Intravenous Narcotic Analgesia Research Articles

Hospital Water Birth: Interim Results of a Pilot Randomized Control Trial [ID 2683557

INTRODUCTION: Water birth is a method of pain relief during labor associated with decreased pain and increased satisfaction. Randomized control trials (RCTs) about water birth and safety outcomes are needed. We conducted an RCT of hospital water birth versus land birth to compare maternal/neonatal outcomes, and differences in analgesia/anesthesia use. This is an updated interim analysis of our findings (Clinical trial: NCT05175599). METHODS: After IRB approval, low-risk pregnant adults were offered study participation between 25 and 34 weeks of gestation. Enrollment began January 2022 using a computer-generated 2:1 (water birth-to-land birth) allocation ratio. Participants in both arms were offered routine care and all available pain relief, with those in the water birth arm given the additional option of birth in the tub. Participants in both groups were excluded if they developed risk factors, including hypertension, preterm labor, or nonvertex presentation. Descriptive and inferential statistics were computed. RESULTS: Overall, n=182 have been enrolled and n=157 have given birth. Following exclusions, n=96 (n=67 water birth, n=29 land birth) remained eligible for the study. Significantly fewer participants had epidural or intravenous narcotic analgesia in the water birth group (37.3% versus 82.8% land birth; P<.0001). Ultimately in the water birth group, n=35 (52.2%) gave birth in water. Using the Birth Satisfaction Scale-Revised Indicator scale, water birth patients expressed a significantly higher level of satisfaction (Mdn=33.0 versus 29.0 land birth; P=.009). To date, no adverse events occurred. CONCLUSION: These preliminary findings suggest that when offered to low-risk laboring people, hospital water birth reduces pain and increases satisfaction without leading to adverse events.

A Descriptive Study ofCasualties Evacuated Out ofAfghanistan by Critical Care Air Transport Teams During the Withdrawal ofU.S. Troops.

The War in Afghanistan ended in August 2021. Evacuation from the country was a large effort during the last days of the conflict. During evacuation efforts at Kabul Hamid Karzai International Airport, a suicide bombing occurred necessitating emergent medical care for many injured troops and civilians. The U.S. Air Force Critical Care Air Transport Teams (CCATTs) played a role in the medical care provided during the operations in Afghanistan. We report on in-flight events and interventions that took place during the final days of the Afghanistan withdrawal. We performed a retrospective chart review of patients requiring aeromedical evacuation from the Afghanistan theater of operations by CCATT from July 1 to August 30, 2021. From the CCATT patient care record, data abstractors collected patient characteristics, flight information, vital signs, laboratory values, in-flight interventions, and in-flight events in a study-specific electronic database. We performed descriptive analyses of patient characteristics and in-flight interventions. This study was approved by the San Antonio Institutional Review Board. Nine patients were included in this analysis. Seven out of nine patients were foreign nationals; the remaining two were U.S. Marines. Five patients suffered penetrating injuries from gunshot wounds and four suffered blast injuries. Six received intravenous narcotic analgesia. Four received intravenous sedatives, and four received antibiotics in flight. Two patients required chest tube management. One patient received blood. Three patients were in acute respiratory distress. Severe injuries were sustained during the withdrawal efforts at the end of the War in Afghanistan. Critical Care Air Transport Teams played a role in the care and evacuation of patients out of theater during this unique and unprecedented time. Even given the limitations associated with retrospective studies and a small sample size, information reported in this study can help inform future decisions, and aid in preparatory efforts for future operations, that may require medical care by CCATT.

