Administration Of Bupivacaine Research Articles

Pharmacologic and physiologic influences affecting sensory evoked potentials: implications for perioperative monitoring.

Pharmacologic and physiologic influences affecting sensory evoked potentials: implications for perioperative monitoring.

242 Phase I study of irinotecan (I), raltitrexed (R), and 5-fluorouracil (5FU) in the treatment of metastatic colorectal cancer (MCRC) refractory to thymidylate synthase inhibitors (TSI)

This study compared a simplified method of intrapleural bupivacaine administration with traditional analgesic therapy to decrease postoperative pain and opioid usage in patients after thoracoscopy.Thirty patients who had non-rib-spreading thoracoscopic operations under general anesthesia were prospectively randomized to no local anesthetic infusion (control), intermittent bolus (30 mL every 6 hours), or continuous infusion (5 mL/h). Bupivacaine (0.25%) was delivered through the pleural infusion channel of a specially designed single silicone 28F chest tube. Total intravenous fentanyl patient-controlled analgesia (boluses with basal rate) infused in the first 24 hours postoperatively was the designated primary study end point. Escalations of analgesic therapy, including ketorolac administration, were standardized across all groups. Nurses assessed pain control at onset and every 6 hours by visual analog pain scales (VAPS, 100 mm). VAPS were repeated 10 minutes later to assess any opioid or bupivacaine bolus effects.No study-related adverse events occurred. Compared with controls, pooled VAPS scores and 24-hour fentanyl consumption were significantly lower for the intermittent and continuous administration groups (1753 vs 1180 vs 1177 μg/24 h, respective median; p = 0.04) Early (6-hour) VAPS analgesic responses were more certain for intermittent (10 of 10) and continuous (10 of 10) patients than controls (7 of 10, p = .04). Five continuous patients successfully maintained VAPS scores below 20 mm throughout the study vs 3 intermittent and 2 controls (p = .045).Intermittent or continuous intrapleural bupivacaine infused through the chest tube reliably reduces postoperative pain and 24-hour opioid usage in thoracoscopy patients.

Comparative, Double-Blind, Randomized, Placebo-Controlled Trial of Intraperitoneal of Bupivacaine and Lidocaine for Pain Control after Diagnostic Laparoscopy

Study Objective To compare the effect of intraperitoneal bupivacaine and lidocaine on reducing pain after diagnostic laparoscopy. Design Randomized, double-blind, placebo-controlled study (Canadian Task Force classification I). Setting University teaching hospital. Patients One hundred thirty-four women with unexplained infertility. Intervention Diagnostic laparoscopy with intraperitoneal administration of bupivacaine or lidocaine. Measurements and Main Results Patients were randomized into one of four groups. In group A, at the end of laparoscopy 0.125% bupivacaine 30 ml was instilled into the pelvic cavity and the same dose was instilled over the diaphragmatic vault. Groups B and C received the same volume of 5% lidocaine and normal saline, respectively. Group D received no intraperitoneal agent. The verbal pain scale questionnaire was used to assess postoperative pain. Pain scores 2 and 24 hours post operatively were significantly lower for group A than for groups B and C (p = 0.0001). Scores in group B were also significantly lower than those in groups C and D (p = 0.0001). Women in group A required less additional analgesia than those in the other groups. Conclusion Compared with lidocaine and placebo, intraperitoneal bupivacaine significantly decreased postoperative pain, and this effect was long lasting.

Hypercarbic and Hypoxic Ventilatory Responses After Intrathecal Administration of Bupivacaine and Sameridine

Hypercarbic and Hypoxic Ventilatory Responses After Intrathecal Administration of Bupivacaine and Sameridine

Effects of intramuscular administration of lidocaine or bupivacaine on induction and maintenance doses of propofol evaluated by bispectral index

