Lockout Period Research Articles

Can Rhomboid Intercostal Block Be an Alternative to Paravertebral Block in Video-Assisted Thoracoscopic Surgery? A Randomized Prospective Study.

Rhomboid intercostal block (RIB) is a new interfascial plane block. RIB is a simple and clinically effective technique. Paravertebral block (PVB) is offered as a first-line regional anesthesia technique for thoracoscopic surgeries. In this study, we aim to compare the analgesic efficacy of RIB to PVB in video-assisted thoracoscopic surgeries (VATSs). This is a prospective randomized study with 84 patients aged 18-75 and ASA I-III, undergoing VATS for primary lung cancer. The study was approved by an ethical committee and registered under clinicaltrials.org. With informed consent, patients were randomized to receive ultrasound-guided RIB or PVB at T5-level with 20 mL of %0.25 bupivacaine preoperatively. Surgeries were performed under general anesthesia. Postoperatively, patient-controlled IV fentanyl analgesia was prescribed, delivering 10 μg boluses upon request with 10 min of a lock-out period. Patients received paracetamol 1 g IV three times a day and tramadol 50 mg IV for breakthrough pain. The postoperative Numeric Rating Scale (NRS) for pain, total opioid consumption, and rescue analgesic requirements were recorded postoperatively at 1, 3, 6, 12, and 24 h. There were no significant differences in 24 h total opioid consumption between the RIB and PVB groups [PVB: 48.5 (39.5-55) mcg; RIB: 48.6 (40.2-65) mcg; p = 0.258], nor in rescue analgesic requirements [PVB: seven patients (20%); RIB: seven patients (17.1%); p = 0.570]. NRS pain scores were also similar between the groups, with no significant difference in overall pain control efficacy (p = 0.833). RIB is comparable to PVB in analgesic efficacy for VATS and can be considered as an alternative analgesic modality.

Seamless MEMS-INS/Geomagnetic Navigation System Based on Deep-Learning Strong Tracking Square-Root Cubature Kalman Filter.

To suppress inertial navigation system drift and improve the seamless navigation capability of microelectromechanical system-inertial navigation systems/geomagnetic navigation systems (MEMS-INS/MNS) in geomagnetically unlocked environments, this paper proposes a hybrid seamless MEMS-INS/MNS strategy combining a strongly tracked square-root cubature Kalman filter with deep self-learning (DSL-STSRCKF). The proposed DSL-STSRCKF method consists of two innovative steps: (i) The relationship between the deep Kalman filter gain and the optimal estimation is established. In this paper, combining the two auxiliary methods of strong tracking filtering and square-root filtering based on singular value decomposition, the heading accuracy error of ST-SRCKF can reach 1.29°, which improves the heading accuracy by 90.10% and 9.20% compared to the traditional single INS and the traditional integrated navigation algorithm and greatly improves the robustness and computational efficiency. (ii) Providing deep self-learning capability for the ST-SRCKF by introducing a nonlinear autoregressive neural network (NARX) with exogenous inputs, which means that the heading accuracy can still reach 1.33° even during the MNS lockout period, and the heading accuracy can be improved by 89.80% compared with the single INS, realizing the continuous high-precision navigation estimation.

High-volume patient-controlled epidural vs. programmed intermittent epidural bolus for labour analgesia: a randomised controlled study.