Deep Inferior Epigastric Perforator Flap (D.I.E.P) for Breast Reconstruction: Impact of Intraoperative Intrathecal Morphine on Outcome

Background: Pain control after breast reconstruction with Deep Inferior Epigastric Perforator (DIEP) often requires intravenous narcotic analgesia and inpatient hospitalization. Intrathecal morphine (ITM) administration analgesia is increasing in popularity because it decreases the use of intravenous analgesic medications and offer comparable pain relief with less systemic side effects. Questions/purposes: The aim of this retrospective study was to evaluate the effect of intrathecal morphine on postoperative morbidity of breast reconstruction by Deep Inferior Epigastric Perforator flap and compare it with intravenous narcotic analgesia. Methods: 269 patients underwent immediate or delayed DIEP reconstruction after mastectomy, by the same surgeon, at Jules Bordet Institute. Patients receiving ITM analgesia (300 μ) were matched 1:3 with patients undergoing intravenous narcotic analgesia for pain control in the same years by the same surgeon. Differences in peri- and postoperative complications across the two groups were assessed. Results: The two groups were comparable in terms of demographic characteristics and factors of morbidity. Intraoperative variables were not statistically different between the groups except for intraoperative blood loss (P = 0.0001), transfusion (P = 0.0001) and Intraoperative liquid requirement (p = 0.0001). Intra and postoperative blood pressure were lower in ITM group (p < 0.05). Patients in ITM group showed lower postoperative analgesia requirement (P < 0,0001), less respiratory complications and less acute respiratory failure (P = 0,003 and P = 0,004, respectively). No statistically significant differences in the length of hospital stay (LOS) were noted Conclusion: We found that intrathecal morphine analgesia was associated with less blood loss and fluid administration, better postoperative pain control, and less respiratory complications with an acceptable security profile than intravenous narcotic analgesia. Clinical relevance: This study suggests that using intrathecal morphine may result in less blood loss and blood transfusion, better postoperative pain control, and less respiratory complications.

THORACIC EPIDURAL ANALGESIA

Objectives: The aim of this study is to determine whether thoracic epiduralanalgesia with bupivacaine is better than intravenous narcotic analgesia for pain relief inthoracotomy patients. Study design: Prospective randomized study. Setting: Department ofThoracic Surgery, Ojha Institute of Chest Diseases and Dow University of Health Sciences.Period: May 2014- Nov 2015. Methods: 144 patients were allocated randomly into 2 Groups.Group A received thoracic epidural analgesia with bupivacaine and Group B received intravenousnarcotic analgesia with tramadol. Pain was monitored in both groups using the VAS pain scaleevery hour for the first 6 hours and then at 20, 24, 30, and 48 hours postoperatively. Results: Itwas observed that Group A patients experienced less pain at rest, coughing and on movementsas compared to patients in Group B throughout the monitoring from first hour to 48 hourspostoperatively. There was no significant difference between the groups in respiratory rate, O2saturation, adverse effects and performance status on day one and day two postoperatively.The mean hospital stay after operation was 7 days in both groups. Conclusions: Optimal painrelief after thoracotomy improves patient recovery and satisfaction. We determined that thoracicepidural analgesia with bupivacaine is better than intravenous narcotic analgesia for pain reliefin thoracotomy patients.

Comparative study between Bupivacaine infiltration in inguinal hernia and intravenous narcotic analgesia a multicenteric study

The object of the study was to assess the pain relief after Bupivacaine infiltration in the wound in the patients following hernioraphy and to compare it with patients who received narcotic analgesia. 400 patients were selected, 200 being allocated to each group. Pain was compared according to pain scale and mobility of the patients post operatively. After the first 6 hours patients who received Bupivacaine were mobilized earlier as compared to 2nd group. This shows that long acting local anesthesia can be used in a day care surgery.

Negligible Effect of Perioperative Epidural Analgesia Among Patients Undergoing Elective Gastric and Pancreatic Resections

