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Balyan R, Dong M, Pilipenko V, Geisler K, Vinks AA, Chidambaran V. Hydromorphone population pharmacokinetics in pediatric surgical patients. Paediatr Anaesth 2020; 30:1091-1101. [PMID: 32702184 DOI: 10.1111/pan.13975] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 07/09/2020] [Accepted: 07/13/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hydromorphone is an opioid agonist used for pediatric analgesia. Due to lack of data, pediatric dosing (based on adult pharmacokinetic models) is not optimal. AIM This study characterizes hydromorphone population pharmacokinetics in pediatric surgical patients. METHODS In this prospective observational study, 34 children (4-18 years, bodyweight 23-89.6 kg) received multiple intravenous hydromorphone boluses followed by postoperative hydromorphone patient-controlled analgesia. Arterial blood samples were collected before and at 3, 10, 30, and 90 (and few samples at 1350) minutes after the first dose. Hydromorphone concentrations were measured by validated LC-MS/MS assay. Nonlinear mixed-effects modeling was used for pharmacokinetic model development. The final population pharmacokinetic model was evaluated by visual predictive check and bootstrap analysis. Monte Carlo simulations based on the final pharmacokinetic model determined optimal patient-controlled analgesia parameters to achieve a target of 20 ng/mL (as the median effective analgesic concentration), using minimum effective analgesic concentration of 4 ng/mL as a proxy for patient-controlled analgesia dose demand, and not exceeding the defined safe upper threshold of 40 ng/mL. RESULTS Hydromorphone pharmacokinetic profiles were adequately described by a two-compartmental model with first-order elimination. Bodyweight was found to be a significant covariate for hydromorphone clearance. Allometrically scaledpharmacokinetic parameter estimates (per 70 kg), systemic clearance (0.748 L/min), volume of distribution (33 L), peripheral clearance (1.57 L/min), and peripheral volume of distribution (146 L) were similar to reported adult parameter estimates. Sex, race, age, and type of surgery were not identified as significant covariates. To identify optimal patient-controlled analgesia dosing parameters, we simulated several initial loading doses, demand doses, and lockout intervals. Our simulations support an initial patient-controlled analgesia loading dose of 15 µg/kg followed by a demand dose of 6 µg/kg with lockout intervals of 20 minutes. CONCLUSIONS After intravenous hydromorphone, plasma pharmacokinetic profiles in children undergoing different surgeries were well described by a two-compartment population allometric pharmacokinetic model using bodyweight as the size descriptor. Model informed simulations identified patient-controlled analgesia parameters to inform initial settings, with adjustments as needed based on observed individual effects.
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Affiliation(s)
- Rajiv Balyan
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Certara Strategic Consulting, Jenkintown, PA, USA
| | - Min Dong
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Valentina Pilipenko
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Kristie Geisler
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Vidya Chidambaran
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
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Hutchins JL, Leiman D, Minkowitz HS, Jove M, DiDonato KP, Palmer PP. An Open-Label Study of Sufentanil Sublingual Tablet 30 Mcg in Patients with Postoperative Pain. PAIN MEDICINE 2019; 19:2058-2068. [PMID: 29126259 PMCID: PMC6176750 DOI: 10.1093/pm/pnx248] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To evaluate sufentanil sublingual tablet 30 mcg (SST 30 mcg) for postoperative pain in an older patient population with comorbidities. Design Multicenter, open-label, single-arm study. Setting Nine hospitals across the United States. Subjects Adults aged ≥40 years who had undergone a surgical procedure. Methods Patients with a postoperative pain intensity score ≥4 on an 11-point numeric rating scale (NRS) were allowed to enter the study and receive SST 30 mcg as requested for pain (minimum 60-minute redosing interval) over the 12-hour study period. Efficacy was assessed by patient reports of pain intensity on the NRS and a five-point pain relief scale. Safety was monitored throughout the study; plasma sufentanil concentrations were also measured. The primary efficacy endpoint was the time-weighted summed pain intensity difference (SPID) to baseline over 12 hours (SPID12). Results Of the 140 patients enrolled, 69% were American Society of Anesthesiologists Physical Class II or III, 44% had a body mass index (BMI) ≥30 mg/kg2, and 29% had hepatic and/or renal impairment. Average age was 54.7 years (SD = 9.9 years), and average baseline pain intensity was 6.2 (SD = 1.9). The most common surgeries were abdominal (59%) and orthopedic (20%). The mean SPID12 was 36.0 (standard error of the mean = 2.2); mean scores were similar, regardless of age, sex, race, and BMI. From baseline, mean pain intensity decreased significantly starting 30 minutes postdose, and mean pain relief increased significantly starting 15 minutes postdose, remaining relatively stable through 12 hours (P < 0.001 at each time point). Four (3%) patients discontinued due to inadequate analgesia, and 45 (32%) patients had one or more adverse events that were considered possibly or probably related to the study drug. Mean plasma sufentanil concentrations were generally similar regardless of age, sex, BMI, or organ impairment status. Conclusions SST 30 mcg was effective and well tolerated for the management of moderate-to-severe acute postoperative pain.
