Intravenous Patient-controlled Opioid Analgesia Research Articles

Patient-Controlled Analgesia Following Lumbar Spinal Fusion Surgery Is Associated With Increased Opioid Consumption and Opioid-Related Adverse Events

Optimal postoperative pain control is critical after spinal fusion surgery. There remains significant variability in the use of postoperative intravenous opioid patient-controlled analgesia (PCA) and few data evaluating its utility compared with nurse-controlled analgesia (NCA) among patients with lumbar fusion. To investigate the efficacy of postoperative PCA compared with NCA to improve opiate prescription practices. A retrospective review from a single institution was conducted in consecutive patients treated with posterior lumbar spinal fusion for degenerative pathology. Patients were divided into cohorts on the basis of postoperative treatment with PCA or NCA. Postoperative pain scores, length of stay, and total opioid consumption data were collected. Patients were stratified according to preoperative opioid consumption as opioid naive (0 morphine milligram equivalents [MME] daily), low consumption (1-60 MME), high consumption (61-90 MME), or very high consumption (>90 MME). A total of 240 patients were identified, including 62 in the PCA group and 178 in the NCA group. PCA patients had higher mean preoperative opioid consumption than NCA patients (49.2vs 24.3 MME, P=.009). PCA patients had higher mean opioid consumption in the first 72 h in all 4 of the preoperative opioid consumption subcategories. Pain control and adverse event rates were similar between PCA and NCA in the low to high preoperative opioid consumption groups. Postoperative PCA is associated with significantly more opioid consumption in the first 72 h after surgery and equal or worse postoperative pain scores compared with NCA after lumbar spinal fusion surgery.

90. Impact of patient-controlled analgesia on clinical outcomes after posterior lumbar spinal fusion surgery

BACKGROUND CONTEXT Optimal postoperative pain control is critical after spinal fusion surgery. Significant variability remains in the use of postoperative intravenous opioid patient-controlled analgesia (PCA) and very little data evaluating its utility compared to nurse-controlled analgesia (NCA) in lumbar fusion patients. PURPOSE We performed a retrospective evaluation of posterior lumbar spinal fusion patients being treated postoperatively with patient-controlled analgesia (PCA) and compared their pain-related outcomes to nurse-controlled analgesia (NCA). PCA utilization was independently associated with increased opioid prescription in the postoperative period. After controlling for preoperative opioid use, we found that opioid naive patients have worse pain control with PCA than NCA, and patients with very high opioid consumption (>90 MME/day) had greater rates of opioid-related adverse events with PCA. STUDY DESIGN/SETTING Retrospective clinical study, single institution. PATIENT SAMPLE A retrospective review from a single institution was conducted in consecutive patients treated with posterior lumbar spinal fusion for degenerative pathology. Patients with scoliosis, traumatic, neoplastic, infectious and minimally invasive treatments were excluded. OUTCOME MEASURES Postoperative numerical rating scale (NRS) pain scores, length of stay, and total opioid consumption were collected and compared. Opioid-related adverse events for each patient were also measured. METHODS Patients were divided into two cohorts: those treated postoperatively with PCA or NCA. Outcome measures were compared for patients in groups. Patients were stratified according to preoperative opioid consumption as naive, low (60 morphine milligram equivalents (MME) daily), high (61-90 MME) or very high (>90 MME) for analysis. RESULTS A total of 240 patients were identified: 62 and 178 patients in PCA and NCA groups, respectively. PCA patients had higher mean preoperative opioid consumption compared to the NCA group (49.2 vs 24.3 MME, p=0.009). PCA patients had higher mean opioid consumption in first 72 hours in all preoperative opioid consumption categories. Pain control and adverse event rates were similar between PCA and traditional opioid therapy in the low to high preoperative opioid consumption groups (>0 to 90 MME daily). Opioid naive patients had worse mean and highest NRS pain scores in the first 72 hours (all p 90 MME daily) had a greater rate of opioid-related adverse events (95% vs 70%, p CONCLUSIONS Postoperative PCA utilization is associated with significantly more opioid consumption and equal or worse postoperative pain scores compared to NCA after lumbar spinal fusion surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Postoperative Pain Outcomes After Nuss Procedures: Comparison of Epidural Analgesia, Continuous Infusion of Local Anesthetic, and Preoperative Self-Hypnosis Training.