The aim of neuraxial analgesia is to achieve excellent pain relief with the fewest adverse effects. The most recently introduced technique for epidural analgesia maintenance is the programmed intermittent epidural bolus. In a recent study, we compared this with patient-controlled epidural analgesia without a background infusion and found that a programmed intermittent epidural bolus was associated with less breakthrough pain, lower pain scores, higher local anaesthetic consumption and comparable motor block. However, we had compared 10 ml programmed intermittent epidural boluses with 5 ml patient-controlled epidural analgesia boluses. To overcome this potential limitation, we designed a randomised, multicentre non-inferiority trial using 10 ml boluses in each group. The primary outcome was the incidence of breakthrough pain and total analgesic intake. Secondary outcomes included motor block; pain scores; patient satisfaction; and obstetric and neonatal outcomes. The trial was considered positive if two endpoints were met: non-inferiority of patient-controlled epidural analgesia with respect to breakthrough pain; and superiority of patient-controlled epidural analgesia with respect to local anaesthetic consumption. A total of 360 nulliparous women were allocated randomly to patient-controlled epidural analgesia-only or programmed intermittent epidural bolus groups. The patient-controlled group received 10 ml boluses of ropivacaine 0.12% with sufentanil 0.75 μg.ml-1 ; the programmed intermittent group received 10 ml boluses supplemented by 5 ml patient-controlled boluses. The lockout period was 30 min in each group and the maximum allowed hourly local anaesthetic/opioid consumption was identical between the groups.Breakthrough pain was similar between groups (11.2% patient controlled vs. 10.8% programmed intermittent, p = 0.003 for non-inferiority). Total ropivacaine consumption was lower in the PCEA-group (mean difference 15.3 mg, p < 0.001). Motor block, patient satisfaction scores and maternal and neonatal outcomes were similar across both groups. In conclusion, patient-controlled epidural analgesia is non-inferior to programmed intermittent epidural bolus if equal volumes of patient-controlled epidural analgesia are used to maintain labour analgesia and superior with respect to local anaesthetic consumption.

Quantitative assessment of land surface temperature and vegetation indices on a kilometer grid scale.

Due to expanding populations and thriving economies, studies into the built environment's thermal characteristics have increased. This research tracks and predicts how land use and land cover (LULC) changes may affect ground temperatures, urban heat islands, and city thermal fields (UTFVI). The current study examines land surface temperature (LST), urban thermal field variance index (UTFVI), normalized difference built-up index (NDBI), normalized difference vegetation index (NDVI), and land use land cover (LULC) on a kilometer scale. According to the comparative study, the mean LST decreases by 3°C and the NDVI increases considerably. Correlation analysis showed that LST and NDVI are inversely connected, while LST and NDBI are positively correlated. NDVI and NDBI have a strong negative association, while LST and UTFVI have a positive correlation. Urban planners and environmentalists can study the LST's effects on land surface parameters in different environmental contexts during the lockout period. The urban heat island (UHI) phenomenon, in which the land surface qualities of an urban region cause a change in the urban thermal environment, forms and intensifies over an urban area. The minimum and maximum LST in grid number 1 in 2009 was 20.30°C and 29.91°C, respectively, with a mean LST of 25.1°C. There was a decline in the minimum and maximum LST in grid number 1 in 2020 with a minimum and maximum LST of 17.31°C and 25.35°C, respectively, with a mean LST of 21.33°C. There was a 3.8°C drop in the LST of this grid. The minimum and maximum NDVI were also - 0.16 and 0.59, respectively, with an average NDVI value of 0.21. Therefore, it is essential to evaluate and foresee the impact of LULC change on the thermal environment and examines the connection between LULC shifts with subsequent changes in land surface temperature (LST) along with the UHI phenomenon. Maps of the UTFVI reveal positive UHI phenomena, with the highest UTFVI zones occurring over the developed area and none over the adjacent rural territory. During the summer months, the urban area with the strongest UTFVI zone grows noticeably larger than it does during the winter months during the forecasted years. Future policymakers and city planners can mitigate the effects of heat stress and create more sustainable urban environments by evaluating the expected distribution maps of LULC, LST, UHI, and UTFVI.

203. Epidural pain catheter improves postoperative pain control following lumbar fusion compared to patient-controlled analgesia (PCA)