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Affiliation(s)
- Jacob L Hutchins
- Department of Anesthesiology, University of Minnesota, Minneapolis
| | - David Leiman
- University of Texas at Houston, Houston, Texas.,HD Research Corp., Houston, Texas
| | | | - Maurice Jove
- Joint Solutions Center, Dekalb Medical Center, Decatur, Georgia
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Zhang J, Yue Y, Zhao L. Intravenous hydromorphone after thoracoscopic lobectomy: a double-blind up-and-down sequential allocation trial of effective doses. Anaesthesia 2019; 74:820-821. [PMID: 31063208 DOI: 10.1111/anae.14686] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- J Zhang
- First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Y Yue
- First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - L Zhao
- Henan Children's Hospital, Zhengzhou, China
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Shanthanna H, Paul J, Lovrics P, Devereaux PJ, Bhandari M, Thabane L. Satisfactory Analgesia with Minimal Emesis in Day Surgeries (SAME DayS): a protocol for a randomised controlled trial of morphine versus hydromorphone. BMJ Open 2018; 8:e022504. [PMID: 29934395 PMCID: PMC6020940 DOI: 10.1136/bmjopen-2018-022504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION There has been an exponential increase in the number of ambulatory surgeries (AS). Pain and postoperative nausea vomiting (PONV) affects the recovery, discharge and overall satisfaction of patients having AS. Opioids remain the primary modality for moderate to severe pain. Since there is no perfect opioid, physicians should ideally use the opioid that optimally balances benefits and risks. Present decisions on the choice between morphine (M) and hydromorphone (HM) are based on individual experience and observation. Our primary objective is to compare the proportion of patients having AS achieving satisfactory analgesia without significant PONV when using M compared with HM. Secondarily we will compare the proportion of patients with adverse events, analgesic used, patient satisfaction, time to discharge and postdischarge symptoms. METHODS AND ANALYSIS This is a two-arm, multicentre, parallel group, randomised controlled trial of 400 patients having AS. Eligible patients undergoing AS of the abdominal and pelvic regions with a potential to cause moderate to severe pain will be recruited in the preoperative clinic. Using a computer-generated randomization, with a 1:1 allocation ratio, patients will be randomised to M or HM. Patients, healthcare providers and research personnel will be blinded. Study interventions will be administered in the recovery using equianalgesic doses of M or HM in concealed syringes. Patients will be followed in hospital and up to 3 months. Intention-to-treat approach will be used for analysis. ETHICS AND DISSEMINATION This study has been approved by the Hamilton integrated research ethics board. We plan to publish our trial findings and present our findings at scientific meetings. TRAIL REGISTRATION NUMBER NCT02223377; Pre-results.