The Nuss procedure to correct pectus excavatum is associated with severe postoperative pain. The purpose of this retrospective study was to compare pain management outcomes of thoracic epidural analgesia and continuous infusion of local anesthetic (CILA) with and without preoperative self-hypnosis training (SHT) after Nuss procedure (4 treatment groups). Between February 2010 and December 2013, 24 of 53 adolescents who underwent Nuss procedure received SHT. Of these, 16 received thoracic epidural analgesia and 8 received CILA postoperatively. Of the 29 patients who did not receive SHT, 19 received thoracic epidural analgesia and 10 received CILA. All patients received intravenous patient-controlled opioid analgesia and intravenous nonsteroidal anti-inflammatory drugs (IVNSAIDs) and then were transitioned to oral opioids and NSAIDs. Postoperative mean and maximum pain scores, opioid (morphine equivalents) use and side effects, and hospital length of stay (LOS) were compared between groups. Patients who received SHT reported lower mean (P = .0047) and maximum (P = .0028) pain scores and used less morphine equivalents/hour over time (P = .046) compared to patients who did not receive SHT. Patients who received thoracic epidural analgesia reported lower mean (P = .0092) and maximum (P = .0083) postoperative pain scores and used more morphine equivalents/hour (P = .01) compared to those who received CILA. In addition, patients who received SHT and CILA had shorter LOS (P = .0013) than patients who received thoracic epidural analgesia without SHT. SHT before pectus excavatum repair by Nuss procedure results in less postoperative pain and requires less morphine equivalents over time for postoperative pain management. Opioid-sparing CILA, when paired with SHT, results in shorter LOS.

(358) Medication errors associated with intravenous patient controlled analgesia: a descriptive analysis of 2005-2015 MEDMARX database

Intravenous (IV) patient-controlled opioid analgesia (PCA) is a mainstay of the management of acute post-operative pain. While IV PCA has the benefit of allowing patient to self-titrate opioids to their level of pain and faster delivery of analgesics, their use is also accompanied by number of challenges, including medication errors, analgesic gaps, and proxy dosing. The objective of this study was to characterize medication errors associated with IV PCA therapy in hospital settings. A retrospective, descriptive analysis of 2005-2015 Quantros™ MEDMARX data was conducted and revealed 1,948 unique medication errors associated with opioid IV PCA occurring in hospitals during this time period. Based on the NCC MERP Index, 89.5 % of these errors were classified as non-harmful, 6.7% as harmful, and 3.8% as potential errors, with majority of these errors occurring during drug administration (55%) and dispensing (23%). Over a quarter (26.3%) of the errors were attributed to pump-related causes including improper use of pump and pump malfunction. Of the 130 harmful errors, 65% (84) occurred during drug administration. Major types of harmful errors included: improper dose/quantity (58.4%), omission error (23.1%), prescribing error (15.4%) and wrong administration technique (13.8%). The leading causes of harmful errors included human performance factors (57%), procedure or protocol not followed (43.8%), and improper pump use (33.8%). Of the 1383 errors that reached the patient, 27.8% required interventions to prevent serious/fatal complications. Despite the advantages of IV PCA, patients are still at risk of IV PCA-related errors. These findings indicate certain types of IV PCA-related errors may be preventable. There is an unmet need for novel PCA systems that could potentially circumvent certain medication errors commonly associated with IV PCA while still retaining the advantages of pain management associated with PCA. Supported by a grant from AcelRx Pharmaceuticals, Inc.