<h3>BACKGROUND CONTEXT</h3> Postoperative pain control for patients in the hospital after lumbar spinal fusion can be quite challenging. Reliance on opioids postoperatively can predispose patients to tolerance and abuse. Multimodal pain control regimens have become the standard of postoperative care, though protocols tend to vary by surgeon and institution. The mainstay of pain control following lumbar spinal fusion surgery involves narcotic pain medication administered by patient controlled intravenous analgesia (PCA), which is typically supplemented by oral pain medications. One potential alternative to PCA is patient-controlled analgesia via epidural catheter. Surgeon-placed epidural catheters under direct visualization have previously been described for their simplicity, efficacy and time efficiency. <h3>PURPOSE</h3> After experiencing clinical success with the use of epidural catheters placed via the loss of resistance technique one- to three- levels above the proximal lumbar fusion level in postoperative care regimens,the senior author (TFA) embarked upon this prospective, randomized trial to assess the relative utility and complication rate of the epidural catheter method of pain management when compared to standard PCA narcotic administration for pain control after one- or two-level circumferential lumbar fusion surgery. <h3>STUDY DESIGN/SETTING</h3> The surgeries in the trial were performed by three surgeons in a university spinal surgery practice. Patients who enrolled agreed to be randomized to either the epidural catheter (EC) or the commonly practiced PCA arm of the study. A power analysis demonstrated that a sample size of 50 patients, using a level of significance of 0.05, would have a power of 0.97 to detect a 2-point difference in pain scores. <h3>PATIENT SAMPLE</h3> Fifty patients from the University spinal surgery practice were recruited to enter the study. Candidates for the study were patients undergoing one- or two-level instrumented lumbar fusion. Patients were randomized over a 10-month period into either the epidural (EA) or IV analgesia (PCA) groups, 27 to EA and 23 to PCA. <h3>OUTCOME MEASURES</h3> Preoperative pain scores, as well as daily postoperative pain scores were recorded. <h3>METHODS</h3> If randomized to the EC arm, an epidural catheter was placed by the surgeon just prior to wound closure, 1-3 levels above the most proximal level of the fusion. A 17-gauge Tuohy epidural needle was used with a loss-of-resistance syringe to locate the epidural space under fluoroscopy if deemed appropriate by the surgeon, and then the catheter was inserted through it. A bolus of 5cc of 0.25% bupivacaine was typically given at the time of catheter placement. Postoperatively, a continuous infusion was begun of 0.125% bupivacaine at 6 cc/hr combined with hydromorphone at 0.2 mg/hr. A patient controlled epidural demand dose of 25mcg of fentanyl with a 10-minute lockout period was also started. If randomized to the PCA group, patients were placed on a patient-controlled analgesia pump administering intravenous hydromorphone with a demand dose of 0.2-0.4 mg with a 10-15-minute lockout <h3>RESULTS</h3> Postoperative pain scores were statistically lower in the EC group on Days 1, 2 and 3: 2.13 vs 4.92 (day 1); 2.71 vs 4.52 (day 2); 3.13 vs 4.52 (day 3). Postoperative complications were similar between the EC and PCA groups. The incidence of nausea/vomiting were 56% and 74% (p=0.43) in EC and PCA groups, respectively, while postoperative symptomatic hypotension was seen in 8% of EC patients and 12% of PCA patients (p=0.67). <h3>CONCLUSIONS</h3> In this prospective, randomized study comparing the use of EC to PCA narcotic for pain control after one- and two-level lumbar fusions, a significant improvement in pain control was noted in the EC group with differences in minor side effects that did not reach statistical significance. Epidural anesthesia for postoperative pain control should be considered for patients undergoing lumbar fusion. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

The Impact of Lockout Laws on Maxillofacial Fractures in South Australia.

Alcohol outlet density and unrestricted trading hours are strongly predictive of domestic and non-domestic assault rates, respectively. international studies report a strong male predominance for facial fractures. Harm minimization policies such as lockout laws have gained considerable attention to reduce accessibility of alcohol consumption and drinking patterns. A retrospective review was conducted from January 2012 to January 2017 at the Women and Children's Hospital and Royal Adelaide Hospital, Adelaide. All maxillofacial fractures that attended or were referred to the unit were included in this study. The primary objective was to determine the impact of facial fracture presentations, particularly assaults, for the pre- and post-lockout periods. From 2012 to 2017, there was a 5.1% decrease in assaults per year ( P = 0.002). Assaults increased by 11.7% for women and alcohol related assaults decreased by 10.2% for men ( P < 0.05). Assault and alcohol related assault rates decreased by 9.3% and 10.5%, respectively, between lockout periods ( P < 0.001). Comparative analysis between Adelaide and control (inner regional city) showed assaults decreased by 9.8% between lockout periods (51.2% versus 41.4%, P < 0.001). Multivariate analysis showed alcohol, open reduction internal fixation and men were associated with a lower risk of assault related fractures, but women and night time presentations had a higher risk ( P < 0.05). The influence of lockout laws contributed to an overall decrease in assaults and operative interventions, particularly alcohol related incidences amongst men. Ongoing longitudinal surveillance should guide current evidence for policy developers to reduce the risk of harm.