BackgroundThere are conflicting data regarding improvements in postoperative outcomes with perioperative epidural analgesia. We sought to examine the effect of perioperative epidural analgesia vs. intravenous narcotic analgesia on perioperative outcomes including pain control, morbidity, and mortality in patients undergoing gastric and pancreatic resections. MethodsWe evaluated 169 patients from 2007 to 2011 who underwent open gastric and pancreatic resections for malignancy at a university medical center. Emergency, traumatic, pediatric, enucleations, and disseminated cancer cases were excluded. Clinicopathologic data were reviewed among epidural (E) and non-epidural (NE) patients for their association with perioperative endpoints. ResultsOne hundred twenty patients (71 %) received an epidural and 49 (29 %) did not. There were no significant differences (P > 0.05) in mean pain scores at each of the four days (days 0–3) among the E (3.2 ± 2.7, 3.2 ± 2.3, 2.3 ± 1.9, and 2.1 ± 1.9, respectively) and NE patients (3.7 ± 2.7, 3.4 ± 1.9, 2.9 ± 2.1, and 2.4 ± 1.9, respectively). Within each of the E and NE patient groups, there were significant differences (P < 0.0001) in mean pain scores from day 0 to day 3 (P < 0.0001). Of the E patients, 69 % also received intravenous patient-controlled analgesia (PCA). Ileus (13 % E vs. 8 % NE), pneumonia (12 % E vs. 8 % NE), venous thromboembolism (6 % E vs. 4 % NE), length of stay [11.0±12.1 (8, 4–107) E vs. 12.2±10.7 (7, 3–54) NE], overall morbidity (36 % E vs. 39 % NE), and mortality (4 % E vs. 2 % NE) were not significantly different. ConclusionsRoutine use of epidurals in this group of patients does not appear to be superior to PCA.

Laparoscopic Appendectomy: Burden or Benefit? A Single-Center Experience

Although laparoscopic appendectomy (LA) is now a common practice, it has not yet become the standard of care because it has no clear advantage when compared to open appendectomy (OA), especially in cases of complicated appendicitis. Moreover, the literature reports an increased incidence of postoperative infections with LA. To review our center's experience with LA and to compare it to the literature. All LAs performed between January 2004 and October 2007 were retrospectively reviewed for age, gross operative findings, pathology reports, operating time, length of hospital stay (LOS), and the time to resume regular diet and reach afebrile status. All patients who presented with phlegmonous appendicitis were treated medically and had a secondary appendectomy. A total of 151 children underwent LA during this period (60 girls, 91 boys); the mean age was 10.4 years (range, 4-16). Forty-five patients (29.8%) presented with perforated appendicitis (PA). Nine patients had normal appendix on pathology. The mean operative time was 58.7 minutes (56.1 minutes for simple appendicitis [SA] and 64.8 minutes for PA). The mean intravenous narcotic analgesia duration was 12.2 hours for SA and 15.1 hours for PA. LOS was 2.82 days for SA and 3.8 days for PA. Regular diet was tolerated 1.47 days postoperatively for SA and 2.4 days for PA. The latter patients remained febrile for an average of 1.9 days. None of the patients presented with intra-abdominal infection postoperatively. Seven patients (4.6%) presented a trocar site infection. Since the introduction of a routine LA in 2004, the operating room time decreased from 66.4 minutes to 51 minutes. This series confirms the safety of LA in almost all cases. The absence of intra-abdominal infections and the low rate of wound infections noted with LA compare favorably with the open approach. This approach is not only advantageous for cosmesis but also allows satisfying parents' requests, helps developing surgeons' laparoscopic skills, and is cost-effective.

Pain management in adult acute sickle cell pain crisis: a view point

The acute pain crisis of sickle cell disease is inadequately treated in many countries. To present a simple protocol that controls acute pain in most adult patients within 72 hours, based on our experience in an area where sickle cell disease is highly prevalent. Patients aged 14 years and above with sickle cell disease presenting with pain crisis are treated initially in the Emergency Room. Those responding adequately are discharged home on oral analgesics while those with persisting pain after 6 hours are treated further, for up to 72 hours, in an Observation Unit attached to the Emergency Room. Narcotic analgesics are administered regularly for the first 24 hours. Using this protocol, acute pain crisis could be terminated or controlled in over 80% of patients within 72 hours. Regular intravenous narcotic analgesia for the initial 24 hours, supplemented by oral analgesia, is useful for adult patients with severe acute sickle cell pain crisis when the pain is inadequately controlled by initial Emergency Room treatment. There may be gender differences in pain perception and response in acute sickle cell pain crisis.