Sufentanil sublingual tablet system for the management of postoperative pain

ABSTRACTIntroduction: Intravenous patient-controlled opioid analgesia has been an important improvement in addressing insufficient management of acute postoperative pain for over 40 years. However, there are number of weaknesses for intravenous patient-controlled analgesia, including operator and device error, intravenous line patency issues, and risk of catheter-related infection, all of which contribute to the complications and increase in cost of care. The sublingual sufentanil tablet system is a major evolution in both drug and technological management of postoperative pain.Areas covered: We reviewed the use of the sublingual sufentanil tablet system in management of moderate to severe postoperative pain in hospitalized patients, with a particular focus on the pharmacological properties of sufentanil and clinical use in different surgical patients.Expert opinion: The sublingual sufentanil tablet system can decrease intravenous opioid based patient-controlled analgesia related complications and safety issues. Current clinical studies have demonstrated this noninvasive-novel system to be safe and effective in management of acute pain in the postsurgical setting. Researchers should focus on comparing it with other available patient controlled analgesia modalities and evaluating the efficiency and cost effectiveness of the sublingual sufentanil tablet system.

Changing Trends in Use of IV-Patient-Controlled Anesthesia (IV-PCA) in a District General Hospital over the Last 15 Years and Proposed Factors behind this

Our study aimed to investigate the changing popularity of intravenous opioid patient-controlled analgesia (PCA) use at our Trust. We collected data from our Trust’s Pain Services database, identifying how many PCAs were used by each specialty from 2000-2014. Our data demonstrated a clear trend of decline in the use of PCA across all specialties since 2004. A survey of all of our hospital’s Consultant Anesthetists was made to gather opinion regarding the reasons for this decline. The survey results suggest that PCA use has declined over the last 15 years for several reasons; the main being increasing popularity of regional anesthesia and the availability of improved oral analgesics. Despite this, 91% of the consultants in our department feel that the availability of PCA should continue and that there is still a place for its use as a form of analgesia in our patient population.

Regional Anesthesia Procedures for Shoulder and Upper Arm Surgery Upper Extremity Update—2005 to Present

This review of the literature since 2005 assesses developments of RA techniques commonly used for shoulder surgery, and their effectiveness for postoperative analgesia. Advantages of regional techniques include site-specific anesthesia and decreased postoperative opioid use. For shoulder surgeries, the ISB provides effective analgesia with minimal complications, whereas the impacts of IA single-injections remain unclear. When combined with GA, ISB can be used in lower volumes and reducing the complications for shoulder and proximal upper extremity. USG ISB and SCB are both effective and safe for shoulder surgery with a low incidence of complications, especially PONS.53 When compared with intravenous patient-controlled opioid analgesia, a perineural LA infusion using a disposable pump with patient-controlled LA bolus function has led to better pain relief and functional recovery while decreasing the need for rescue analgesics and the number of adverse events after ambulatory orthopedic surgery. The most remarkable advance in RA in the past 5 years is the increased usage of USG. Although there are no large-scale prospective studies to show the safety, efficacy, and success and complication rates for USG blocks, USG RA theoretically could have less risk for neurologic symptoms, except for those induced by LA (less likely perineurally, much more likely intraneurally). The next "quantum leap" lies in reducing LA concentrations and augmenting anesthetic-analgesic effects with perineural additives (including clonidine, buprenorphine, and likely low-dose dexamethasone). Since 2005, perineural catheters have been an analgesic option that offers improved pain relief among other benefits, and are now being used at home. It is clear that patients benefit greatly from a single injection and continuous nerve block for postoperative pain management,but the financial and logistical aspects need to be resolved, not to mention the phrenic hemiparesis coin toss. Whether combined perineural analgesic adjuvants prolong low-concentration LA nerve blocks sufficiently to render brachial plexus catheters as unnecessary would certainly represent another quantum leap.