Effect of patient-controlled epidural analgesia with and without automatic intermittent bolus on levobupivacaine consumption during labour: A single-centre prospective double-blinded randomised controlled study

BackgroundDuring labour, the effects of adding a programmed intermittent epidural bolus (PIEB) baseline analgesic regimen to patient-controlled epidural analgesia (PCEA) remain uncertain. MethodsThis single centre prospective double-blinded controlled study randomised nulliparous women over 35 weeks of gestational age in a PCEA + PIEB or PCEA only group. After an epidural analgesia catheter was inserted, a specific pump administered a solution of levobupivacaine 0.625 mg mL−1, sufentanil 0.25 µg mL−1, and clonidine 0.375 µg mL−1. In both groups the PCEA mode delivered an 8 mL bolus with a lockout period of 8 min. In the PCEA + PIEB group, women also received a programmed 8 mL bolus every 60 min. Additional bolus were allowed if required. The primary outcome was the hourly consumption of levobupivacaine from epidural catheter placement to new-born delivery. Secondary outcome were motor block, oxytocin use, sufentanil consumption, additional bolus required, instrumental vaginal delivery, unplanned caesarean section, pain during labour and women’s satisfaction. ResultsAnalysis included 162 and 155 women in the PCEA and PCEA + PIEB groups, respectively. The median [IQR] hourly consumption of levobupivacaine was significantly lower in the PCEA group (9.9 (7.8–12.4] mg h−1) as compared to the PCEA + PIEB group (11.2 [7.9–14.3] mg h−1; p = 0.046). The difference between medians was 1.3 mg h−1 95 % CI (0.1–2.9). There was no difference between groups for secondary outcomes. ConclusionsPCEA only modestly decreased the hourly consumption of local anaesthetic as compared to PCEA + PIEB but the difference was not clinically relevant.

Investigating the Effects of Cuing Medication Availability on Patient-controlled Analgesia Pump Usage in Pediatric Patients

Objectives: The study of patient-controlled analgesia (PCA) behaviors has led to a greater understanding of factors that affect the pain experience. Although PCA behaviors can be influenced by cues to medication availability, no studies have examined the effects of such cues in pediatric populations. Materials and Methods: This randomized controlled trial examined patient satisfaction with pain management, PCA behaviors, opioid consumption, and state anxiety in a sample of 125 postsurgical children and adolescents (7 to 17 y). Patients were randomized to a “light” group (lockout period status cued by light on the PCA button) or control group (no cues to medication availability). Results: Although cuing did not affect patient satisfaction with pain management (P=0.11), patients in the light group consumed significantly more opioid than those in the control group (adj. P=0.016). This effect was primarily because of children in the light group (median, 0.019; interquartile range, 0.012 to 0.036 mg/kg/h) consuming more opioid than children (12 y or younger) in control group (median, 0.015; interquartile range, 0.006 to 0.025 mg/kg/h) (P=0.007). In contrast to the control group, for patients in the light group, opioid consumption was unrelated to pain and the proportion of patients with a 1:1 injections:attempts ratio was higher (P&lt;0.001) across the study period. Discussion: The overall pattern of results suggests that patients in the light group used their PCA in response to the light more than in response to their pain, which likely reflects operant influences on PCA behavior by pediatric patients.

The Affordable Care Act 10 Years In: What Nursing Leaders Should Know

The Affordable Care Act (ACA) introduced wide-ranging health care reforms but faces many challenges. This article reviews 6 key points for today’s nurse leader on the law’s 10th anniversary: a renewed legal battle is on its way to the Supreme Court; 27 million people still lack coverage, partly due to nonexpansion of Medicaid in 15 states; Medicaid waivers provide coverage for some low-income people but leave many people out; value-based purchasing has allocated billions of dollars in rewards and penalties; ACA Marketplace plans are not always affordable, but premiums are stabilizing; and the 2020 elections could result in dramatic consequences for health care reform.