The Efficacy of Continuous Local Anesthetic Infiltration in Breast Surgery: Reduction Mammaplasty and Reconstruction

Pain control after reduction mammaplasty and breast reconstruction with tissue expanders often requires intravenous narcotic analgesia and inpatient hospitalization. Regional and local anesthetic techniques are increasing in popularity because they decrease the use of intravenous analgesic medications and offer comparable pain relief without the systemic side effects. This study examined the use of indwelling catheters for the continuous infiltration of local anesthetic (bupivacaine) in 74 consecutive breast reduction and 74 consecutive tissue expander breast reconstruction patients. Patients entering the study before February of 2003 had conventional methods of analgesia (39 patients for each group), whereas those entering afterwards received the infusion pumps (35 patients for each group). The number of hospital admissions among the breast reduction patients with infusion pumps was significantly less than that for those without pumps (p < 0.01). Pain, measured on a verbal response scale of 0 to 10, while in the recovery room was significantly less in the pain pump group than in the comparison group (p < 0.01), as were cumulative amounts of pain medications (p < 0.01). There were no statistically significant differences in the number of complications or in the rate of nausea or vomiting. The number of inpatient days among the tissue expander reconstruction patients with infusion pumps was not significantly different from that for those without pumps; the average pain score was significantly lower (p < 0.01). The cumulative amounts of pain medication in patients receiving the infusion pump were significantly lower than those in patients without the pumps (p < 0.01). There were no statistically significant differences in the number of complications or in the rate of nausea or vomiting. There were no tissue expander infections in patients with the indwelling catheters adjacent to the implant. The continuous infiltration of local anesthetic with an infusion pump represents another tool for pain management in surgical patients.

Nurse-initiated intravenous morphine in the emergency department: efficacy, rate of adverse events and impact on time to analgesia.

The objectives of this study were: (i) to measure the analgesic efficacy and frequency of adverse events following autonomous nurse-initiated intravenous morphine in patients presenting with acute pain, awaiting medical assessment; and (ii) to determine whether such a process would improve the time to analgesia. A prospective convenience sample of patients presenting in acute pain received titrated intravenous morphine by experienced emergency nurses. Pain scores on a 10.0 cm visual analogue scale and predetermined adverse events defined by physiological parameters were measured at regular intervals over the following 60 min. Demographic, diagnostic and waiting time data were also recorded. Three hundred and forty nine patients were enrolled over a 12-month period. The median initial pain score was 8.5 cm, with a reduction to 4.0 cm at 1 h. Respiratory rate, oxygen saturation, heart rate and blood pressure all showed small but statistically significant reductions over 60 min. There were 15 predefined adverse events, 10 episodes of hypotension and five episodes of oxygen desaturation. No intervention other than supplemental oxygen was required. There were no episodes of bradycardia, bradypnoea or reduced level of consciousness. The median time to narcotic was 18 min and the median time to be seen by a doctor was 52 min. Experienced emergency nurses can initiate effective intravenous narcotic analgesia for patients in acute pain awaiting medical assessment, with minimal change in physiological parameters. This process can improve the time to analgesia for patients in acute pain.

A process approach to improving pain management in the emergency department: development and evaluation

Aim—(1) To describe a process approach to the improvement of pain management in emergency departments. (2) To compare analgesia ordering and administration practices for patients with acute fractures before and...

Thoracic versus lumbar epidural anesthesia's effect on pain control and ileus resolution after restorative proctolectomy