Interest in combining local and general anaesthesia has lead to studies investigating possible interactions. In a prospective, randomized, double-blind study, we tested whether local anaesthetics administered i.m. potentiate the hypnotic effect of propofol. Sixty patients (three groups, n=20) undergoing lower abdominal surgery with total i.v. propofol anaesthesia were investigated. Patients in Group B received i.m. bupivacaine (5 mg ml(-1)) 1 mg kg(-1), patients in Group L received i.m. lidocaine (100 mg ml(-1)) 2 mg kg(-1) and patients in Group C received i.m. saline 5 ml before operation. Hypnosis was measured with bispectral index (BIS). The induction (BIS <45), and the maintenance doses of propofol (BIS between 40 and 50) were significantly less in Group B and Group L compared with the control group. Induction doses were 1.58 (SD 0.39), 1.56 (0.24) and 2.03 (0.33) mg kg(-1) respectively; P<0.0001. Maintenance doses were 6.33 (2.06), 7.08 (1.23) and 9.95 (2.02) mg kg(-1) respectively in the first hour; P<0.0001. Groups B and L were associated with an attenuated haemodynamic response to both induction and intubation. I.M. administered local anaesthetics are associated with a decrease in both the induction and maintenance doses of propofol during total i.v. anaesthesia and a reduction in haemodynamic responses.

Investigation of systemic bupivacaine toxicity using the in situ perfused working heart-brainstem preparation of the rat.

The inadvertent systemic administration of bupivacaine has been associated with fatal cardiovascular collapse. Systemic bupivacaine may affect neural control of the cardiovascular system in addition to having toxic actions on the heart. The study tested the hypothesis that systemic bupivacaine has toxic effects on brainstem cardiorespiratory control. The working heart-brainstem preparation (WHBP) of rat was used to examine the actions of bupivacaine administered either by arterial injection or brainstem microinjection. The WHBP is a decerebrate rostral-half of a bisected rat, which is artificially perfused with a carbogenated Ringer solution via the aorta. Phrenic nerve activity, perfusion pressure, and electrocardiographic results were recorded. Systemic bupivacaine (3 microg/ml) evoked a prolonged pressor response (10.5 +/- 5 mmHg) associated with marked bradycardia (-45 +/- 22 beats/min) and prolonged the PR and QRS intervals of the electrocardiogram. The amplitude of respiratory sinus arrhythmia was attenuated (64 +/- 15%) by bupivacaine without affecting activity recorded from the phrenic nerve. Bupivacaine selectively attenuated the baroreflex gain (55 +/- 19%) but had no effect on the peripheral chemoreflex-evoked bradycardia. The bradycardia elicited by stimulation of the aortic depressor nerve was inhibited by bupivacaine, indicating baroreflex inhibition within the brainstem. Furthermore, bilateral microinjections of bupivacaine in the nucleus of the solitary tract reversibly inhibited the baroreflex. These results demonstrate that arterial concentrations of bupivacaine that previously were shown to be cardiotoxic can selectively affect key cardiovascular control processes within the brainstem. Such impairment of neural cardiovascular control may contribute to the cardiovascular collapse associated with systemic bupivacaine.

The BCH Epidural System, a safe system for epidural infusion analgesia in children

Epidural infusions in children are usually delivered by syringe drivers because of the lower volumes of local anaesthetic solutions used in children rather than in adult practice. Recently concern has arisen both via the media and anecdotally over a number of adverse events associated with intravenous administration of bupivacaine. We have designed and validated a system that should significantly reduce the possibility and incidence of this adverse effect. image [ The system is based on the reversal of the standard luer‐lock system. ]A female 60 cc syringe is connected to a reversed 150 cm infusion line that is connected to a male epidural filter. The filter connects with standard epidural infusion catheters. The reversal of the luer‐lock system requires that devices are also available for the initial doses of local anaesthetic, for the preparation of the epidural infusion syringe and for administration of rescue boluses of local anaesthetic.With this system it is extremely unlikely that the epidural syringe or infusion catheter can be connected to an intravenous line. It is also less likely that intravenous drugs may be connected to the epidural filter.

The effect of intra-articular neostigmine, tramadol, tenoxicam and bupivacaine on postoperative pain