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Affiliation(s)
- Harsha Shanthanna
- Department of Anesthesia, St Joseph’s Health Care, McMaster University, Hamilton, Ontario, Canada
| | - James Paul
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Peter Lovrics
- Department of Surgery, Joseph’s Healthcare, McMaster University, Hamilton, Ontario, Canada
| | - P J Devereaux
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mohit Bhandari
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Yang Y, Wu J, Li H, Ye S, Xu X, Cheng L, Zhu L, Peng Z, Feng Z. Prospective investigation of intravenous patient-controlled analgesia with hydromorphone or sufentanil: impact on mood, opioid adverse effects, and recovery. BMC Anesthesiol 2018; 18:37. [PMID: 29636011 PMCID: PMC5894128 DOI: 10.1186/s12871-018-0500-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 03/26/2018] [Indexed: 11/20/2022] Open
Abstract
Background Radical surgery for colorectal cancer, associated with moderate to severe postoperative pain, needs multimodal analgesia with opioid for analgesia. Despite considerable advancements, the psychological implications and other side effects with opioid remain substantially unresolved. This study aimed to investigate the impact on mood, side effects relative to opioid, and recovery of the patients with hydromorphone or sufentanil intravenous patient-controlled analgesia (IV-PCA) in a multimodal perioperative analgesia regimen undergoing radical surgery for colorectal cancer. Methods Eighty patients undergoing elective laparoscopic or open radical surgery for colorectal cancer under general anesthesia were randomized to receive postoperative IV-PCA with either sufentanil (group S) or hydromorphone (group H). All patients received additionally flurbiprofen axetil 50 mg 30 min before the end of surgery and wound infiltration with 10 ml of 0.75% ropivacaine at the end of surgery. The primary endpoint was mood changes at 48 and 96 h after surgery. The secondary endpoints were the incidence of opioid-related adverse effects, recovery results and patient satisfaction after surgery. Results Seventy-two patients completed the study finally. There were no significant differences between the two groups with respect to preoperative parameters, surgical and anesthetic characteristics (P > 0.05). No obvious significant differences were observed in VAS score (at rest and during mobilization) and rescue analgesics use (P > 0.05). Compared with group S, the anger scores in the group H at 48 h and 96 h after surgery were significantly lower (P = 0.012 and 0.005; respectively), but the incidences of pruritus and nausea were higher (P = 0.028 and 0.008; respectively). There were no significant differences in the incidences of vomiting, respiratory depression, dizziness, Ramsay score, and hemodynamic changes between the two groups (P > 0.05). Moreover, there were no significant differences in the time to gastrointestinal recovery, time to drainage tube removal, time to walk, hospital stay after surgery and patient satisfaction between the two groups (P > 0.05). Conclusions Under the similar analgesia effect with different opoiods postoperatively, hydromorphone IV-PCA resulted in an improved mood, however, a higher occurrence of pruritus and nausea while compared to sufentanil IV-PCA in a multimodal perioperative analgesia regimen. Both regimens of opioid with IV-PCA may serve as promising candidates for good postoperative pain management, and provide with similar postoperative recovery for the patients undergoing radical surgery for colorectal cancer. Trial registration This study was registered with the Chinese Clinical Trial Registry on September 20, 2015 (URL: http://www.chictr.org.cn. Registry number: ChiCTR-IPR-15007112).
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Affiliation(s)
- Yanqing Yang
- Department of Anesthesiology & Pain Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qing Chun Road, Hangzhou, Zhejiang, 310003, People's Republic of China.,Department of Anesthesiology, Taizhou Hospital, Linhai, Zhejiang, People's Republic of China
| | - Jianping Wu
- Department of Anesthesiology & Pain Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qing Chun Road, Hangzhou, Zhejiang, 310003, People's Republic of China.,Department of Anesthesiology, The Second Affiliated Hospital of Jiaxing College, Jiaxing, Zhejiang, People's Republic of China
| | - Huiling Li
- Department of Anesthesiology & Pain Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qing Chun Road, Hangzhou, Zhejiang, 310003, People's Republic of China
| | - Sujuan Ye
- Department of Anesthesiology & Pain Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qing Chun Road, Hangzhou, Zhejiang, 310003, People's Republic of China
| | - Xiaoying Xu
- Department of Anesthesiology & Pain Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qing Chun Road, Hangzhou, Zhejiang, 310003, People's Republic of China
| | - Ling Cheng
- Department of Anesthesiology & Pain Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qing Chun Road, Hangzhou, Zhejiang, 310003, People's Republic of China
| | - Lina Zhu
- Department of Anesthesiology & Pain Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qing Chun Road, Hangzhou, Zhejiang, 310003, People's Republic of China
| | - Zhiyou Peng
- Department of Anesthesiology & Pain Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qing Chun Road, Hangzhou, Zhejiang, 310003, People's Republic of China
| | - Zhiying Feng
- Department of Anesthesiology & Pain Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qing Chun Road, Hangzhou, Zhejiang, 310003, People's Republic of China.
