Outcomes in patients with fractured ribs: middle aged at same risk of complications as the elderly

AIMS

Rib fractures occur in up to 10% of hospitalised trauma patients and are the most common type of clinically significant blunt injury to the thorax. There is strong evidence that elderly patients have worse outcomes compared with younger patients. Evolving evidence suggests adverse outcomes start at a younger age. The aim of this study was to explore the effect of age on outcomes in patients with rib fractures in Northland, New Zealand.

METHOD

A two-year retrospective study of patients admitted to any Northland District Health Board hospital with one or more radiologically proven rib fracture was performed. Patients with an abbreviated injury scale score >2 in the head or abdomen were excluded. The study population was stratified by age into three groups: >65, 45 to 65 and <45 years old.

RESULTS

170 patients met study inclusion criteria. Patients <45 had a significantly shorter length of stay (LOS) and lower rates of pneumonia compared to patients 45 and older, despite a higher Injury Severity Score and pulmonary contusion rate. There was no difference seen between groups in rates of intubation, ICU admission, mortality, empyema or acute respiratory distress syndrome.

CONCLUSION

This study found higher rates of pneumonia and an increased LOS in patients 45 and older despite their lower overall injury severity when compared to patients under 45. Patients aged 45-64 had outcomes similar to patients >65. Future clinical pathways and guidelines for patients with rib fractures should consider incorporating a younger age than 65 in risk stratification algorithms.

A multicentre, prospective, observational cohort study of variation in practice in perioperative analgesia strategies in elective laparoscopic colorectal surgery (the LapCoGesic study)

INTRODUCTION

Enhanced recovery programmes are established as an essential part of laparoscopic colorectal surgery. Optimal pain management is central to the success of an enhanced recovery programme and is acknowledged to be an important patient reported outcome measure. A variety of analgesia strategies are employed in elective laparoscopic colorectal surgery ranging from patient-controlled analgesia to local anaesthetic wound infiltration catheters. However, there is little evidence regarding the optimal analgesia strategy in this cohort of patients. The LapCoGesic study aimed to explore differences in analgesia strategies employed for patients undergoing elective laparoscopic colorectal surgery and to assess whether this variation in practice has an impact on patient-reported and clinical outcomes.

MATERIALS AND METHODS

A prospective, multicentre, observational cohort study of consecutive patients undergoing elective laparoscopic colorectal resection was undertaken over a two-month period. The primary outcome measure was postoperative pain scores at 24 hours. Data analysis was conducted using SPSS version 22.

RESULTS

A total of 103 patients undergoing elective laparoscopic colorectal surgery were included in the study. Thoracic epidural was used in 4 (3.9%) patients, spinal diamorphine in 56 (54.4%) patients and patient-controlled analgesia in 77 (74.8%) patients. The use of thoracic epidural and spinal diamorphine were associated with lower pain scores on day 1 postoperatively (P < 0.05). The use of patient-controlled analgesia was associated with significantly higher postoperative pain scores and pain severity.

DISCUSSION

Postoperative pain is managed in a variable manner in patients undergoing elective colorectal surgery, which has an impact on patient reported outcomes of pain scores and pain severity.

Effects of intraoperative propofol-based total intravenous anesthesia on postoperative pain in spine surgery: Comparison with desflurane anesthesia - a randomised trial

BACKGROUND

As reported, patients experience less postoperative pain after propofol-based total intravenous anesthesia (TIVA). In the present study, we investigated the postoperative analgesic effects between propofol-based TIVA and desflurane anesthesia after spine surgery.

METHODS

Sixty patients were included who received (surgical time >180 minutes) lumbar spine surgery. Patients were randomly assigned to receive either TIVA (with target-controlled infusion) with propofol/fentanyl-based anesthesia (TIVA group) or desflurane/fentanyl-based anesthesia (DES group), titrated to maintain Bispectral Index values between 45 and 55. All patients received patient-controlled analgesia (PCA) with fentanyl for postoperative pain relief. Numeric pain rating scale (NRS) pain scores, postoperative fentanyl consumption, postoperative rescue tramadol use, and fentanyl-related side effects were recorded.

RESULTS

The TIVA group patients reported lower NRS pain scores during coughing on postoperative day 1 but not day 2 and 3 (P = .002, P = .133, P = .161, respectively). Less fentanyl consumption was observed on postoperative days 1 and 2, but not on day 3 (375 μg vs 485 μg, P = .032, 414 μg vs 572 μg, P = .033, and 421 μg vs 479 μg, P = .209, respectively), less cumulative fentanyl consumption at postoperative 48 hours (790 μg vs 1057 μg, P = .004) and 72 hours (1210 μg vs 1536 μg, P = .004), and total fentanyl consumption (1393 μg vs 1704 μg, P = .007) when compared with the DES group. No difference was found in rescue tramadol use and fentanyl-related side effects.

CONCLUSION

Patients anesthetized with propofol-based TIVA reported less pain during coughing and consumed less daily and total PCA fentanyl after lumbar spine surgery.

Correlation of P2RX7 gene rs1718125 polymorphism with postoperative fentanyl analgesia in patients with lung cancer

The aim of this study was to investigate the association between purinergic receptor P2X7 (P2RX7) gene rs1718125 polymorphism and analgesic effect of fentanyl after surgery among patients with lung cancer in a Chinese Han population.A total of 238 patients with lung cancer who received resection were enrolled in our study. The genotype distributions of P2RX7 rs1718125 polymorphism were detected by polymerase chain reaction and direct sequencing. Postoperative analgesia was performed by patient-controlled intravenous analgesia, and the consumption of fentanyl was recorded. The postoperative pain was measured by visual analog scale (VAS). Differences in postoperative VAS score and postoperative fentanyl consumption for analgesia in different genotype groups were analyzed by analysis of variance assay.The frequencies of GG, GA, and AA genotypes were 46.22%, 44.96%, and 8.82%, respectively. After surgery, the postoperative VAS score of GA group was significantly high in the period of analepsia after general anesthesia and at 6 hours after surgery (P = .041 and P = .030, respectively), while AA group exhibited obviously high in the period of analepsia after general anesthesia (P < .001), at postoperative 6 hours (P = .006) and 24 hours (P = .016). Moreover, the patients carrying GA and AA genotypes needed more fentanyl to control pain within 48 hours after surgery (P < .05 for all).P2RX7 gene rs1718125 polymorphism is significantly associated with postoperative pain and fentanyl consumption in patients with lung cancer.

Changing Patterns in the Acute Pain Service: Epidural versus Patient-controlled Analgesia

This study involved an audit and a survey of the Acute Pain Service at Princess Alexandra Hospital. It was found in the audit that the relative choice of epidural analgesia had declined by 50% over the five-year time period of 1998–2003. The survey of consultants showed that 82% of them had changed their practice and that they were performing fewer epidural anaesthetics. Two of the most common reasons given for this change in practice related to fear of litigation (34%) and lack of evidence (21%). These results show that within this department approaches to postoperative pain control had changed and that this appears to have resulted from factors such as the medicolegal environment and the possible influence of evidence based medicine.

Patient-controlled Analgesia and Postoperative Pressure Ulcer: A Meta-analysis of Observational Studies

BACKGROUND

Patient-controlled analgesia (PCA) has become a common practice after surgery, but research has shown that the use of PCA is also a significant risk factor for pressure ulcers. However, no meta-analysis or conclusive review has investigated whether patients using PCA have a significantly higher prevalence of pressure ulcers.

OBJECTIVE

This study explores the association between the use of postoperative PCA and the prevalence of pressure ulcers.