Objctive: The present study, investigates the analgesic effects and complications of intra-articular neostigmine, tramadol, tenoxicam and bupivacaine on postoperative pain in patients undergoing day case knee arthroscopy. Subjects: Group 1 received 0.5 mg neostigmine, Group 2 received 100 mg tramadol, Group 3 received 20 mg tenoxicam, Group 4 received 20 ml 0.5% bupivacaine (control) in 20 ml normal saline intra-articularly at the end of the surgery. All patients had the same anaesthetic technique. Patients were observed in the recovery room with respect to pain scores, haemodynamic changes and postoperative analgesia at 1, 2 and 4 h postoperatively. Analgesic therapy in the recovery room was managed with 25 mg bolus doses of meperidine when the patients had visual analosue scale (VAS) scores higher than three points. The patients were discharged from hospital with a prescription for diclofenac 75 mg to be used as required. They were asked to complete their pain measures at 24 h and record their analgesic consumption. Results: There were no significant differences among the study groups regarding pain scores, haemodynamic changes, the first analgesic requirement time and complications. All patients in our study had adequate postoperative analgesia without any severe complication. Conclusion: Intra-articular administration of neostigmine, tramadol, tenoxicam or bupivacaine is a simple and effective postoperative analgesic technique after outpatient arthroscopic knee procedures.

The use of salvaged blood after intra‐articular administration of bupivacaine

The use of salvaged blood after intra‐articular administration of bupivacaine

Intrathecal Bupivacaine for Chronic Pain: A Review of Current Knowledge

Objective. This article presents an overview of the use of intrathecal bupivacaine (with and without opioid), focusing on laboratory data and clinical use for chronic pain. Some background on epidural use is included to support the intrathecal literature. Materials and Methods. Currently available literature (MEDLINE) regarding the use of intrathecal bupivacaine is reviewed. Prior to presenting the intrathecal bupivacaine data, an overview of data related to bupivacaine stability, microbiology, preclinical toxicology, and pharmacokinetics is presented, along with a brief review of the epidural bupivacaine literature. Results. Based on the current available literature, intrathecal bupivacaine appears to be a safe and acceptable method of treatment for chronic pain in both cancer and noncancer patients. The stability and bacteriologic studies support the use of bupivacaine in external or implantable drug administration devices. Toxicity studies in laboratory animals suggest complications only at plasma levels that would not be seen at clinically relevant doses of intrathecal administration. Bupivacaine is a clinically effective addition to intrathecal opioids. Bupivacaine administration is more effective intrathecally, providing better pain relief than epidural administration. Reports of complications are infrequent. Further studies are needed to define the use of intrathecal bupivacaine and should include long-term safety. Compatibility studies will also be needed when bupivacaine is used in combination with other agents. In addition, outcome studies are needed specifically to differentiate use of intrathecal bupivacaine based on the source and mechanism of pain. Conclusions. While there are few long-term randomized prospective studies at this point, we conclude that intrathecal bupivacaine appears to be a safe and efficacious treatment in both cancer and noncancer pain.

Long-term degeneration and regeneration of the rabbit facial nerve blocked with conventional lidocaine and bupivacaine solutions.

The alterations due to the long-term degeneration and regeneration of the rabbit facial nerve were investigated. The facial nerve was blocked with conventional lidocaine and bupivacaine solutions. The rabbits were sacrificed and facial nerves were removed 2, 4, 6 and 8 weeks after the administration of normal saline, lidocaine and bupivacaine. The samples were then processed for electron microscopic observation. Degenerations were seen 2-4 weeks after the injection of normal saline, lidocaine and bupivacaine. In the normal saline group the regeneration process was observed after 6 weeks, whereas in the lidocaine and bupivacaine groups this process was first noticed after 8 weeks. In the lidocaine and bupivacaine groups, regeneration was not completed at the end of 8 weeks; however, it was faster in the bupivacaine group. Bupivacaine is therefore suggested as the drug of choice for neural blockade as it caused less damage and a faster regeneration.

Intrathecal Administration of Bupivacaine 5mg/ml and Levobupivacaine 5mg/ml to Patients Undergoing Primary Total Hip Replacement Surgery. A Double Blind Efficacy Study

Intrathecal Administration of Bupivacaine 5mg/ml and Levobupivacaine 5mg/ml to Patients Undergoing Primary Total Hip Replacement Surgery. A Double Blind Efficacy Study

Bupivacaine pharmacokinetics and motor blockade following epidural administration of the bupivacaine-sulphobutylether 7-β-cyclodextrin complex in sheep

Bupivacaine pharmacokinetics and motor blockade following epidural administration of the bupivacaine-sulphobutylether 7-β-cyclodextrin complex in sheep

The effectiveness of an anesthetic continuous-infusion device on postoperative pain control