Nalbuphine Combined with Ropivacaine for Epidural Labour Analgesia

Background: The addition of a small amount of opioids during epidural labour analgesia can enhance the local analgesic effect, reduce the amount of local anaesthetics required, and prevent motor blockade as much as possible. The use of nalbuphine, a κ-opioid receptor agonist, in epidural labour analgesia has not yet been reported. Methods: This clinical trial applied a prospective, randomized, double-blind, parallel-controlled, multicentre experimental design and was carried out in six tertiary hospitals in different regions of China. We included parturients aged 20 years or older,with a singleton pregnancy cephalic presentation, and who requested labor pain relief. Recruited parturients were randomly divided into two groups: the nalbuphine group (Group N) and the sufentanil group (Group S). Epidural puncture was performed at the L2-3 space. After successful catheterization, the drug was administered in the supine position. Medication regimen:(1) Group N received an epidural injection (5 mL mixture) of 0·1% ropivacaine, 0·3 mg/mL nalbuphine, and 1:400,000 epinephrine. A 10-mL mixture of 0·1% ropivacaine and 0·3 mg/mL nalbuphine was injected; subsequently, the drug was administered by patient-controlled epidural analgesia (PCEA). The background dosage was 6 mL/h, the patient-controlled analgesia (PCA) dose was 6 mL, and the lock-out period was 15 min. (2) Except that nalbuphine was replaced with 0·3 μg/mL sufentanil; all other drug administration and analgesia procedures in Group S were the same as those in Group N. The primary outcome was the time to the first PCA dose. Secondary outcomes included the ropivacaine dose per hour. Findings: Between November 2018 and February 2019,180 parturients were recruited for the study. Compared to the time to the first PCA dose in Group S (131·2 (89·9) min), the time to the first PCA dose in Group N (101·8 (76·7) min) was not significantly extended (P=0·050). The ropivacaine dose per hour in Group N (9·3 (2·4) mg) was significantly greater than that in Group S (8·4 (2·5) mg) (P=0·024). adverse drug reactions or serious adverse events directly associated with analgesics were noted during the study. Interpretation: The combinations of 0·3 mg/mL nalbuphine with ropivacaine and 0·3 μg/mL sufentanil with ropivacaine have comparable effects for labour epidurals. Both combinations are safe, effective, and suitable for labour epidurals, with few adverse reactions. Trial Registration: This study was registered at the Chinese Clinical Trial Registration Center (registration number: ChiCTR1800018810). Funding Statement: The authors stated: No funding received. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: This study was approved by the ethics committee of the Obstetrics & Gynecology Hospital Affiliated of Fudan University (approval number: Obstetrics and Gynecology ethics review 2018-52). Informed consent was obtained from all participating parturients.

Comparison of postoperative pain between patients who underwent primary and repeated cesarean section: a prospective cohort study

BackgroundThe differences in post-operative pain are unclear between the primiparas who underwent a primary cesarean section and multiparas who underwent their first repeat cesarean section. The study aimed to explore the possible differences in postoperative pain between primiparas and multiparas.MethodsA prospective cohort study was performed only including women who underwent cesarean deliveries under spinal anesthesia. Postoperative patient-controlled intravenous analgesia (PCIA) was administered to all subjects with 0.2 mg/kg hydromorphone and 4 mg/kg flurbiprofen; the pump was programmed as 2.0 mL/h background infusion with a loading dose of 1 mL and a lockout period of 15 min. Postoperative incision and visceral pain intensity were evaluated using the visual analogue scale, and inadequate analgesia was defined as a visual analogue scale score ≥ 40 during 48 h post-operation. Additionally, the patients’ pain statuses in postoperative week 1 and week 4 were also assessed during follow-up via telephone.ResultsFrom January to May 2017, a total of 168 patients (67 primiparas and 101 multiparas) were included. The relative risk for multiparas to experience inadequate analgesia on incision pain was 0.42 (95% CI: 0.25 to 0.74) compared to primiparas. In patients aged < 30 years, inadequate analgesia on visceral pain was higher in multiparas than in primiparas (RR, 3.56 [1.05 to 12.04], P = 0.025). There was no significant difference in the combined incidence of inadequate analgesia in both types of pain between the multiparas and primiparas (33.7% vs. 40.2%, P = 0.381). No difference was found in PCIA use between the two groups (111.1 ± 36.0 mL vs. 110.9 ± 37.3 mL, P = 0.979). In addition, a significantly higher incidence of pain was noted 4 weeks post-surgery in primiparas than that in multiparas (62.2% vs. 37.7%, P = 0.011).ConclusionMultiparas who underwent their first repeat cesarean section have a lower for inadequate analgesia on incision pain during the first 48 h after surgery than primiparas. Multiparas aged under 30 years may be more prone to experiencing postoperative inadequate analgesia on visceral pain.Trail RegistrationClinicalTrial.gov: NCT03009955, Date registered: December 30, 2016.