MATERIALS AND METHODS

PubMed, the Cochrane Controlled Register of Trials, Web of Science, China National Knowledge Infrastructure, Wanfang, and Vip databases were searched to identify studies, published up until November 2016, concerning the association between PCA and pressure ulcer prevalence. A manual search of the references of relevant studies also was performed. Odds ratio (OR) and corresponding 95% confidence interval (CI) were used to evaluate the strength of association between the use of PCA after surgery and pressure ulcer prevalence. The methodological quality of included case-control studies and cohort studies was assessed by the Newcastle-Ottawa Scale. The test of heterogeneity, subgroup analysis, meta-regression, Begg's funnel plot, and Egger's test also were used.

RESULTS

Four cohort studies and 1 case-control study were included. In these 5 studies, 265 participants were identified. In pooled analysis, heterogeneity was 0 among the studies. In a fixed effects model, postoperative pressure ulcer was associated with PCA (pooled OR, 3.525; 95% CI, 1.655-7.509). Subgroup analysis of these 5 studies yielded an OR of 3.29 (95% CI, 1.47-7.40) for cesarean section, 5.10 (95% CI, 0.24-107.55) for general surgery, and 5.10 (95% CI, 0.24-107.55) for orthopedic surgery. There was no heterogeneity among the 5 studies. Additional meta-regression of year and incidence did not find significant outcomes.

CONCLUSIONS

This meta-analysis shows PCA may be associated with an increased risk of postoperative pressure ulcer, especially after caesarean section. More evidence-based studies on this research field are needed to draw a firmer conclusion.

Patient-controlled oral analgesia for acute abdominal pain: A before-and-after intervention study on pain intensity and use of analgesics

AIM

To compare the use of patient-controlled oral analgesia with nurse-controlled analgesia for patients admitted to hospital with acute abdominal pain. The primary outcome measure was pain intensity. The secondary outcome measures were the use of analgesics and antiemetics.

BACKGROUND

Inadequate pain management of patients with acute abdominal pain can occur during hospital admission. Unrelieved acute pain can result in chronic pain, stroke, bleeding and myocardial ischemia.

METHODS

A before-and-after intervention study was conducted in an emergency department and a surgical department with three subunits. Data were collected from medical charts and analyzed using chi-squared and Kruskal-Wallis tests.

RESULTS

A total of 170 patients were included. The median pain intensity score, using the numeric ranking scale, was 2.5 and 2 on Day 2 (p = 0.10), 2 and 2 on Day 3 (p = 0,40), 2.5 and 0 on Day 4 (p = 0.10), 2 and 0 on Day 5 (p = 0.045) in the control and intervention group, respectively. The percentage of patients receiving analgesics was 93 and 86 on Day 2 (p = 0.20), 91 and 75 on Day 3 (p = 0.02), 89 and 67 on Day 4 (p = 0.009) and 80 and 63 on Day 5 (p = 0.39). The use of antiemetics was similar in the two groups.

CONCLUSION

Patient-controlled oral analgesia significantly reduced the numerical ranking pain scale score on Day 5 and the consumption of analgesics on Days 3 and 4 after hospital admission. Patient-controlled oral analgesia is feasible as pain management for patients, but only with minor impact on experienced pain intensity and use of analgesics.

Effect of preoperative pregabalin as an adjunct to a multimodal analgesic regimen in video-assisted thoracoscopic surgery: A randomized controlled trial

BACKGROUND

Depending on the type of injury, the pain mechanisms are multifactorial. Preoperative pregabalin administrations as an adjunct to a multimodal postoperative pain management strategy have been tested in various surgical settings. The purpose of current study was to evaluate the effects of preoperative pregabalin administration on postoperative pain intensity and rescue analgesic requirement following video-assisted thoracoscopic surgery (VATS).

METHODS

Sixty adult patients undergoing VATS were randomly assigned either to receive pregabalin 150 mg (Pregabalin group) or placebo (Control group) 1 hour before anesthesia. Primary efficacy variable was pain intensity. Secondary efficacy variables were the requirement of rescue analgesics, total volume of intravenous patient-controlled analgesia (IV-PCA), and adverse effects induced by pregabalin or IV-PCA.

RESULTS

Pain intensity scores at post-anesthesia care unit (PACU), 6 and 24 hours were lower significantly in the Pregabalin group compared with the Control group (mean [SD]; 5.6 [2.0] vs 6.8 [1.8]; mean difference: 1.2, 95% CI of difference: 0.2166-2.1835, P = .018, mean [SD]; 3.8 [1.9] vs 5.6 [1.4]; mean difference: 1.8, 95% CI of difference: 1.0074-2.7260, P = .001 and mean [SD]; 2.6 [1.6] vs 3.5 [1.5]; mean difference: 0.9, 95% CI of difference: 0.0946-1.7054, P = .029, respectively]. Also, the frequency of additional rescue drug administered at PACU (median [interquartile range]; 2 [2-3] vs 1 [1-2], P = .027) was significantly less in the Pregabalin group. The incidences of adverse effects related to pregabalin or IV-PCA were not different between the groups.

CONCLUSION

A single administration of pregabalin 150 mg before VATS decreased postoperative pain scores and incidence of additional rescue analgesics in the immediate postoperative period without increased risk of adverse effects.

Effect of dexmedetomidine as an adjuvant to ropivacaine for wound infiltration in patients undergoing open gastrectomy: A prospective randomized controlled trial

OBJECTIVES

The primary objective of this study was to investigate whether dexmedetomidine could potentiate the analgesic efficacy of ropivacaine, when added to ropivacaine for wound infiltration in patients undergoing open gastrectomy.

METHODS

Fifty patients scheduled for open gastrectomy were divided into 2 equal groups that were received wound infiltration using 20 mL 0.3% ropivacaine plus 2 mL normal saline (group R) or 20 mL 0.3% ropivacaine plus 2 mL 1.0 μg/kg dexmedetomidine (group DR). Visual analogue scale (VAS) pain score, patient-controlled analgesia (PCA) pump press number, sufentanil consumption, postoperative nausea and vomiting (PONV), and wound healing score were recorded.

RESULTS

The VAS pain score were comparable between the 2 groups at the observation time points (P > .05), PCA pump press number and sufentanil consumption were higher in group R than that in group DR at 0 to 2, 2 to 4, 4 to 6 time intervals (P < .05) except for 6 to 8, 8 to 10, 10 to 12 time intervals (P > .05), meanwhile, the 24 hours total sufentanil consumption was also higher in group R than that in group DR (90.4 ± 20.5 vs 79.2 ± 9.4) (P < .05), there were no significant differences in PONV and wound healing score between the 2 groups (P > .05).

CONCLUSIONS

Dexmedetomidine as an adjuvant to ropivacaine for wound infiltration promoted the analgesic efficacy of ropivacaine, reduced sufentanil consumption, and had no effect on wound healing; it could be as an ideal adjuvant which could potentiate the analgesic efficacy of local anesthetics.

Comparative Safety of Morphine Delivered via Intravenous Route vs. Patient-Controlled Analgesia Device for Pediatric Inpatients

CONTEXT

Although patient-controlled analgesia (PCA) is an effective pain control modality, there is a lack of large studies on PCA safety in pediatric patients.

OBJECTIVES

This study compared the delivery of morphine either via intravenous route (morphine IV) or via PCA device (morphine PCA) on risk of cardiopulmonary resuscitation (CPR) and mechanical ventilation (MV) using a large administrative database.

METHODS

We assembled a retrospective cohort of pediatric inpatients between five and 21 years old in 42 children's hospitals between 2007 and 2011 from the Pediatric Health Information System database. After propensity score matching, we created matched cohorts of morphine PCA and morphine IV patients, in both surgical and nonsurgical samples, who were similar on demographic, clinical, and hospital-level factors. We examined if PCA administration was associated with greater likelihood of CPR or MV up to two days after drug administration.