Purpose: To evaluate the effectiveness of an anesthetic continuous-infusion device on postoperative pain after outpatient shoulder surgery. Type of Study: Double-blinded randomized trial. Methods: A prospective, double-blinded, randomized study of 50 consecutive patients undergoing outpatient arthroscopic shoulder surgery was performed. Patients were assigned by computer-generated randomized permuted block of four to 2 groups (25 each) receiving either a saline or 0.5% bupivacaine solution via an infusion pump after surgery. All patients gave informed consent and were randomized immediately before surgery. The surgical team, patient, clinic staff, and data collector were blinded to the randomization. Procedures performed included arthroscopic rotator cuff repairs, SLAP lesion repairs, subacromial decompressions, and capsular reefings. The infusion pump that was tested was used continuously for 48 hours and administered 2 mL each hour. For subacromial and rotator cuff surgery, the catheter was placed in the subacromial space. For glenohumeral surgery, the catheter was placed in the glenohumeral joint. Routine pain-control efforts were continued. Interviews were conducted at 1, 2, and 8 hours after surgery, followed by daily telephone interviews for 1 week. Visual analog scale (VAS), categorical pain scale (Likert) data, and oral medication use data were recorded. Results: Complete data sets were collected from 25 bupivacaine and 24 saline patients because 1 pump malfunctioned and was removed early. The average age of the bupivacaine group patients was 47.4 ± 16.3 years (range, 16 to 84); patients in the saline group had an average age of 46.0 ± 15.5 years (range, 19 to 73). There were 17 men and 8 women in the bupivacaine group and 16 men and 8 women in the saline group. The Likert and VAS mean values showed lower pain scores for the patients using the pump containing bupivacaine than for the saline group at all recorded times ( P < .05) throughout the 7 days of data collection. The interval of greatest pain was on day 2. Postoperative oral medication use was always greater for the saline group than for those receiving bupivacaine. Conclusions: Postoperative pain control after arthroscopic shoulder surgery is essential so that these procedures can be successfully carried out in an outpatient setting. The first 2 postoperative days is the period of greatest pain. Continuous postoperative bupivacaine infusion is effective during this critical period, and the effect lingers even after the infusion is discontinued. The administration of bupivacaine via a continuous-infusion anesthetic pump statistically reduced postoperative pain after outpatient arthroscopic rotator cuff repairs, SLAP lesion repairs, subacromial decompressions, and capsular reefings.

Increasing the Efficacy of a Celiac Plexus Block in Patients with Severe Pancreatic Cancer Pain

The purpose of this study was to evaluate the technical possibilities of placing a catheter near the celiac plexus for performance of a celiac plexus block, and to study the efficacy of repeated neurolytic celiac plexus blocks with alcohol in patients with advanced pancreatic cancer pain resistant to opioid treatment. In 12 patients, a neurolytic celiac plexus block with alcohol, administered via an indwelling celiac catheter, was performed. To evaluate the efficacy, visual analog scale scores were recorded every day. Quality of life scores were registered before and 4 weeks following the procedure. Alterations in opioid consumption, and the time between the diagnosis of pancreatic cancer and the performance of the block, were registered. All patients were followed until they died. Two patients remained without pain after the first neurolytic celiac plexus block. In all other patients a second block was administered which provided only temporary relief. Additional intermittent administration of bupivacaine through the catheter was necessary to provide adequate pain relief in these patients. Quality of life increased significantly during the treatment. Opioid consumption decreased significantly in all patients. Our study indicates that a neurolytic celiac plexus blockade with alcohol results in a significant but short-lasting analgesic effect. The use of a celiac catheter improves the long-term management of pancreatic cancer pain.

Effects of intrathecal sufentanil on plasma oxytocin and cortisol concentrations in women during the first stage of labor