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Lee JJ, Kim WY, Um JH, Min TJ. Hydromorphone attenuates intercellular adhesion molecule-1 expressions induced by lipopolysaccharide on HCT-116 human colon cancer cells. Korean J Anesthesiol 2015; 67:S124-6. [PMID: 25598885 PMCID: PMC4295959 DOI: 10.4097/kjae.2014.67.s.s124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Jae Jin Lee
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Woon Young Kim
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Ji Hye Um
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Too Jae Min
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Ansan, Korea
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DiGiusto M, Bhalla T, Martin D, Foerschler D, Jones MJ, Tobias JD. Patient-controlled analgesia in the pediatric population: morphine versus hydromorphone. J Pain Res 2014; 7:471-5. [PMID: 25152630 PMCID: PMC4140230 DOI: 10.2147/jpr.s64497] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective Patient controlled analgesia (PCA) is commonly used to provide analgesia following surgical procedures in the pediatric population. Morphine and hydromorphone remain the most commonly used opioids for PCA. Although both are effective, adverse effects may occur. When these adverse effects are unremitting or severe, opioid rotation may be required. In this study, we retrospectively evaluated PCA use, the adverse effect profile, and the frequency of opioid rotation. Methods This retrospective study was performed at Nationwide Children’s Hospital (Columbus, OH). The hospital’s electronic registry was queried for PCA use delivering either morphine or hydromorphone from January 1, 2008 to December 31, 2010. Results A total of 514 patients were identified, that met study entry criteria. Of the 514 cases, 298 (56.2%) were initially started on morphine and 225 (43.8%) were initially started on hydromorphone. There were a total of 26 (5.1%) opioid changes in the cohort of 514 patients. Of the 26 switches, 23 of 298 (7.7%) were from morphine to hydromorphone, and 3 of 225 (1.3%) were from hydromorphone to morphine (P=0.0008). Of the 17 morphine-to-hydromorphone switches with adverse effects, pruritus (64.7%), and inadequate pain control (47.1%) were the most common side effects. The most common side effect resulting in a hydromorphone-to-morphine switch was nausea (66.7%). Conclusion PCA switches from morphine-to-hydromorphone (88.5%) were more common than vice-versa (11.5%). The most common reasons for morphine-to-hydromorphone switch were pruritus and inadequate pain control. These data suggest that a prospective study is necessary to determine the side effect differences between morphine and hydromorphone in pediatric PCA.
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Affiliation(s)
- Matthew DiGiusto
- The Ohio State School of Medicine, The Ohio State University, Columbus, OH, USA
| | - Tarun Bhalla
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital and the Ohio State University, Columbus, OH, USA
| | - David Martin
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital and the Ohio State University, Columbus, OH, USA
| | - Derek Foerschler
- Department of Anesthesiology, The Ohio State University, Columbus, OH, USA
| | - Megan J Jones
- The Ohio State School of Medicine, The Ohio State University, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital and the Ohio State University, Columbus, OH, USA
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Imhof K, Krall K, Gombotz H. [Life-threatening opioid overdose. Decoding the physician pin code of a patient-controlled anesthesia pump by patients]. Anaesthesist 2013; 61:815-9. [PMID: 22965181 DOI: 10.1007/s00101-012-2068-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Patient-controlled analgesia (PCA) is an established standard therapy for providing postoperative analgesia. To avoid possible abuse by patients each PCA pump is secured by a pin code that should be neither known nor accessible to patients. The two case reports described illustrate how manipulation of a PCA pump led to massive opioid abuse by the patients who decoded the pin code for unlimited additional doses. One patient developed withdrawal symptoms after switching the therapy and, as a consequence even had to be admitted to the intensive care unit (ICU). Easy access to the PCA pump codes on the internet for the patients and the impossibility of changing the pin codes by the medical staff played an important role in these two cases.
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Affiliation(s)
- K Imhof
- Abteilung für Anästhesiologie und Intensivmedizin, AKH Linz, Krankenhausstr. 9, 4020 Linz, Österreich.