RESULTS

Surgical and nonsurgical patients administered morphine PCA generally had lower odds of having MV on the baseline day and up to two days after PCA exposure, although these estimates were not statistically significant. Similarly, PCA exposure was associated with about 20%-44% lower odds of same day CPR in both surgical and nonsurgical patients, with a slightly greater reduction in the odds of CPR in the surgical patients.

CONCLUSION

In this large pediatric inpatient population, morphine administered via PCA device for surgical and nonsurgical pain was not associated with an increased risk of receiving CPR or MV, and was associated with slightly better safety outcomes than intravenous morphine.

Prediction of Patient-Controlled Analgesic Consumption: A Multimodel Regression Tree Approach

Several factors contribute to individual variability in postoperative pain, therefore, individuals consume postoperative analgesics at different rates. Although many statistical studies have analyzed postoperative pain and analgesic consumption, most have identified only the correlation and have not subjected the statistical model to further tests in order to evaluate its predictive accuracy. In this study involving 3052 patients, a multistrategy computational approach was developed for analgesic consumption prediction. This approach uses data on patient-controlled analgesia demand behavior over time and combines clustering, classification, and regression to mitigate the limitations of current statistical models. Cross-validation results indicated that the proposed approach significantly outperforms various existing regression methods. Moreover, a comparison between the predictions by anesthesiologists and medical specialists and those of the computational approach for an independent test data set of 60 patients further evidenced the superiority of the computational approach in predicting analgesic consumption because it produced markedly lower root mean squared errors.

Effects of Intraoperative Dexmedetomidine on Postoperative Pain in Highly Nicotine-Dependent Patients After Thoracic Surgery: A Prospective, Randomized, Controlled Trial

To investigate the effects of intraoperative dexmedetomidine on pain in highly nicotine-dependent patients after thoracic surgery.Highly nicotine-dependent men underwent thoracic surgery and received postoperative patient-controlled intravenous analgesia with sufentanil. In dexmedetomidine group (experimental group, n = 46), dexmedetomidine was given at a loading dose of 1 μg/kg for 10 minutes, followed by continuous infusion at 0.5 μg/kg/h until 30 minutes before the end of surgery. The saline group (control group, n = 48) received the same volume of saline. General anesthesia was administered via a combination of inhalation and intravenous anesthetics. If necessary, patients were administered a loading dose of sufentanil by an anesthesiologist immediately after surgery (0 hours). Patient-controlled analgesia was started when the patient's resting numerical rating scale (NRS) score was less than 4. Resting and coughing NRS scores and sufentanil dosage were recorded 0, 1, 4 hours, and every 4 hours until 48 hours after surgery. Dosages of other rescue analgesics were converted to the sufentanil dosage. Surgical data, adverse effects, and degree of satisfaction were obtained.Cumulative sufentanil dosage, resting NRS, and coughing NRS in the first 24 hours after surgery and heart rate were lower in the experimental compared with the control group (P <0.05). No patient experienced sedation or respiratory depression. Frequency of nausea and vomiting and degree of satisfaction were similar in both groups.Intraoperative dexmedetomidine was associated with reduced resting and coughing NRS scores and a sufentanil-sparing effect during the first 24 hours after thoracic surgery.

Penalised logistic regression and dynamic prediction for discrete-time recurrent event data

We consider methods for the analysis of discrete-time recurrent event data, when interest is mainly in prediction. The Aalen additive model provides an extremely simple and effective method for the determination of covariate effects for this type of data, especially in the presence of time-varying effects and time varying covariates, including dynamic summaries of prior event history. The method is weakened for predictive purposes by the presence of negative estimates. The obvious alternative of a standard logistic regression analysis at each time point can have problems of stability when event frequency is low and maximum likelihood estimation is used. The Firth penalised likelihood approach is stable but in removing bias in regression coefficients it introduces bias into predicted event probabilities. We propose an alterative modified penalised likelihood, intermediate between Firth and no penalty, as a pragmatic compromise between stability and bias. Illustration on two data sets is provided.

Evaluation of use of electronic patient controlled analgesia pumps to improve patient safety in an academic medical center

Patient controlled analgesia (PCA) and Patient-controlled epidural analgesia (PCEA) pumps are methods of pain control with complex smart infusion devices and are widely used in hospitals. Smart PCA/PCEA pumps can be programmed with the dose and rate of medications within pre-set ranges. However, adverse effects have been reported associated with these pumps' use. In this paper, we describe a prevalence observational study where observers used an electronic data collection tool to record pump settings and medications with PCA pumps, corresponding medication orders to identify errors. The results showed that there were many labeling and tubing change tag errors, which were a violation of hospital policy. A few potential harmful medication errors were identified but no critical errors. Study results suggest the importance of a standard process of PCA pump use. Next steps include implementing a safety bundle for improving PCA practice to support safe and effective pain management.

Postoperative pain is undertreated: results from a local survey at Jordan University Hospital

Postoperative pain management is nowadays considered an integral part of modern surgical practice. An audit was made in 2010 to assess the status of acute postoperative pain management at Jordan University Hospital. Data were collected from patients' files and through face-to-face interviews of all patients aged over 16 years who underwent general, gynaecological, ear-nose-throat and orthopaedic surgery. Of 275 patients, 72.0% experienced moderate to severe pain postoperatively at rest and 89.3% on movement. No analgesics were prescribed to 4.7% of the patients and of the remainder, a single analgesic was prescribed to 51.5%. Pethidine and paracetamol were the drugs most commonly prescribed (to 66.9% and 42.5% of patients respectively), most often on a regular schedule rather than on-demand. Despite improvements in pain management worldwide, patients at this hospital were still suffering from postoperative pain. Awareness among professionals and the public is needed and a structured acute pain management programme is essential.

[Postoperative pain management by intravenous patient-controlled analgesia in patients undergoing upper abdominal gastrointestinal surgery]

BACKGROUND

We conducted a retrospective study to evaluate the effectiveness of intravenous patient-controlled analgesia (IVPCA) in the early postoperative period after upper abdominal gastrointestinal surgery. We also evaluated the postoperative effects of intraoperative analgesic dosage in patients after this surgery.

METHODS

A total of 59 adult patients classified as ASA 1-3 were allocated to one of two groups: Group A, 23 patients who requested IVPCA more than 50 times, and Group B, 36 patients with fewer than 50 requests. IVPCA was induced using morphine 1 mg x ml(-1) without a base dose. The bolus dose was 1 ml and the lock-out time was 5 min.

RESULTS

There was no significant difference between the two groups in the total intraoperative remifentanil dosage/body weight/surgical duration, predicted effect-site concentration of fentanyl during extubation, and utilization of flurbiprofen. The doses of morphine were significantly higher, and the visual analogue scale scores for pain at rest and during movement tended to be lower in group A than in group B.

CONCLUSIONS

The results of this study suggest that the effects of intraoperative analgesics may not be significant. Patients who had received the above mentioned anesthetic regimen intraoperatively also required full postoperative analgesia as well.

Development and validation of a new instrument to evaluate the ease of use of patient-controlled analgesic modalities for postoperative patients

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.

Using the patient global assessment of the method of pain control to assess new analgesic modalities in clinical trials

OBJECTIVE

To assess the validity of the patient global assessment (PGA) of the method of pain control, a single-item patient-reported outcome measure of a method of pain control for patients experiencing postoperative pain.

RESEARCH DESIGN AND METHODS

Content validity of the PGA of the method of pain control was assessed using cognitive debriefing interviews. Construct validity was evaluated using data from six clinical trials that compared the efficacy of the fentanyl HCl iontophoretic transdermal system (fentanyl ITS) with morphine intravenous patient-controlled analgesia or placebo fentanyl ITS for acute postoperative pain management.