Background and Objectives: Intrathecal sufentanil provides analgesia comparable to epidural bupivacaine for the first stage of labor. Both epidural local anesthetics and intrathecal opioid reduce some parameters of the neuroendocrine response to labor pain and the reflex release of oxytocin in animals. In humans, epidural local anesthetics only reduce the spurt release of oxytocin. This study compared the effect of intrathecal sufentanil and epidural bupivacaine administration on the plasma concentration of oxytocin and cortisol in women with labor pain during the first stage of labor. Methods: Thirty healthy parturients requesting analgesia were enrolled in this randomized and open-label study. Each patient was in spontaneous labor at greater than 5 cm cervical dilatation. Using a combined spinal and epidural technique, patients received either intrathecal sufentanil 10 [mu ]g (SUF = intrathecal sufentanil group) or epidural plain bupivacaine 0.25%, 12 mL (BUPIV = epidural bupivacaine group). Analgesia was assessed using a visual analog scale, and blood samples for oxytocin and cortisol plasma concentration measurements were collected immediately before analgesia and 15, 30, 60, and 90 minutes after induction of the analgesia. Plasma cortisol and oxytocin concentrations were determined by specific radioimmunoassay. The values were expressed as mean [plusmn] SEM. Results: Intrathecal sufentanil provided faster and more complete analgesia within 15 and 30 minutes of its administration, compared with epidural bupivacaine. Plasma oxytocin concentrations were similar in the 2 groups before analgesia (7.24 [plusmn] 2.1 and 6.6 [plusmn] 3.1 pg/mL SUF and BUPIV, respectively). It decreased significantly in the SUF and increased in the BUPIV after analgesic administration. Cortisol concentrations were elevated in both groups before analgesia (51.6 [plusmn] 5.3 and 54.2 [plusmn] 4.8 [mu ]g/dL SUF and BUPIV, respectively). Both analgesic treatments significantly decreased the plasma cortisol levels. Conclusions: Intrathecal sufentanil analgesia decreases plasma concentrations of oxytocin and cortisol in women with labor pain during the first stage of labor, but epidural bupivacaine only reduced the cortisol concentration. Reg Anesth Pain Med 2001;26;545-550.

Randomized prospective study comparing preoperative epidural and intraoperative perineural analgesia for the prevention of postoperative stump and phantom limb pain following major amputation

Background and Objectives: Acute stump pain and phantom limb pain after amputation is a significant problem among amputees with a reported incidence of phantom limb pain in the first year following amputation as high as 70%. Epidural analgesia before limb amputation is commonly used to reduce postamputation acute stump pain in the immediate postoperative period and phantom pain in the first year. We investigated whether immediate postamputation stump pain and phantom pain in the first year is reduced by preoperative epidural block with bupivacaine and diamorphine compared with intraoperative placement of a perineural catheter infusing bupivacaine. Methods: In a randomized prospective trial, 30 patients scheduled for lower limb amputation were randomly assigned epidural bupivacaine at the standard rate used in our hospital (0.166%, 2 to 8 mL/h) and diamorphine (0.2 to 0.8 mg/h) for 24 hours before and during operation (14 patients; epidural group) and 3 days postoperatively, or an intraoperatively placed perineural catheter (16 patients; perineural group) for intra and postoperative administration of bupivacaine (0.25%, 10 mL/h). All patients had general anesthesia for the amputation and were asked about stump and phantom pain in the first 3 days and then at 6 and 12 months by an independent examiner. Study endpoints were rate of stump and phantom pain, intensity of stump and phantom pain, and consumption of opioids. The groups were well matched in baseline characteristics. Results: Stump pain scores in the first 3 days were significantly higher in the perineural group compared with the epidural group (P < .01). After 3 days, 4 (29%) patients in the epidural group and 7 (44%) in the perineural group had phantom pain (P = .32). Numbers of patients with phantom pain for epidural versus perineural group were: 5 (63%) versus 7 (88%) (P = .25) at 6 months; 3 (38%) versus 4 (50%) (P = .61) at 12 months. Stump pain and phantom sensation were similar in both groups at 6 and 12 months. Conclusions: Using our regimen, perioperative epidural block started 24 hours before the amputation is not superior to infusion of local anaesthetic via a perineural catheter in preventing phantom pain, but gives better relief of stump pain in the immediate postoperative period. Reg Anesth Pain Med 2001;26:316-321.

Epidural Analgesia with a Combination of Bupivacaine and Buprenorphine in Rats

We determined the analgesic effects of epidural administration of either bupivacaine at 62.5, 125, 250, and 500 micrograms/kg; buprenorphine at 5 and 10 micrograms/kg; and the combination of bupivacaine at 125 micrograms/kg and buprenorphine at 5 or 10 micrograms/kg, using the tail flick (TF) and colorectal distension (CD) tests in rats and compared the results with those obtained using morphine at 100 micrograms/kg. In both the TF and CD tests, all doses of bupivacaine alone produced potent anti-nociceptive effects, although the effect rapidly diminished after 20-30 min of administration. The administration of buprenorphine at 10 and 5 micrograms/kg produced mild to moderate anti-nociceptive effects in both the TF and CD tests, and the effects were relatively constant throughout the 2-h experimental period. Combinations of 5 or 10 micrograms/kg of buprenorphine with 125 mg/kg of bupivacaine produced a significantly higher percentage of maximum possible analgesic effect (%MPE) than that of the calculated additive effect of each drug alone in the TF and CD tests. The analgesic effect of this combination was similar to that of morphine. Minimal ataxia was observed in rats administered this combination.