Preoperative Gabapentin for Acute Post‐thoracotomy Analgesia: A Randomized, Double‐Blinded, Active Placebo‐Controlled Study

The role of preoperative gabapentin in postoperative pain management is not clear, particularly in patients receiving regional blockade. Patients undergoing thoracotomy benefit from epidural analgesia but still may experience significant postoperative pain. We examined the effect of preoperative gabapentin in thoracotomy patients. Adults undergoing elective thoracotomy were enrolled in this prospective, randomized, double-blinded, placebo-controlled study, and randomly assigned to receive 600 mg gabapentin or active placebo (12.5 mg diphenhydramine) orally within 2 hours preoperatively. Standardized management included thoracic epidural infusion, intravenous patient-controlled opioid analgesia, acetaminophen and ketorolac. Pain scores, opioid use and side effects were recorded for 48 hours. Pain was also assessed at 3 months. One hundred twenty patients (63 placebo and 57 gabapentin) were studied. Pain scores did not significantly differ at any time point (P = 0.53). Parenteral and oral opioid consumption was not significantly different between groups on postoperative day 1 or 2 (P > 0.05 in both cases). The frequency of side effects such as nausea and vomiting or respiratory depression was not significantly different between groups, but gabapentin was associated with decreased frequency of pruritus requiring nalbuphine (14% gabapentin vs. 43% control group, P < 0.001). The frequency of patients experiencing pain at 3 months post-thoracotomy was also comparable between groups (70% gabapentin vs. 66% placebo group, P = 0.72). A single preoperative oral dose of gabapentin (600 mg) did not reduce pain scores or opioid consumption following elective thoracotomy, and did not confer any analgesic benefit in the setting of effective multimodal analgesia that included thoracic epidural infusion.

The effect of intravenous opioid patient-controlled analgesia with and without background infusion on respiratory depression: A meta-analysis

Although the addition of a background infusion for intravenous patient-controlled analgesia (IV-PCA) has been identified as a risk factor for the development of respiratory depression, this has not clearly been examined in a systematic fashion. The authors undertook a systematic review and meta-analysis of available randomized controlled trials (RCTs) to examine whether the addition of a background or continuous infusion to an IV-PCA regimen would be associated with an increased risk of respiratory depression. Studies were identified by searching the National Library of Medicine's PubMed database (1966 to November 30, 2008). Inclusion criteria were a clearly defined analgesic technique of demand-only IV-PCA versus IV-PCA utilizing both a demand dose and background infusion, opioid medication used, and randomized trials. Data were abstracted and analyzed with the RevMan 4.2.7 (The Cochrane Collaboration, 2004). The search yielded 687 abstracts from which the original articles were obtained and data abstracted with a total of 14 articles analyzed. There were 402 subjects in the continuous IV-PCA with demand group versus the 394 subjects in the demand-only IV-PCA group. Addition of a background infusion to the demand dose for IV-PCA with opioids was associated with a significant increased risk for respiratory depression (odds ratio [OR] = 4.68, 95% confidence interval [CI]: 1.20-18.21). Subgroup analysis revealed that this increased risk was seen in adult but not in pediatric patients. Our meta-analysis indicates that the addition of a continuous or background infusion to the demand dose for IV-PCA is associated with a higher incidence of respiratory events than demand IV-PCA alone in adult but not in pediatric patients; however, our overall results should be interpreted with caution due to the relatively small sample size and the wide range of definitions for respiratory depression in studies examined.

Postoperative analgesia and flap perfusion after pedicled TRAM flap reconstruction – continuous wound instillation with ropivacaine 0.2%. A pilot study

Transverse rectus abdominis musculocutaneous (TRAM) flap surgery is a complex procedure characterised by an extensive wound site. We present a pilot study with 17 patients receiving continuous wound instillation with ropivacaine or isotonic saline. Patients undergoing TRAM flap surgery were included in the study and randomised to the ropi group or the control group. Two catheters were placed subcutaneously before wound site closure. At the end of surgery patients received a single shot dose of 20 ml ropivacaine 0.2% or isotonic saline. After surgery the continuous instillation of ropivacaine or isotonic saline was commenced at an infusion rate of 10 ml/h per catheter. The perfusion of the TRAM flap was measured intraoperatively and postoperatively over 48 h. Pain scores, patient satisfaction, and the quality of recovery score were also assessed postoperatively over 48 h. Ropivacaine plasma levels were quantified 24 and 48 h after start of infusion. Pain scores at rest and on coughing were lower for the ropi group and reached significance in the first 8h at rest (P=0.007). Patient satisfaction, quality of recovery score, and adverse events were also comparable between the groups. Patients of the ropi group had bowel movement earlier than the control group (P=0.003). No differences were seen in the flap perfusion. Ropivacaine plasma levels were within therapeutic range. Our data show a trend that continuous wound instillation of ropivacaine 0.2% increases pain relief after TRAM flap surgery with earlier bowel movement than intravenous opioid patient controlled analgesia (IV-PCA) alone. A does of 960 mg of ropivacaine daily did not result in toxic plasma concentrations. Ropivacaine 0.2% did not show a vasoconstrictor effect.