MAIN OUTCOME MEASURES

To assess the construct validity of the PGA rating scale, four hypotheses were developed that related positive PGA ratings ('good' or 'excellent') to (1) lower pain intensity scores, (2) higher satisfaction ratings, (3) a greater propensity to select the assigned pain control method in the future, and (4) favorable ratings of ease of use/convenience on the Patient Ease-of-Care Questionnaire. Descriptive statistics were used to evaluate the association of pain intensity and Overall Ease-of-Care scores with PGA ratings. An exact linear-by-linear association test was conducted to evaluate the association of satisfaction ratings and propensity to select the pain control method in the future with PGA ratings.

RESULTS

Results of cognitive debriefing interviews indicated that the PGA incorporates patient perceptions of several aspects of treatment with an analgesic modality, including level of pain, ease of use, and control of administration. PGA ratings were associated in the expected direction with other patient-reported outcomes used in several clinical studies.

CONCLUSIONS

Findings suggest that both the content and construct validity of the PGA of the method of pain control in clinical trial settings are supported. However, this conclusion is potentially limited by the use of a narrow range of therapeutic interventions and, in some cases, small sample sizes in the clinical trials used to assess construct validity. The PGA of the method of pain control is an informative and useful measure for assessing pain control provided by different drug delivery systems for patients experiencing postoperative pain.

Clinical Staff Resource Use With Intravenous Patient-Controlled Analgesia in Acute Postoperative Pain Management: Results From a Multicenter, Prospective, Observational Study

The purpose of this study was to evaluate hospital resource utilization associated with intravenous patient-controlled analgesia (IV-PCA), with a focus on nursing, pharmacy, and central supply/engineering time spent from a hospital perspective. Data were collected during a multicenter (29 sites), prospective observational study in the United States of subjects who underwent total knee replacement (TKR), total hip replacement (THR), or abdominal hysterectomy (AH) and were administered analgesia through IV PCA for the management of acute postoperative pain. Nursing staff recorded the IV PCA-related tasks they performed for a subject and the duration of time required to perform each task from initial IV PCA set-up to discontinuation. Hospital administrators, nursing managers, central supply/engineering staff, and pharmacy directors were interviewed to obtain data regarding other IV PCA labor resource use. The distribution of surgery type among the 457 subjects was 31.1% THR, 35.9% TKR, and 33.0% AH. The average duration of IV PCA use was 32.6 hours. Nurses reported having to perform an average of 39.6 IV PCA-related tasks, which required an average of 67.4 minutes. The most common IV PCA-related tasks were evaluating pump use and settings, assessing the IV site, evaluating and addressing analgesia side effects, instructing/reinstructing the subject on use, administering supplemental pain medications, assisting with self-care or moving the subject, and assisting the subject with use of the button. Pharmacists reported that they spend approximately 7.9 minutes and pharmacy technicians spend approximately 9.8 minutes, per subject daily course of IV PCA therapy, on the following tasks: checking and verifying the order, doing inventory of the analgesia, preparing the analgesia (ie, filling reservoirs), checking the analgesia, and delivering the analgesia to the nursing units. In addition, pharmacists and RNs spend an average of 47.3 and 40.7 minutes per year in IV PCA-related training. Intravenous patient-controlled analgesia postoperative care requires coordination and involvement of numerous hospital departments. It is labor intensive and involves numerous time-consuming tasks, oversight of IV PCA, and ongoing training. Alternative methods of patient-controlled pain management with similar efficacy that reduces labor resource utilization may be warranted.

Intravenous patient-controlled analgesia for labour: a survey of UK practice

BACKGROUND

Although regional techniques offer superior analgesia during labour, many women receive other methods of pain relief. Furthermore, there is a specific need for analgesia in a small population of labouring women for whom regional techniques are contraindicated, unavailable or impossible to perform. We surveyed current UK practice of labour analgesia for such patients, with particular reference to the use of intravenous patient-controlled analgesia.

METHODS

Following approval from the Obstetric Anaesthetists' Association, a questionnaire was sent to the lead anaesthetic consultants of 243 obstetric units in the United Kingdom. The questionnaire evaluated the availability of methods of pain relief other than regional blocks. Information was sought on patient-controlled intravenous analgesia regimens and patient monitoring.

RESULTS

A total of 159 questionnaires were returned giving a response rate of 65.4%. The majority of units that responded (95.5%) used either intramuscular pethidine or diamorphine. Nearly half (49%) offered patient-controlled intravenous analgesia for labour pain. One third of units (36%) had an analgesic protocol for women in whom regional anaesthetic techniques were contraindicated. With patient-controlled intravenous analgesia, remifentanil (34.6%) was the most commonly used opioid for live births while morphine (35.5%) was used more commonly for deliveries involving intrauterine deaths.

CONCLUSION

The survey demonstrated that, when regional techniques were contraindicated, patient-controlled intravenous opioid analgesia was employed in almost half of the units responding to the questionnaire.

A survey of labor patient-controlled epidural anesthesia practice in California hospitals

BACKGROUND

Patient-controlled epidural analgesia (PCEA) offers many advantages over continuous epidural infusions for labor analgesia including fewer physician interventions, improved analgesia and satisfaction, and reduced local anesthetic doses. However, anesthesiologists have been slow to adopt this technique, first described in 1988. No previous studies have evaluated specific labor patient-controlled epidural analgesia practices in the United States. The aim of this study was to determine labor epidural and patient-controlled epidural analgesia practices among California hospitals.

METHODS

Following institutional review board exemption approval, an online survey was created using freeonlinesurveys.com. An anonymous survey was sent via e-mail to 230 California Society of Anesthesiologists' members chosen at random to represent their hospitals' labor analgesia practices.

RESULTS

We received 133 replies from the 230 survey requests sent, a 58% response rate. The median labor epidural rate among the hospitals involved was 65% (range 0-95%). Overall, only 25% of California hospitals use patient-controlled epidural analgesia for analgesia in labor, with greater use among hospitals with dedicated obstetric anesthesia coverage and larger numbers of deliveries. Reasons given for not using patient-controlled epidural analgesia include cost, clinician preference, safety concerns and the inconvenience of change.

CONCLUSIONS

Despite the potential advantages of patient-controlled epidural analgesia over continuous epidural infusions for labor analgesia, patient-controlled epidural analgesia has not been widely adopted in California hospitals. Education regarding this technique is needed to encourage its increased use.

[Femoral nerve block for postoperative analgesia after anterior cruciate ligament reconstruction: comparison of 2 concentrations of bupivacaine with clonidine in 3 modes of administration]

BACKGROUND

The continuous femoral nerve block is used for postoperative orthopedic analgesia.

OBJECTIVE

To evaluate 2 concentrations of bupivacaine with clonidine in 3 methods of administration for performing a continuous femoral nerve block.

MATERIAL AND METHODS

Randomized controlled trial in ASA 1-2 patients in 6 groups. In groups 1, 2, and 3, the combination used was 0.125% bupivacaine plus clonidine. In groups la, 2a, and 3a, the combination was 0.0625% bupivacaine plus clonidine. Methods of administration were as follows: groups 1 and la, 10 mL x h(-1) in continuous infusion; groups 2 and 2a, 5 mL h x (-1) in continuous infusion plus 2.5 mL every 30 minutes through a patient-controlled analgesia (PCA) system; groups 3 and 3a, 5 mL every 30 minutes in a PCA system. Pain on a visual analog scale (VAS) and amounts of bupivacaine and morphine used were recorded 2 and 48 hours after surgery.

RESULTS

A total of 105 patients were enrolled: 17 in group 1, 18 in group la, 18 in group 2, 17 in group 2a, 17 in group 3, and 18 in group 3a. No significant differences between any of the 6 groups were observed for patient characteristics, postoperative VAS scores, or morphine use.