Effects of Local Bupivacaine Instillation on Pain after Laparoscopy

Study Objective To evaluate the effect of preincisional and intraperitoneal bupivacaine administration on immediate and late pain after operative laparoscopy. Design Randomized study (Canadian Task Force classification I). Setting University teaching hospital. Patients One hundred fifty women undergoing laparoscopy for various gynecologic indications. Intervention A dose of 0.5% bupivacaine 10 ml (50 mg) was injected into cannula sites before incisions and another 10 ml diluted with 100 ml saline into the peritoneal cavity at completion of the procedure. Equal amount of physiologic saline was used in controls. Measurements and Main Results Modified McGill pain intensity scores and amount of analgesic required in the recovery room and within 24 hours postoperatively were evaluated. Of 150 women, 142 completed the study (71 bupivacaine group, 71 controls). Groups did not differ significantly in body mass index, duration of surgery, return to consciousness, and analgesic requirement during 3-hour observation in the recovery room and 24 hours after discharge. Pain scores were highest 30 minutes after the procedure in both groups. At that time the pain score in the bupivacaine group was lower than that in the control group (1.8 ± 0.2 vs 2.3 ± 0.2, p <0.05). Beyond that time, the groups did not differ in pain scores and analgesic requirements. Conclusion Postoperative pain is the highest within 30 minutes after laparoscopy. Local instillation of bupivacaine before incision and intraperitoneally was effective in reducing pain immediately after operative laparoscopy, but the effect was not seen beyond 30 minutes.

Evidence that postoperative pain is a mediator of the tumor-promoting effects of surgery in rats

We have previously shown in rats that the provision of analgesic doses of morphine significantly reduces the tumor-promoting effects of undergoing and recovering from surgery. Because morphine had no effect in non-operated animals, and because a single preoperative dose given hours before tumor inoculation was effective, we have suggested that it is the pain-relieving effects of the drug that underlies its beneficial impact. To support and strengthen this suggestion, two different regimens of analgesia were employed, the systemic administration of the more selective μ-agonist, fentanyl, and the intrathecal (i.t.) administration of bupivacaine plus morphine. To assess host resistance against metastasis, we used a lung clearance assay of the MADB106 mammary adenocarcinoma, a natural killer (NK)-sensitive syngeneic cell line that metastasizes only to the lungs. Female and male Fischer 344 rats were randomly assigned to one of four groups using a 2×2 experimental design: experimental laparotomy under halothane anesthesia versus anesthesia alone, by drug treatment versus vehicle. In the first in vivo experiment, fentanyl was administered 20 min before surgery (40 μg/kg subcutaneously (s.c.)), and at the end of surgery in a slow-release suspension (20 μg/kg s.c.). In the second in vivo experiment, bupivacaine (10 μg) plus morphine (20 μg) in 50 μl was administered i.t. before surgery. Surgery resulted in a 3- to 4-fold increase in the lung retention of MADB106 cells in both males and females, and the observed surgery-induced increase in lung tumor retention was reduced by more than 65% in the fentanyl-treated animals and more than 45% in the animals receiving i.t. bupivacaine plus morphine. Neither drug regimen exerted effects in the anesthesia only animals. Surgery also resulted in a significant suppression of whole blood NK activity assessed at 5 h postoperatively, the same time point at which MADB106 tumor cells were inoculated in the in vivo studies. Unlike the in vivo study, fentanyl suppressed NK activity at this time point in non-operated rats, but had no effect in operated rats. Taken together, these findings strengthen the suggestion that the management of perioperative pain is a critical factor in preventing surgery-induced decreases in host resistance against metastasis. If similar relationships between pain and metastasis occur in humans, then pain control must become a priority in the postoperative care of individuals with cancer.