Management of postoperative pain: influence of anesthetic and analgesic choice

Trauma and inflammation modulate lymphocyte localization in vivo: quantitation of tissue entry and retention using indium-111-labeled lymphocytes

OBJECTIVE

Determine the in vivo localization pattern of indium-111-labeled lymphocytes after a standardized extremity injury or standardized laparotomy and after sterile inflammation of the central nervous system.

DESIGN

Prospective animal study with concurrent controls.

SETTING

Animal research laboratory.

SUBJECTS

Male Lewis rats weighing 150-175 g.

INTERVENTIONS

Indium-111-labeled splenic lymphocytes were injected into animals after a standardized hind limb trauma or laparotomy and after induction of sterile central nervous system inflammation.

MEASUREMENTS AND MAIN RESULTS

Lymphoid and non-lymphoid organs were removed at fixed intervals after lymphocyte injection and the proportion of injected lymphocytes/gram of tissue was determined using a quantitative radionuclide calculation. Results from treated animals were compared with results from untreated control animals. Muscle injury caused early localization of lymphocytes to injured hind limbs, liver, and spleen compared with controls, whereas laparotomy decreased lymphocyte localization in the thymus and colon. Encephalitis increased localization to the central nervous system with no effect on other tissues.

CONCLUSIONS

These results identify a sensitive method to track in vivo leukocyte localization and specifically demonstrate that lymphocyte localization is altered in both traumatic and nontraumatic models of inflammation.

Patients' evaluation of pain and nurses' management of analgesics after surgery. The effect of a study day on the subject of pain for nurses working at the thorax surgery department

The effect of a study day on the subject of pain for nurses working at the thorax surgery department The aims of this investigation were: to describe patients' evaluation of pain and the treatment of pain after thorax surgery via sternotomy; to repeat the evaluation with another group of patients following a study day for nurses, featuring pain and pain treatment; and to examine whether the study day influenced the nurses in their treatment of pain. The investigation included daily evaluation of pain using a visual analogue scale (VAS), and an interview with the patients before discharge, where they were asked to review their experience of pain and its treatment. The nurses on the thorax surgery ward and on the intensive care unit (ICU) completed a questionnaire before and after the study day. Finally, a retrospective study of the case notes of the patients taking part was carried out. The results of the investigation showed a low assessment of pain by most patients during the daily evaluation. Asked to recall their pain when interviewed, the rating was higher. A small group of patients had more evident pain than others. When administering opiates the ICU nurses often chose a lower dose than the standing order prescribed. After the study day the nurses gave larger doses of intravenous opioids and the patients experienced less pain.

The management of postsurgical pain in the elderly population

It is likely that the trend towards ever more aggressive surgery in elderly and possibly frail patients will continue, with the lifting of traditional age limits. Recent evidence has show that surgical trauma induces processes of nervous system sensitisation that contributes to and enhances postoperative pain and leads to chronic pain. This knowledge provides a rational basis for pro-active, pre-operative and post-operative analgesic strategies which can reduce the neuronal barrage associated with tissue damage. As well as a reduction or elimination of post-operative pain, an improvement in physiological variables, such as neuroendocrine stress responses and post-operative pulmonary function can be expected. Complete pain control cannot be achieved with a single agent or technique without significant serious adverse effects, a problem which is compounded in the elderly patient due to a combination of slower drug metabolism, decreased organ function and physiological changes in cardiovascular and respiratory reserves. A balanced analgesic regimen that includes an effective afferent block (regional analgesia) is more appropriate. By preventing postoperative pain and its associated neuroendocrine sequelae, major surgical procedures in traditionally unsuitable patients can be seriously considered.

Effect of intraoperative anesthetic events on postoperative patient satisfaction

OBJECTIVE

To assess overall perioperative and anesthetic care-specific patient satisfaction.

DESIGN

We mailed questionnaires postoperatively to three groups of surgical patients (those who underwent anesthesia without complications, those who experienced airway management difficulties, and those who had cardiovascular perturbations) and analyzed the responses.

MATERIAL AND METHODS

All patients 18 to 75 years of age who underwent hospital-based surgical procedures in our acute-care hospitals during the interval from January to September 1993 were eligible for this investigation. We asked a total of 315 patients--105 in each of the three study groups--about their satisfaction with perioperative care. Specific positive or negative comments that the patients returned in their questionnaires were tabulated into the following sub-categories: physician, nurse, technique, time, and institution concerns.

RESULTS

Of the 315 questionnaires sent to patients, 239 (75.9%) were returned. No difference in overall patient satisfaction (defined as very satisfied or a combination of very satisfied and satisfied) was noted among the groups. No patients identified themselves as dissatisfied or very dissatisfied with their overall care, although a small percentage expressed dissatisfaction because of time delays. The specific patient comments suggested that the positive interactions with physicians and nurses outweighed the concerns about time delays.

CONCLUSION

This study showed that intraoperative anesthetic events did not affect patient satisfaction. Interactions with physicians and nurses dominated the decision about patient satisfaction, and time delays were the most frequently cited negative comment.

The antinociceptive effect of S-(+)-ibuprofen in rabbits: epidural versus intravenous administration

This study was designed to determine whether systemic absorption plays any role in the antinociceptive effect of epidural (EP) sodium S(+)-ibuprofen (IB). One week after surgical implantation of EP catheters, six rabbits were given EP injections with either normal saline (NS) 0.4 mL or IB 10 mg in 0.4 mL NS (Group 1) on separate days. Each animal was injected with IB 10 mg intravenously (i.v.) on another day. Six control rabbits (Group 2) had neither surgery nor any injection. Analgesic testing was performed using electric stimulation through two electrocardiogram (ECG) skin electrodes with built-in adhesive, attached to shaved hip areas using 50 V, 1 Hz, 3 ms, before and 0.5,1,2 and 3 h after injection in Group 1, and in similar times in controls. The 95% confidence intervals (CI) of the mean difference between baseline and maximal nociceptive response latency of all groups were compared using analysis of covariance (ANCOVA) adjusted for baseline measurements. This comparison covered all possible pairs among all groups. Significant antinociceptive effects were seen after EP IB but not after control or i.v. IB. Neither motor dysfunction nor evidence of systemic toxicity or neurotoxicity was observed in any animal.