Effect of alvimopan (ALV) on gastrointestinal (GI) recovery, length of hospital stay (LOS), and postoperative ileus (POI)-related morbidity in patients (PTS) undergoing bowel resection (BR) for colon or rectal cancer (CRC)

4014 Background: POI, an interruption of bowel motility, occurs universally after BR and is exacerbated by exogenous opioid analgesia. ALV, a peripherally acting mu-opioid receptor (PAM-OR) antagonist, accelerated GI recovery after BR in multicenter, randomized phase III efficacy trials. CRC is the most common reason for BR in the US, and in the ALV trials CRC was the primary reason for BR for 723 of 1,409 (51%) PTS. This abstract examines GI recovery, LOS, POI-related morbidity, and safety in only this subset of PTS. Methods: This pooled ad hoc analysis assessed the subset of PTS in phase III ALV trials who underwent BR via laparotomy because of CRC and received ALV 12 mg or placebo (PLA) (N = 723). All PTS were scheduled for postoperative intravenous patient-controlled opioid analgesia and received oral ALV or PLA preoperatively and BID postoperatively until hospital discharge or for = 7 postoperative days. Efficacy endpoints included GI-2 recovery (first bowel movement and tolerance of solid food) and postoperative LOS (calendar day after surgery to hospital discharge order written). Treatment effect on GI-2 recovery was analyzed using Cox proportional hazards models, and magnitude of effect was expressed with Kaplan-Meier means. POI-related morbidity included nasogastric tube insertion or complications of POI resulting in prolonged hospital stay or readmission. Safety was monitored by adverse event reports. Conclusions: ALV significantly accelerated GI recovery, reduced postoperative LOS, and reduced the proportion of PTS with POI-related morbidity compared with PLA in PTS undergoing BR for CRC. ALV was well tolerated with a lower incidence of nausea and vomiting in the ALV group than in the PLA group. [Table: see text] No significant financial relationships to disclose.

Patient-Controlled Analgesia

Using a portable infusion pump, intravenous opioid patient-controlled analgesia (PCA) permits a patient to self-deliver a small bolus of opioid to achieve prompt relief without over sedation. Use of PCA for pain management is increasing in hospitals, largely because it can provide equivalent or better analgesia than conventional nurse-administered opioid analgesia, and patients are more satisfied with its use. There is no decisive pharmacological or clinical argument for the choice of one opioid rather than another. Thus, morphine remains the most frequently used opioid in PCA. The adjunction of non-opioid drugs to morphine in the PCA reservoir is still very controversial. A new investigational PCA transdermal system using iontophoresis to deliver fentanyl seems to provide an adequate pain control with the advantages of needle-free, preprogrammed, self-contained device. Whatever drug or device used, the overall success of the PCA technique relies mainly on the expert supervision of nurses or anesthesiologists in an Acute Pain Service. Indeed, PCA is effective and significant only on the condition that there is careful preoperative patient education and strict postoperative monitoring. In addition, preoperative patient selection allows to exclude patients with evidence of cognitive dysfunction or physical disabilities, making the use of the patient-controlled device impossible. Caution is required among patients with respiratory or renal insufficiency. In the future, the indispensable improvement in the management of postoperative pain should lead to a greater expansion of PCA. However, more pharmaco-economic evaluations will be needed on the cost-effectiveness issue.