Comparison of the Effects of Epidural Levobupivacaine with Tramadol or Morphine Addition on Postoperative Analgesia following Major Abdominal Surgery.

The study was designed to compare the postoperative analgesic efficacy of epidural tramadol or epidural morphine as adjuvant to levobupivacaine in major abdominal surgery. Patients in ASA I-II group aged between 18 and 65 years were included in study. Epidural catheter was introduced. Patients were randomised into three groups to receive levobupivacaine (Group L), levobupivacaine+morphine (Group LM) and levobupivacaine+tramadol (Group LT). General anaesthesia was administered to all patients. The solution intended for Group L contained 25 mg 0.5% levobupivacaine+15 mL saline, that for Group LM contained 25 mg 0.5% levobupivacaine+14.5 mL salin+100 μg morphine and that for Group LT contained 25 mg 0.5% levobupivacaine+13 mL salin+100 mg tramadol, which was administered via epidural catheter as loading dose 30 min before the end of the operation. Patient-controlled analgesia device was connected to the epidural catheter to provide postoperative analgesia. Bolus dose was adjusted to 12 mg levobupivacaine in Group L, 12 mg levobupivacaine +1.2 mg morphine in Group LM and 12 mg levobupivacaine+12 mg tramadol in Group LT. Lock-out period was adjusted to 15 min in three groups. Quality of analgesia was evaluated using Visual Analogue Scale; administered and demand doses of levobupivacaine, morphine and tramadol were compared at 30 min, 1, 2, 6, 12 and 24 h postoperatively. Visual Analogue Scale scores were significantly higher in Group L than Groups LM and LT. Nausea and vomiting observed in Group L were lesser than those in Groups LM and LT. Continuous epidural analgesia using levobupivacaine combined with morphine or tramadol is an effective method for managing postoperative analgesia in major abdominal surgery.

The Effect of Ibuprofen on Postoperative Opioid Consumption Following Total Hip Replacement Surgery.

Postoperative pain following hip surgery can be severe. Non-steroidal anti-inflammatory drugs are used in the treatment of postoperative pain to reduce opioid consumption. Our aim was to investigate the effect of ibuprofen on postoperative opioid consumption following total hip replacement surgery. Patients undergoing elective total hip replacement under general anaesthesia were included into this randomised, prospective and double-blind study. Forty patients classified according to the American Society of Anesthesiologists as Class I and II were randomised to receive 800 mg ibuprofen intravenously (IV) every 6 hours, or placebo. At the end of surgery, all patients were also administered tramadol 100 mg IV and paracetamol 1 gm IV. In the postoperative period, all patients were provided with a morphine PCA device. The PCA device was set to deliver 1 mg bolus dose and had 8 minutes of lockout period and 6 mg 1-hour limit. VAS scores were recorded at 1, 6, 12 and 24 h postoperatively. The incidence of nausea and vomiting, total morphine consumption during the 24 h postoperative period was recorded. The Mann-Whitney U and chi-squared tests were used for statistical analysis. The VAS score at postoperative 24 h was lower in the ibuprofen group (p=0.006). Morphine consumption at 24 hours was significantly lower at the ibuprofen group compared to the control group (p=0.026) (the mean doses were 16 mg and 24 mg, respectively). Five patients in the control group and 3 patients in the ibuprofen group reported vomiting. No other side effects or complications were observed. Following total hip replacement surgery, the administration of ibuprofen IV significantly reduced morphine consumption.

A randomized clinical study comparing the analgesic efficacy of intra venous patient- controlled analgesia of morphine with fentanyl in post-operative pain management of major surgery patients