CONCLUSIONS

A continuous femoral nerve block is useful for managing pain after anterior cruciate ligament surgery. The application of 5 mL x h(-1) in continuous infusion or in PCA system bolus doses provides excellent postoperative analgesia. Use of 0.0625% bupivacaine decreases overall consumption of analgesic and is not detrimental to quality of analgesia.

Determinants of Patient-controlled Epidural Analgesia Requirements

OBJECTIVES

Patient-controlled epidural analgesia (PCEA) has been widely used in postoperative pain management. Many factors may correlate with PCEA requirements but no previous study has ever investigated this subject. Therefore, we conducted this study to explore the relationship among patients' characteristics and total PCEA consumption during the 3-day postoperative course.

METHODS

This prospective study was conducted with surgical patients receiving postoperative PCEA and completing the 3-day course. The PCEA regimen was prepared as 0.0625% bupivacaine with fentanyl (l microg/mL). Patients' characteristics including demographic data and surgical procedures were collected. The total doses were recorded after the course terminated. Stepwise regression analyses were conducted to select significant variables, which could determine total PCEA demand. Subgroup analyses were also performed to investigate whether differences exist among distinct surgical sites.

RESULTS

There were 1753 patients (1094 men and 659 women) included in the analysis. Weight, age, height, body mass index, sex distribution, and total PCEA consumption were significantly different among various surgical sites (all P<0.001). Operational sites, procedures involving malignant disease, weight, and age are the most significant factors in sequence to determine total PCEA requirements. Height and sex have no impact on PCEA demand. The multiple correlation coefficient of our model is 0.688 and the predictive formula of the 3-day postoperative PCEA requirement was 240.1+(130.5xsite)+(66.6xmalignancy)+(1.7xweight)-(0.4xage).

CONCLUSIONS

Our study demonstrated the association between patients' characteristics and total PCEA requirements from a large-scaled clinical data. Surgical procedures have more influence on PCEA consumption than demographic variables. Background infusion rate of PCEA could be determined from our predictive model.

[Pediatric acute postoperative pain management service: 6 years' experience]

OBJECTIVE

[corrected] To describe the introduction and activities of a low-cost acute postoperative pain management service for children.

PATIENTS AND METHODS

A descriptive study of patients treated with patient-controlled analgesia (PCA), nurse-controlled analgesia (NCA), continuous epidural analgesia (CEA), and patient-controlled epidural analgesia (PCEA) from October 1998 through December 2004. We analyzed demographic information and data on most frequent surgical procedures, analgesic techniques, pain on our nurse observation scale, side effects (nausea and/or vomiting, pruritus, urinary retention, excessive sedation, respiratory depression), and parent and patient satisfaction.

RESULTS

Three hundred treatments per year were performed, for a total of 1870; 46.6% were in children under 5 years old. Orthopedic operations with osteotomy (22.5%) and laparotomies (13.4%) were the most common procedures. The most frequently used approach was NCA (53%), followed by PCA with bolus doses (24.5%), PCA with infusion (16.9%), and continuous epidural analgesia or PCEA (5.6%). On the nurse observation scale (no pain; slight, moderate or intense pain) absence of pain or slight pain was observed in 82%, 90%, and 94% of the patients on days 1, 2, and 3 after surgery. Postoperative nausea and vomiting were observed in 20% of the patients and respiratory depression in 0.16%. Satisfaction was good or very good for 98% of the parents and 94% of the children interviewed.

CONCLUSIONS

The pain management service in our hospital was able to control postoperative pain safely and effectively.

What postoperative outcomes matter to pediatric patients?

Children are often excluded from making decisions related to their medical treatment, and parents' proxy reports are often used. This approach fails to consider that parents and children may differ in their perception of the child's health. In this study, we assessed children's decision-making processes related to postoperative pain management. Forty-five children who underwent an anterior cruciate ligament repair or Nuss procedure for pectus excavatum repair were studied. A standard gamble technique was used to assess children's perceptions of the utility of a hypothetical treatment that would provide them with perfect pain control, with respect to different rates of risk for vomiting during the postoperative period. The maximum risk of vomiting that the overall study population was willing to accept to decrease the pain level to zero was 32% +/- 24%. Girls were willing to take a significantly higher risk (41% +/- 24%) compared to boys (25% +/- 22%) (P = 0.02). Children who actually experienced vomiting before they were questioned were willing to take a higher risk (46% +/- 26%) compared to those who did not (23% +/- 17%) (P = 0.035). Children can express opinions about preferred postoperative outcomes and provide useful input about their care. Girls, more than boys, seem to perceive vomiting as less important than improved pain control in the postoperative period.

Does Bilateral Superficial Cervical Plexus Block Decrease Analgesic Requirement After Thyroid Surgery?

In this randomized, double-blind and controlled study we evaluated and compared the analgesic efficacy of bilateral superficial cervical plexus block and local anesthetic wound infiltration after thyroid surgery. Forty-five patients were assigned to 3 groups. After general anesthesia induction, bilateral superficial cervical plexus block with 0.25% bupivacaine 15 mL in each side was performed in Group I, and local anesthetic wound infiltration with 0.25% bupivacaine 20 mL was performed in Group II. In Group III (control) no regional block was administered. Intravenous patient-controlled analgesia was used to evaluate postoperative analgesic requirement. Neither visual analog scale scores nor total patient-controlled analgesia doses were different among groups. We concluded that bilateral superficial cervical plexus block or local anesthetic wound infiltration with 0.25% bupivacaine did not decrease analgesic requirement after thyroid surgery.

Differences in Postoperative Opioid Consumption in Patients Prescribed Patient-Controlled Analgesia Versus Intramuscular Injection

The purpose of this study was to examine differences in opioid consumption in patients prescribed patient-controlled analgesia (PCA) versus intramuscular injection (IMI) in the early postoperative period after open abdominal surgery. A retrospective audit of 115 patients elicited demographic and clinical data. No significant differences were found between the demographic variables of the PCA and IMI groups. There was a significant difference in the mean opioid dose used during the first 3 postoperative days (p < .01). Mean opioid consumption was 136.89 mg for the PCA group and 50.79 mg for the IMI group. Although there was a reduction in the amount of opioid consumed over the first 3 postoperative days, the PCA group consistently consumed more opioid analgesia compared with the IMI group. Furthermore, there was a disproportionate reduction in opioid consumption between the two groups from Day 1 (r = .34; p < .01) to Day 3 (r = .14; p = .14). This study shows that the amount of analgesia consumed during the postoperative period by patients who had abdominal surgery varied markedly depending on the mode of analgesia (PCA or IMI). The difference in analgesic consumption was also found to increase throughout the 3-day postoperative period. This divergence in the amount of opioid consumption between patients who were prescribed PCA and patients who were prescribed IM analgesia heightens the need for vigilance in assessment and management of pain during the early postoperative period, particularly in patients prescribed IM analgesia on an "as-needed" basis.

Is Postoperative Pain a Self-Fulfilling Prophecy? Expectancy Effects on Postoperative Pain and Patient-Controlled Analgesia Use Among Adolescent Surgical Patients

OBJECTIVE

To explore relationships among anxiety, anticipated pain, coping styles, postoperative pain, and patient-controlled analgesia (PCA) use among adolescent surgical patients and their parents.

METHODS

Sixty-five 12- to 18-year-old surgical patients undergoing surgery with postoperative PCA pain management were included. Before surgery, adolescents and parents reported anxiety and expected levels of postoperative pain. Pain catastrophizing and coping style were assessed within 48 hr after surgery, with pain scores and PCA use recorded through the end of the second postoperative day.

RESULTS

Adolescents' preoperative psychological characteristics (anxiety and anticipated pain) predicted postoperative pain scores, number of PCA injections and demands, and the PCA injections:demands ratio, with reports of anticipated pain associating most closely with these postoperative pain outcomes. Parental anxiety and anticipated pain did not predict teens' postoperative pain. Coping style did not moderate the relationship between anticipated pain and pain outcomes.