Epidural anesthesia as a perioperative adjunct has been shown to provide superior pain control and has been implicated in more rapid ileus resolution after major abdominal surgery, possibly through a sympatholytic mechanism. Studies suggest that the vertebral level of epidural administration influences these parameters. One hundred seventy-nine patients (120 male, 59 female; average age, 36 years) underwent restorative proctocolectomy for ulcerative colitis or familial polyposis between 1989 and 1995. Patients were grouped according to type of anesthesia. Group THO (n = 53) received thoracic (T6 to T10) epidurals. Group LUM (n = 51) received lumbar (L2 to L4) epidurals, and group PCA (n = 75) received patient-controlled intravenous narcotic analgesia. Patients were compared for complications, perioperative risk factors, postoperative pain, and ileus resolution. Epidural narcotics, alone or combined with local anesthetics, were administered for an average of 2 (LUM) to 4 (THO) days without significant complications. Infrequent problems related to the epidural catheters included self-limited headaches or back pain (four) and site infections (two). Epidural failure, as measured by conversion to PCA for inadequate pain control, was not significantly greater for LUM (25%) than THO (23%). Average pain scores, rated daily on a visual analog scale, were significantly higher (indicating more pain) for PCA patients (4.2) during postoperative days 1 through 5 than for LUM (3.5) (p < 0.05) and for THO (2.4) (p < 0.05). Ileus resolution, as determined by stool output and return of bowel sounds, was significantly faster in THO than in LUM or PCA (p < 0.05). Resolution of ileus was not significantly different between PCA and LUM (p > 0.05). Thoracic epidural analgesia has distinct advantages over both lumbar epidural or traditional patient-controlled analgesia in shortening parameters measuring postoperative ileus and in reducing surgical pain. The procedure is safe and associated with low morbidity. Thoracic epidural anesthesia is also economically justifiable and may prove to impact significantly on future postoperative management by reducing length of hospitalization. Our data and those of others are most striking in these regards for patients with thoracic catheters, indicating the importance of vertebral level in epidural drug administration.

Efficacy of Bupivacaine Delivered by Wound Catheter for Post‐Caesarean Section Analgesia

A prospective, randomized, double-blind trial was conducted to assess contribution to postoperative analgesia of intermittent instillation of 0.25% bupivacaine beneath the rectus sheath in 70 women delivered by lower uterine segment Caesarean section. The operations were performed via a Pfannenstiel incision under spinal anaesthesia. Background intravenous narcotic analgesia was provided with a patient controlled analgesia system (PCAS) using a standard morphine regimen. Overall (44 hr) mean morphine consumption was significantly greater in the placebo (saline) group compared to the treatment group (84.2 mg versus 63.3 mg. Two tailed t test p < 0.001). The most significant intergroup differences in narcotic use were found in the first 4 hours and between 24 and 36 hours after commencing PCAS (Two tailed t test p = 0.014 and 0.003 respectively). Subjective pain scores were assessed with a 10 cm visual analogue scale (VAS). The mean peak VAS score was greater in controls (5.37) than the treatment group (4.25) between 18 and 24 hours postoperatively (Mann-Whitney U = 424, p = 0.027). There were no intergroup differences in pain scores for any other time period. The overall incidence of nausea was lower in the treatment group compared to the control group (Chi squared with Yates' correction p = 0.046) and a lower degree of sedation was seen in those receiving bupivacaine between 4 and 8 hours after commencing PCAS (Mann-Whitney U = 427, p = 0.028). No differences in other narcotic related side-effects (vomiting and pruritus) were shown between groups. Regular instillation of 0.25% bupivacaine beneath the rectus sheath of women delivered by Caesarean section reduces their morphine requirements by 25% in the 44 hours after operation, with an associated reduction in both nausea and early sedation.

Ketorolac and Patient Controlled Analgesia in the Treatment of Postoperative Pain

Ketorolac tromethamine (Toradol [Syntex, Palo Alto]), a new commercially available nonsteroidal antiinflammatory drug (NSAID), has appropriate solubility and minimal tissue irritation, making it suitable for intramuscular injection. Previously, NSAID have only been available for oral use in the United States for the treatment of pain. Ketorolac, the most potent NSAID known, relieves pain through inhibition of arachidonic acid synthesis at the cyclooxygenase level and has no central opioid effects. The results of previous studies using parenteral ketorolac in combination with patient administered narcotics have shown a 40 percent reduction in narcotic requirements. However, ketorolac is presently only approved for intramuscular injection and oral use in the United States. In a prospective, randomized study, we compared intramuscular ketorolac in combination with patient controlled intravenous narcotic analgesia (morphine) (PCA-M) to PCA-M alone for the control of pain after extensive colonic resections. The combination of intramuscular ketorolac and PCA-M provided equal pain relief with no increased side effects when compared with narcotics alone. However, narcotic requirements of the patients were decreased by an average of 45 percent. Ketorolac and narcotics in combination provide effective postoperative pain relief and significantly decrease narcotic requirements. This combination may be particularly beneficial in the subpopulation of patients especially prone to narcotic related complications.