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Min TJ, Kim WY, Jeong WJ, Choi JH, Lee YS, Kim JH, Park YC. Effect of ketamine on intravenous patient-controlled analgesia using hydromorphone and ketorolac after the Nuss surgery in pediatric patients. Korean J Anesthesiol 2012; 62:142-7. [PMID: 22379569 PMCID: PMC3284736 DOI: 10.4097/kjae.2012.62.2.142] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Revised: 09/19/2011] [Accepted: 10/11/2011] [Indexed: 11/23/2022] Open
Abstract
Background Nuss surgery is preferred in pectus excavatum repair because this procedure produces excellent cosmetic results and prevents postoperative distressed pulmonary function. However, the procedure causes severe pain due to thoracic expansion. This study was designed to investigate the analgesic effect of small doses of ketamine on an intravenous patient-controlled analgesia (IV-PCA) using hydromorphone and ketorolac for pain control after Nuss surgery. Methods Forty-four patients undergoing elective Nuss surgery were randomly assigned to receive hydromorphone 3 µg/kg/hr, ketorolac 0.05 mg/kg/hr and ondansetron 0.1 mg/kg/day (Group HO, n = 22) or hydromorphone 3 µg/kg/hr, ketorolac 0.05 mg/kg/hr, ondansetron 0.1 mg/kg/day and ketamine 0.15 mg/kg/hr (Group HK, n = 22) via an IV-PCA pump after surgery. A blind observer evaluated each patient using the Modified Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) for the assessment of pain control. The total administered PCA volume, side effects and parents satisfaction with pain control were assessed at postoperative 1, 4, 8, 12, 24, and 48 hours. Results There were no significant differences in Modified CHEOPS between the groups during postoperative 48 hours. The total PCA volume in group HK was significantly lower than that in group HO (P < 0.05). The side effects in both groups did not significantly differ except for pruritus. The levels of satisfaction from the parents were not significantly different between the groups. Conclusions A small dose of ketamine on IV-PCA reduced the total administered dose of IV-PCA with hydromorphone and ketorolac and reduced the incidence of pruritus after the Nuss procedure in pediatric patients.
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Affiliation(s)
- Too Jae Min
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Ansan, Korea
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National study of injury‐increasing analgesics in the elderly. INTERNATIONAL JOURNAL OF PHARMACEUTICAL AND HEALTHCARE MARKETING 2011. [DOI: 10.1108/17506121111121569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeThe purpose of this paper is to identify the probability of the occurrence of an analgesic medication injury when controlling for potential risk factors, as well as gain a better understanding of which risk factors appear more problematic.Design/methodology/approachCross‐sectional retrospective review of 2004 Centers for Medicare and Medicaid Service Medicaid Pharmacy claims data. Logistic regression analysis performed to examine the risk of injury‐related emergency room (ER) visits following the use of analgesics controlling for potential risk factors.FindingsMethadone, an agent to treat severe pain, and propoxyphene, an agent to treat non‐severe pain, are problematic opioids in the elderly. White origin, male gender, and increased disease burden are potential risk factors influencing injury‐related ER visits for elderly analgesic recipients. Increased age in the elderly is a potential risk factor for severe pain analgesics; decreased age for non‐severe pain analgesics.Research limitations/implicationsThe study uses administrative data which, by its nature, makes conducting outcomes research on inappropriate medication use problematic. A number of confounders are present.Practical implicationsAppropriate drug therapy in an elderly patient is complicated by age‐related changes in pharmacokinetics as well as chronic disorders that affect drug response. Knowing of additional risk factors that may place the patient at greater odds of having an adverse outcome should improve prescribing practices.Originality/valueThe findings add to the literature by identifying problematic risk factors associated with injury among elderly recipients of analgesics.
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Rüsch D, Eberhart LHJ, Wallenborn J, Kranke P. Nausea and vomiting after surgery under general anesthesia: an evidence-based review concerning risk assessment, prevention, and treatment. DEUTSCHES ARZTEBLATT INTERNATIONAL 2010; 107:733-41. [PMID: 21079721 DOI: 10.3238/arztebl.2010.0733] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Accepted: 04/13/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND The German-language recommendations for the management of postoperative nausea and vomiting (PONV) have been revised by an expert committee. Major aspects of this revision are presented here in the form of an evidence-based review article. METHODS The literature was systematically reviewed with the goal of revising the existing recommendations. New evidence-based recommendations for the management of PONV were developed, approved by consensus, and graded according to the scheme of the Scottish Intercollegiate Guidelines Network (SIGN). RESULTS The relevant risk factors for PONV include female sex, nonsmoker status, prior history of PONV, motion sickness, use of opioids during and after surgery, use of inhalational anesthetics and nitrous oxide, and the duration of anesthesia. PONV scoring systems provide a rough assessment of risk that can serve as the basis for a risk-adapted approach. Risk-adapted prophylaxis, however, has not been shown to provide any greater benefit than fixed (combination) prophylaxis, and PONV risk scores have inherent limitations; thus, fixed prophylaxis may be advantageous. Whichever of these two approaches to manage PONV is chosen, high-risk patients must be given multimodal prophylaxis, involving both the avoidance of known risk factors and the application of multiple validated and effective antiemetic interventions. PONV should be treated as soon as it arises, to minimize patient discomfort, the risk of medical complications, and the costs involved. CONCLUSION PONV lowers patient satisfaction but is treatable. The effective, evidence-based measures of preventing and treating it should be implemented in routine practice.