CONCLUSIONS

Findings are interpreted as suggesting a self-fulfilling prophecy in adolescents' postoperative pain experience wherein teens who expect to have high levels of postoperative pain ultimately report more pain and use more opioid PCA medication than those who report lower levels of pain.

Obstetric regional analgesia services in New Zealand: a national survey

AIMS

To investigate the availability and pattern of obstetric regional analgesia services in New Zealand.

METHODS

A postal survey of all registered obstetric facilities in New Zealand for year 2000 was carried out.

RESULTS

A total of 87 obstetric facilities were identified. Sixty-two percent of them responded to our survey, which covered 75% of all deliveries in year 2000. Numerous non-pharmacological and systemic analgesia modalities were widely available. Obstetric regional analgesia services were available in 20 facilities (38%), which provided obstetric care for 92.5% of all deliveries identified in this survey. Only the number of deliveries per year in a facility was associated with the availability of obstetric regional analgesia services (OR: 1.03; 95% CI: 1.01-1.06; p=0.03), not the location of the facility, whether in non-major urban or major urban areas. Among all the obstetric regional analgesia techniques that were available, patient controlled epidural analgesia (PCEA) was not widely used at the time of this survey.

CONCLUSIONS

Availability of obstetric regional analgesia services in New Zealand is very geographically focused, and appears to match closely with the distribution of obstetric deliveries in New Zealand.

A background infusion of morphine enhances patient-controlled analgesia after cardiac surgery

PURPOSE

We compared the efficacy of patient-controlled analgesia (PCA), with or without a background infusion of morphine, on postoperative pain relief in patients extubated in the operating room after coronary artery bypass grafting (CABG) surgery.

METHODS

With Faculty Ethics approval, 60 consenting adults undergoing elective coronary artery surgery were randomly assigned to receive either morphine PCA alone (group PCA-A, n = 30) or morphine PCA plus a background infusion (group PCA-B, n = 30) for 24 hr postoperatively. Pain scores with verbal rating scale (VRS; from 0 to 10) at rest, sedation scores, morphine consumption and delivery/demand ratios were assessed at zero, one, two, four, six, 12 and 24 hr after surgery. Hemodynamic variables and arterial blood gases were also recorded in the same periods.

RESULTS

Sedation scores in the two groups were similar. At all study periods after the first postoperative hour, VRS remained below 5 in both groups. Pain scores were significantly lower in the background infusion group, which also had greater cumulative morphine consumption (61.7 +/- 10.9 mg vs 38.5 +/- 16.2 mg). There were no episodes of hypoxemia or hypertension.

CONCLUSION

Morphine PCA effectively controlled postoperative pain after cardiac surgery. The addition of a background infusion of morphine enhanced analgesia and increased morphine consumption.

Patient-controlled deep brain stimulation can overcome analgesic tolerance

We report a technique based on patient-controlled stimulation to restore analgesia after development of tolerance to deep brain stimulation (DBS). A 45-year-old female with neurogenic pain after cerebellar stroke underwent DBS implantation in the right ventralis caudalis (VC) thalamus with excellent stimulus-controlled analgesia for 29 months, followed by development of tolerance and loss of analgesia. Analgesia was restored when a stimulation module that allowed patient-controlled stimulation was implanted.

Pain levels experienced with activities after cardiac surgery

BACKGROUND

Acute pain is common after cardiac surgery and can keep patients from participating in activities that prevent postoperative complications. Accurate assessment and understanding of pain are vital for providing satisfactory pain control and optimizing recovery.

OBJECTIVES

To describe pain levels for 5 activities expected of patients after cardiac surgery on postoperative days 1 to 6 and changes in pain levels after chest tube removal and extubation.

METHODS

Adults who underwent cardiac surgery were asked to rate the pain associated with various types of activities on postoperative days 1 to 6. Pain levels were compared by postoperative day, activity, and type of cardiac surgery. Pain scores before and after chest tube removal and extubation also were analyzed.

RESULTS

Pain scores were higher on earlier postoperative days. The order of overall pain scores among activities (P < .01) from highest to lowest was coughing, moving or turning in bed, getting up, deep breathing or using the incentive spirometer, and resting. Changes in pain reported with coughing (P = .03) and deep breathing or using the incentive spirometer (P = .005) differed significantly over time between surgery groups. After chest tubes were discontinued, patients had lower pain levels at rest (P = .01), with coughing (P = .05), and when getting up (P = .03).

CONCLUSIONS

Pain relief is an important outcome of care. A comprehensive, individualized assessment of pain that incorporates activity levels is necessary to promote satisfactory management of pain.

Patient-controlled analgesia for sickle cell pain crisis in a pediatric emergency department

OBJECTIVE

To determine whether a protocol to start patient-controlled analgesia (PCA) in the emergency department (ED-PCA) would shorten the length of time between narcotic bolus doses and PCA initiation as compared with standard inpatient initiation of PCA (IP-PCA). Also, to compare patient satisfaction and inpatient length of stay for the 2 groups.

METHODS

To improve care, we developed a protocol to institute ED-PCA after an initial bolus dose of narcotics. This was a nonrandomized pilot study. Patient records were reviewed for location of PCA initiation, time from narcotic bolus to initiation of PCA, and length of stay. A brief patient/parent satisfaction survey was collected.

RESULTS

Sixty-nine records were reviewed. Patients treated using the protocol had initiation of PCA therapy within 35 +/- 7 minutes from the last bolus narcotic dose in the emergency department versus 211 +/- 17 minutes for nonprotocol patients. Forty-eight of 50 patient surveys indicated preference for starting ED-PCA; 2 did not have a preference. No complications were identified in either group.

CONCLUSIONS

A protocol to initiate PCA for sickle cell patients in a pediatric emergency department shortened the time of its initiation and was preferred by patients.

A background infusion of morphine does not enhance postoperative analgesia after cardiac surgery

PURPOSE

To compare the effects of patient-controlled analgesia (PCA), with or without a background infusion of morphine on postoperative pain relief and stress response after cardiac anesthesia.

METHODS

With University Ethics approval, 35 consenting adults undergoing elective open-heart surgery were randomly assigned preoperatively in a double-blind fashion to receive either morphine PCA alone (Group I, n = 15) or morphine PCA plus a continuous basal infusion (Group II, n = 14) for 44 hr postoperatively. Pain scores with visual analogue scale (VAS) at rest, deep inspiration and with cough, sedation scores, stress hormone levels [cortisol, adrenocorticotropin (ACTH) and growth hormone (GH)] and morphine consumption were assessed, and serum morphine levels were measured at four, 20, 28 and 44 hr after surgery. Adverse effects including nausea, vomiting, constipation, urinary retention and pruritus were noted. Total blood, fluid requirements, drainage and urinary output were recorded.

RESULTS

Postoperative morphine consumption at 44 hr was less in Group I (29.43 +/- 12.57 mg) than in Group II (50.14 +/- 16.44 mg), P = 0.0006. There was no significant difference between groups in VAS scores, GH levels, blood levels of morphine and adverse effects. While VAS scores, ACTH and GH levels decreased significantly in both groups, plasma cortisol levels increased significantly in Group I only at four hours. In Group II, ACTH and cortisol were higher at four and 44 hr respectively.

CONCLUSION

PCA with morphine effectively controlled postoperative pain after cardiac surgery. The addition of a background infusion of morphine did not enhance analgesia and increased morphine consumption.

Intrathecal + PCA morphine improves analgesia during the first 24 hr after major abdominal surgery compared to PCA alone

PURPOSE

To compare, over a 48-hr follow-up period, the analgesia and side-effects of patient controlled iv analgesia (PCA) with morphine alone vs combined intrathecal and PCA morphine (IT+PCA) in patients undergoing major abdominal surgery.

