Cancer 2007; 16:917-23. [PMID: 17960428 DOI: 10.1007/s00520-007-0352-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2007] [Accepted: 10/02/2007] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Studies on opioid use in terminally ill cancer patients have shown a prefinal dose increase in the majority of patients. Mostly oral opioids were used. Due to the pharmacokinetic properties of opioids, it is rather difficult to get a reliable estimate of the true opioid need from those results. MATERIALS AND METHODS Retrospectively, we analyzed opioid use during the last week of life of 30 consecutive outpatients with cancer on intravenous (i.v.) morphine patient-controlled analgesia (PCA). A dose increase (decrease) was defined as an increase (decrease) of the patient's individual daily dose by at least 30% with respect to their prior daily dose. We also analyzed circadian variations in morphine use. RESULTS Thirty patients fulfilled the primary study inclusion criteria. Fulfilling the exclusion criteria, seven patients had to be excluded from analysis (n = 3, on PCA for less than 7 days; n = 4, PCA was finished before death). Twenty-three patients with a total of 161 treatment days were analyzed. The patients' median age was 57 years (range, 4 to 72). The median duration of intravenous morphine PCA was 19 days (range, 8 to 58). The median daily intravenous morphine dose during the last week of life was 96 to 115 mg, without significant change over time/from day to day (Friedman test). On 144/161 days (89.2%), morphine dose remained stable. On 9 treatment days (5.6%), the dose increased, and on 8 days (5.0%), it decreased. In three patients, only dose increases, and in four patients, only dose decreases were observed. In four patients, both dose increases and decreases were observed. Twelve patients showed no change in daily morphine dose. Opioid use lacked a diurnal pattern. CONCLUSION During their end-of-life phase, cancer patients on i.v. morphine PCA showed a stable daily opioid need.
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Affiliation(s)
- Christine Schiessl
- Department of Anesthesiology, University Hospital Erlangen, Erlangen, Germany.
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Pogatzki-Zahn EM, Zahn PK. Preface. Best Pract Res Clin Anaesthesiol 2007. [DOI: 10.1016/j.bpa.2006.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ruggiero A, Barone G, Liotti L, Chiaretti A, Lazzareschi I, Riccardi R. Safety and efficacy of fentanyl administered by patient controlled analgesia in children with cancer pain. Support Care Cancer 2006; 15:569-73. [PMID: 17146653 DOI: 10.1007/s00520-006-0193-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2006] [Accepted: 11/08/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Pain is the most common discomfort experienced by children with cancer and occurs in almost 89% of patients in an advanced stage of the disease. It is most often not adequately treated because of inexperience and unfounded fears of analgesic treatment. In adults, patient controlled analgesia (PCA) is widely administered, while in children with moderate to severe cancer pain its use is still under evaluation for safety and efficacy. GOALS OF WORK To evaluate the efficacy and safety of fentanyl administered by PCA in children with cancer pain. MATERIALS AND METHODS Eighteen children (range 6 to 15 years) with moderate to severe pain were enrolled and treated with fentanyl by PCA plus background infusion (BI) (BI of 1 microg/kg/h with booster doses of 1 microg/kg by intravenous route). To evaluate efficacy and safety of the analgesic treatment, different subjective and objective parameters were monitored at 4-h intervals. In addition, patients' satisfaction was assessed by a questionnaire at the end of the treatment. MAIN RESULTS All children experienced a good degree of analgesia and did not require any other analgesic drug during the treatment. Both subjective and objective parameters improved after starting pain-relieving treatment and no major side effects occurred. The questionnaire administered to the children showed a high grade of satisfaction. CONCLUSIONS PCA plus BI with fentanyl administered by intravenous route is a safe and efficacious method for analgesia in children with moderate to severe cancer pain. Our policy of fentanyl-treatment did not show any major side effects.
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Affiliation(s)
- A Ruggiero
- Division of Paediatric Oncology, Department of Paediatric Sciences, A Gemelli Hospital, Catholic University, Largo A Gemelli 8, Rome, Italy.
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Abstract
This article is the second in a two-part series which explores pain and its management from a physiological perspective. Nurses play an important role in assessing and managing pain. Effective pain management by nurses requires them to have an understanding of the biological basis of the pain interventions which may be used to control pain. This article emphasizes the importance of pain assessment as a precursor for effective pain management and explores the biological basis of pain interventions which contribute to pain control. The role of non-pharmacological approaches in alleviating pain and their actions which contribute to pain relief are explored. The three main types of pharmaceutical agents used, non-opioids, opioids and adjuvant drugs, are introduced and their mechanisms of actions discussed.
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Affiliation(s)
- Helen Godfrey
- Faculty of Health and Social Care, University of the West of England, Bristol, UK
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