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Affiliation(s)
- Dirk Rüsch
- Klinik für Anästhesie und Intensivtherapie, Universitätsklinikum Gießen und Marburg GmbH
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Weinstein SM. A new extended release formulation (OROS) of hydromorphone in the management of pain. Ther Clin Risk Manag 2009; 5:75-80. [PMID: 19436600 PMCID: PMC2697506 DOI: 10.2147/tcrm.s1124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Opioid analgesics are essential in the treatment of moderate to severe cancer-related pain. Opioids are also recognized as important in the management of other severe, persistent refractory painful conditions, such as sickle cell disease and arthritis. In the clinical practice of pain management, stable opioid dosing generally depends on achieving maximal analgesia with tolerable side effects typical of opioid analgesics. There is a wide interindividual variability of responsiveness to exogenous opioids both in terms of analgesic efficacy and side effects. Optimizing pain management for the individual patient may require sequential trials of opioid medications until the regimen with the most favorable therapeutic ratio of efficacy to side effects is determined.
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Affiliation(s)
- Sharon M Weinstein
- University of Utah, Huntsman Cancer Institute, Salt Lake City, Utah, USA
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Weiner DK, Rudy TE, Morrow L, Slaboda J, Lieber S. The Relationship Between Pain, Neuropsychological Performance, and Physical Function in Community-Dwelling Older Adults with Chronic Low Back Pain. PAIN MEDICINE 2006; 7:60-70. [PMID: 16533199 DOI: 10.1111/j.1526-4637.2006.00091.x] [Citation(s) in RCA: 203] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Chronic pain and cognitive impairment are prevalent and disabling in older adults (OA), but their interrelationship has not been rigorously tested. We did so in OA with chronic low back pain (CLBP). DESIGN A total of 323 OA (160 pain-free, 163 CLBP; mean age 73.5 years, 45% female) had neuropsychological (NP) testing with the Repeatable Battery for the Assessment of Neuropsychological Status, Trail Making Test, and the Grooved Pegboard Test. Pain intensity was measured with the McGill Pain Questionnaire Short Form. Physical performance (gait speed, functional reach, chair rise, trunk rotation, and static/dynamic lifting), psychosocial disruption (Geriatric Depression Scale, the Short Form-36 Mental Health and Role Limitations-Emotional Composite scale), and self-reported disability (Functional Status Index, the Short From-36 Physical Functioning/Role-Physical Composite scale) were also measured. SETTING Outpatient research laboratory. RESULTS There were no group differences in age, gender, or educational level, but significant differences in NP scores (P = 0.01) were found. Five scales accounted for the differences: immediate memory (P = 0.002), language (P = 0.004), delayed memory (P = 0.04), mental flexibility (Trails B [P = 0.02]), and Grooved Pegboard (P = 0.05). NP scores were significantly correlated with physical performance (R2= 0.30, P < 0.001), but not self-reported disability (R2= 0.04, P = 0.52) or psychosocial disruption (R2= 0.05, P = 0.46). NP function was correlated with pain intensity (R2= 0.17, P < 0.001), and NP function mediated the relationship between pain and physical performance. CONCLUSIONS OA with CLBP demonstrated impaired NP performance as compared with pain-free OA. Further, pain severity was inversely correlated with NP performance, and NP performance mediated the relationship between pain and physical performance. Future research should examine whether cognitive function and impaired physical performance can be improved with pain reduction.
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Affiliation(s)
- Debra K Weiner
- Department of Medicine,University of Pittsburgh, Pittsburgh, Pennsylvania 15206, USA.
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