METHODS

Sixty adult patients undergoing abdominal surgery for cancer were randomly allocated to receive preoperative IT (0.3 or 0.4 mg) plus postoperative PCA morphine or postoperative PCA morphine alone. Postoperative analgesia was tested at rest and while coughing on a visual analogue pain scale and morphine consumption was recorded. Patients' satisfaction, arterial oxygen saturation, respiratory rate, episodes of nausea, vomiting and pruritus were also noted.

RESULTS

Analgesia at rest and while coughing was significantly better in the IT+PCA morphine group (rest: P = 0.01; coughing: P = 0.005) on the first postoperative day only. IT+PCA morphine constantly provided adequate analgesia during this period. Morphine consumption was lower in the IT+PCA morphine group during this period also (IT+PCA: 9 (17) vs PCA: 40 (26); mg of morphine, mean (SD), P = 0.0001). No difference was found in pain relief and morphine consumption between the groups on the second postoperative day. Nausea and vomiting were more frequent with IT+PCA morphine on the first postoperative day. No respiratory depression occurred in either group. Satisfaction was high in both groups.

CONCLUSIONS

IT+PCA morphine improves patient comfort constantly during the first postoperative day after major abdominal surgery. However, after the first postoperative day, IT+PCA morphine provides no additional benefit.

Non-opioid analgesia improves pain relief and decreases sedation after gastric bypass surgery

PURPOSE

Several non-opioid drugs have been shown to provide analgesia during and after surgery. We compared sevoflurane anesthesia with fentanyl analgesia to sevoflurane and non-opioid drug treatment for gastric bypass surgery and recovery.

METHODS

Thirty obese patients (body mass index > 50 kg.m(-2)) undergoing gastric bypass were randomized to receive sevoflurane anesthesia with either fentanyl or a non-opioid regimen including ketorolac, clonidine, lidocaine, ketamine, magnesium sulfate, and methylprednisolone. Morphine use by patient-controlled analgesia (PCA) pump and pain score measured by visual analogue scale were determined in the postanesthesia care unit (PACU) and for the first 16 hr after surgery. Sedation was evaluated in the PACU. Investigators assessing patient outcomes were blinded to the study group.

RESULTS

Fentanyl treated patients were more sedated in the PACU compared to the non-opioid group. Non-opioid treated patients required 5.2 +/- 2.6 mg.hr(-1) morphine by PCA during their stay in the PACU while patients anesthetized with fentanyl used 7.8 +/- 3.3 mg.hr(-1) (P < 0.05). Fentanyl and non-opioid treated patients showed no difference in pain score one or 16 hr after surgery.

CONCLUSION

Our results show that non-opioid analgesia produced pain relief and less sedation during recovery from gastric bypass surgery compared to fentanyl.

Management of vaso-occlusive pain in children with sickle cell disease

PURPOSE

A descriptive, longitudinal design was used to evaluate the pain management strategies used in children with sickle cell disease who were experiencing pain during a vaso-occlusive episode.

METHODS

A list of the medications (name, amount, mode of delivery, and frequency) prescribed and administered for pain management for each participant was recorded on the Medication Quantification Scale Worksheet, starting from day 1 of hospitalization to the day of discharge. Children were asked once each evening to provide three separate ratings of how much the pain medication helped them during the day, evening, and night using a 0-to-10 rating scale.

RESULTS

Using patient-controlled analgesia (PCA), children self-administered only 35% of the analgesic medications that were prescribed and reported little pain relief. No significant relationships were found between changes in pain relief scores and the amount of analgesics administered.

CONCLUSIONS

Clinicians need to monitor the amount of analgesics delivered in relationship to pain relief and assist children to titrate PCA administration of analgesics to achieve optimal pain control, or to advocate for changes in the PCA regimen when children cannot assume control of pain management.

Intravenous patient-controlled analgesia after thoracotomy: a comparison of morphine with tramadol

BACKGROUND AND OBJECTIVE

This study examined the quality of analgesia together with the side-effects produced by tramadol compared with morphine using intravenous patient-controlled analgesia during the first 24 h after thoracotomy.

METHODS

Forty-four patients scheduled for thoracotomy were included in the study. Morphine 0.3 mg kg(-1) was given interpleurally 20 min before a standard general anaesthetic. In the postanaesthetic care unit, the patients were randomly allocated to one of two groups to self-administer tramadol or morphine using a patient-controlled analgesia device throughout a 24 h period. The patient-controlled analgesia device was programmed to deliver tramadol 20 mg as an intravenous bolus or morphine 2 mg with a lockout time of 10 min.

RESULTS

Mean cumulative morphine and tramadol consumption were 48.13 +/- 30.23 and 493.5 +/- 191.5 mg, respectively. There was no difference in the quality of analgesia between groups. Five (26.3%) patients in the tramadol group and seven (33%) in the morphine group had nausea, and three of the latter patients vomited. The incidence rate of vomiting with tramadol was 5.2%. All vital signs were within safe ranges. Sedation was less in the tramadol group, but not statistically significant.

CONCLUSIONS

In this clinical setting, which includes interpleural morphine pre-emptively, postoperative analgesia provided by tramadol was similar to that of morphine at rest and during deep inspiration. Side-effects were slight and comparable between the patients receiving morphine and tramadol.

Patient-controlled bupivacaine wound instillation following cesarean section: the lack of efficacy of adjuvant ketamine

STUDY OBJECTIVE

To assess the analgesic efficacy of ketamine when administered as an adjuvant to bupivacaine for patient-controlled wound instillation following cesarean section.

DESIGN

Prospective, randomized, double-blind study.

SETTING

Large referral hospital.

PATIENTS

50 term parturients undergoing cesarean section.

INTERVENTION

In all cases, a standard spinal anesthetic was administered. On completion of the surgery, a multihole 20 G epidural catheter (B. Braun, Melsungen, Germany) was placed above the fascia such that the tip was sited at the point which demarcated 50% of the length of the surgical wound. Thereafter, the catheter was connected to a patient-controlled drug delivery device. The device was filled with either 0.125% bupivacaine (bupivacaine group) or 0.125% bupivacaine and ketamine (1 mg/mL) (bupivacaine-ketamine group). Postoperatively, wound instillation was performed via the patient-controlled analgesia device. During the first 6 postoperative hours, a co-investigator administered "rescue" morphine (2 mg IV). Thereafter, "rescue" dipyrone (1 g) was administered on patient request.

MEASUREMENTS AND MAIN RESULTS

At all time intervals, visual analog scale (VAS) for pain at rest, on coughing, and during leg raise were similar between the groups. All patients (100%) in both treatment groups received "rescue" morphine. Similarly, the number of doses of 2 mg "rescue" morphine administered was unaffected by patient randomization. The total "rescue" morphine administered during the first 6 postoperative hours was 11.2 +/- 4.6 mg versus 11.3 +/- 5.6 mg for the bupivacaine group and bupivacaine-ketamine group, respectively. The number of pump infusions during the 24-hour study period was 9 +/- 2 and 9 +/- 3 for the bupivacaine group and bupivacaine-ketamine group, respectively. The volume infused via the delivery device was similar between the groups (81 +/- 18 mL vs. 85 +/- 24 mL for the bupivacaine group and bupivacaine-ketamine group, respectively). Psychomental and cognitive function as measured by the Digit Symbol Substitution and Mini Mental Tests were unaffected by adjuvant ketamine administration. Patient satisfaction was similar between the groups.

CONCLUSION

Adjuvant local ketamine does not enhance bupivacaine-induced wound instillation following cesarean section.

[Postoperative pain therapy in Germany]

OBJECTIVE

A survey was performed to obtain information on the organization and practice of postoperative pain management.

METHODS

A questionnaire was mailed to 773 directors of German departments of anesthesiology.

RESULTS

A total of 446 replies (57.7%) could be analyzed. Of the departments, 161 (36.1%) had established an acute pain service (APS), more often in hospitals > or = 1000 beds (63%) than in hospitals with 400-999 beds (40%) and hospitals with < 400 beds (27%). Epidural analgesia was practiced in 97% of the departments, however, it was the analgesic technique of choice for larger abdominal surgery or amputation of the lower limb only in 60.8% and 45.5% of the departments, respectively. Departments with APS provided epidural analgesia more often on general wards than departments without APS (88.2% vs. 68.4%, p < 0.01). Technically more challenging methods (e.g. catheters for regional anesthesia, PCA, PCEA) were more often provided in hospitals running an APS (p < 0.001).

CONCLUSIONS

The number of departments with APS has increased over the last 10 years. Future decisions on reimbursement should consider this extensive service.

Patient safety, potential adverse drug events, and medical device design: a human factors engineering approach

Adverse drug events are the single leading threat to patient safety. Human factors engineering has been repeatedly proposed, but largely untested, as the key to improving patient safety. The value of this approach was investigated in the context of a commercially available patient-controlled analgesia device that has been linked with several alleged patient injuries and deaths. Several reports have stated that errors in programming drug concentration were made during these adverse drug events. A simulation of the commercially available interface was compared experimentally with a simulated prototype of a new interface designed according to a human factors process. Professional nurses, averaging over 5 years of clinical experience with the commercially available interface and only minimal experience with the new interface, programmed both interfaces. The new interface eliminated drug concentration errors, whereas the simulated commercially available interface did not. Also, the new interface led to significantly fewer total errors and faster performance. These findings may have broad implications for the design, regulation, and procurement of biomedical devices, products, or systems that improve patient safety in clinical settings.

High-dose intrathecal diamorphine for analgesia after Caesarean section

Forty women undergoing elective Caesarean section under spinal anaesthesia using hyperbaric 0.5% bupivacaine were randomly allocated to receive either 0.5 mg or 1 mg intrathecal diamorphine. All women received diclofenac 100 mg at the end of surgery and morphine via a patient-controlled analgesia system. Oral analgesics were not used. Postoperative analgesia was more prolonged and more reliable in the 1-mg group. Mean time to first analgesia was 10.2 h in the 1-mg group and 6.9 h in the 0.5-mg group, and 45% in the 1-mg group used no morphine, compared with 10% in the 0.5-mg group. Mean morphine consumption over 24 h was 5.2 mg in the 1-mg group and 10.6 mg in the 0.5-mg group. Pain scores all tended to be lower in the 1-mg group but this was only significant at 4 h. There were no serious side-effects. Minor side-effects were common but well tolerated, and the incidence did not differ between the groups. If intrathecal diamorphine is used in combination with rectal diclofenac and without oral analgesia, then 1 mg provides superior analgesia to 0.5 mg without any worsening of the side-effects.

Satisfaction in childbirth and perceptions of personal control in pain relief during labour

Satisfaction in childbirth is influenced by individual and environmental factors. Of specific interest in this study is the extent to which women feel that they have been able to control what happened to them during labour. The main purpose of this study was to examine the influence of personal control on women's satisfaction with pain relief during labour. A questionnaire-based retrospective study of women's pain experiences within 48 hours of delivery was carried out on the postnatal ward of one teaching hospital in Northern Ireland. One hundred women who had had a vaginal delivery consented to take part in the study. Two main measures were used in the study; personal control in and satisfaction with pain relief during labour. The key finding of this study indicates that feelings of personal control influenced positively the women's satisfaction with pain relief during labour. Demographic and other psycho-social variables had little impact on the women's satisfaction scores. These findings have implications for clinical practice and for the management of maternity services and are discussed.

Acute pain services in Europe: a 17-nation survey of 105 hospitals. The EuroPain Acute Pain Working Party

A 17-nation survey was undertaken with the aim of studying the availability of acute pain services (APS) and the use of newer analgesic techniques, such as epidural and patient-controlled analgesia (PCA). A questionnaire was mailed to selected anaesthesiologists in 105 European hospitals from 17 countries. Depending on the population, between five and ten representative hospitals from each country were selected by a country coordinator. A total of 101 (96.2%) completed questionnaires were returned. A majority of respondents were dissatisfied with pain management on surgical wards. Pain management was better in post-anaesthesia care units (PACUs); however, 27% of participating hospitals did not have PACUs. There were no organized APS in 64% of hospitals, although anaesthesiologists from chronic pain centres were available for consultation. In the hospitals that had APS, the responsible person for the APS was either: (1) a junior anaesthesiologist (senior anaesthesiologist available for consultation); or (2) a specially trained nurse (supervised by consultant anaesthesiologists). Many anaesthesiologists were unable to introduce techniques such as PCA on wards because of the high equipment costs. Although 40% of hospitals used a visual analogue scale (VAS) or other methods for assessment of pain intensity, routine pain assessment and documenting on a vital sign chart was rarely practised. There was a great variation in routines for opioid prescription and documentation procedures. Nursing regulations regarding injection of drugs into epidural and intrathecal catheters also varied considerably between countries. This survey of 105 hospitals from 17 European countries showed that over 50% of anaesthesiologists were dissatisfied with post-operative pain management on surgical wards. Only 34% of hospitals had an organized APS, and very few hospitals used quality assurance measures such as frequent pain assessment and documentation. There is a need to establish organized APS in most hospitals and also a need for clearer definition of the role of anaesthesiologists in such APS.

[Postoperative peridural analgesia. Continuous versus patient-controlled administration of a low-dose mixture of sufentanil, clonidine and bupivacaine]

The purpose of our study was to find out whether patient-controlled epidural administration (PCEA) of a mixture containing a low-dose local anaesthetic, opioid and alpha 2-agonist provides as good or better postoperative analgesia as continuous epidural administration of the same analgetic solution.

METHODS

30 patients (ASA I-III), scheduled for major abdominal surgery, were randomly divided into 2 groups. 90 minutes after induction of general anaesthesia all patients received a continuous epidural infusion of 5 ml/h of the analgetic solution (50 micrograms sufentanil + 150 micrograms clonidine in 50 ml 0.125% bupivacaine) until the end of surgery. Immediately postoperatively the patients of group A received a continuous infusion of the study solution (5-8 ml/h), the patients of group B received a baseline continuous epidural infusion (3 ml/h), additionally they could self-administer 5 ml boli via a PCEA device. Measurements included the total dose of infused drug solution, pain at rest and on exercise by a visual analogue scale, cardiorespiratory data and side effects within the first 24 hours postoperatively. A standardised interview on analgesia and side effects was held 2 days after surgery.

RESULTS

The PCEA group demanded less epidural analgesics (gr. B: 112 +/- 33 ml vs. gr. A: 135 +/- 20 ml) p < 0.01). Both continuous epidural infusion and patient-controlled administration provided very good analgesia at rest (gr. A: VAS 0.4 +/- 0.4 and gr. B: VAS 0.4 +/- 0.5) (n.s.). On exercise continuous epidural infusion of analgesics resulted in significantly lower pain scores (gr. A: 1.9 +/- 1.1) than patient-controlled application (gr. B: 3.4 +/- 1.1) (p < 0.01). We did not notice severe side effects such as respiratory depression or drop of heart rate or blood pressure.

CONCLUSION

In patients at rest both continuous and patient-controlled epidural administration of analgesics provides excellent analgesia after major abdominal surgery. Contrariwise, patients on exercise who could use a PCA-device experienced more pain compared to those with a continuous epidural infusion technique. On the other hand the patients of the PCA-group consumed less epidural analgesics. We did not notice any severe side effects such as respiratory depression or cardiovascular instability during the study.