Background: Post-operative pain is a protective but an unwanted effect which is to be treated for the better outcome of surgery. Aims and Objectives: The aim of this study is to compare the safety and analgesic efficacy of intravenous patient-controlled analgesia (IV PCA) using morphine and fentanyl for post-operative pain management in major surgery patients. Materials and Methods: The randomized clinical study initiated after the ethics committee approval and informed consenting. A total of 60 patients belonging to the American Society of Anesthesiology Grade - I, II, and III physical status, scheduled for major abdominal, oncological surgeries under general anesthesia were randomly allocated to two groups. Group M received IV PCA with morphine (basal continuous infusion 0.02 mg/kg/h, bolus dose of 0.02 mg/kg, and lockout period of 20 min), and the Group F received IV PCA with fentanyl (basal continuous infusion 0.5 μg/kg/h, bolus dose of 0.5 μg/kg, and lockout period of 20 min). Fentanyl dosage was converted into morphine equivalents. The outcomes such as visual analog scale (VAS), sedation score, hemodynamic parameters, and adverse effects were compared between groups and analyzed statistically. Results: Morphine provides better analgesia than fentanyl as indicated by lower VAS scores (score = 3) at the end of 24-72 h. Mean cumulative analgesic consumption was higher in fentanyl group (436.3 ± 330.2 mg) compared with morphine group (123.9 ± 28.2 mg) by 72 h. Regarding the hourly consumption, Group M consumed less drug than fentanyl group was statistically significant (P = 0.05). Conclusion: Morphine provides more effective post-operative analgesia than fentanyl administered through IV PCA. The PCA allows patients to balance between administration of analgesics and adverse events by self-adjusting the dose of analgesic used.

I1. A Randomized, Placebo- and Active-Controlled Phase 2b Study Investigating Oliceridine (TRV130)

Opioids are widely employed for management of moderate to severe acute pain; however, opioid-related adverse events (ORAEs) may limit dosing required for analgesic efficacy. Oliceridine (TRV130) is a novel μ receptor G protein Pathway Selective (μ-GPS) modulator that activates G protein while causing low β-arrestin recruitment to the μ receptor. The objective of this IRB-approved, randomized, double-blind, adaptive patient-controlled analgesia (PCA) phase 2b study was to investigate the efficacy, safety, and tolerability of oliceridine compared to placebo and morphine in patients with moderate to severe pain following abdominoplasty. Patients (N=200) were randomized to intravenous oliceridine (1.5mg loading dose followed by either 0.1mg or 0.35mg self-administered demand PCA doses), placebo, or morphine (4mg loading dose followed by 1mg demand PCA doses), in a 1:1:1:2 ratio. All arms included a 6-minute PCA lockout period. The primary endpoint was time-weighted average change in numeric pain rating scale over 24 hours (NPRS TWA 0-24). Rescue analgesics were available as necessary. Oliceridine 0.1mg and 0.35mg demand dose groups reduced NPRS TWA 0-24 vs placebo by 2.3 and 2.1 points, respectively (p=0.001 and p=0.0005 vs. placebo), similar to morphine (2.1 points; p<0.0001 vs. placebo). Median time to meaningful pain relief was 1.1 hours and 0.3 hours with oliceridine 0.1mg and 0.35mg, respectively, compared with 1.1 hours with morphine. Adverse Events (AEs) associated with oliceridine were similar in nature to ORAEs; however, oliceridine had a significantly lower prevalence of respiratory safety events, nausea, and vomiting than the morphine group (post hoc p<0.05 for both oliceridine regimens vs. morphine). No serious AEs were reported. In patients with pain following abdominoplasty, oliceridine achieved a magnitude of pain relief comparable to morphine over 24 hours with a lower prevalence of ORAEs. These results suggest that oliceridine may widen the therapeutic window between effective, rapid analgesia and typical ORAEs.

Post-operative effectiveness of continuous wound infiltration, continuous epidural infusion and intravenous patient-controlled analgesia on post-operative pain management in patients undergoing spinal surgery.

Background and Aims:Very few studies have compared continuous wound infiltration (CWI), continuous epidural infusion (CEI) and intravenous Patient Controlled Analgesia (PCA) with morphine in spine surgery. This study compared these modalities in patients undergoing microdissectomy.Methods:This prospective, randomized control trial was conducted on 75 patients of American Society of Anesthesiologists' physical status I or II undergoing microdiscectomy. Patients in all the three groups received morphine 1 mg IV, with a lockout period of 10 min after each bolus, and the maximum allowed dose was 15 mg/5 h postoperatively. Patients in Group A received CWI with 0.25% levobupivacaine 20 mL as bolus after extubation followed by infusion at 5 mL/h. Group B received CEI with 0.25% levobupivacaine at 5 mL/h. Patients in Group C received intravenous (IV) morphine by PCA pump only. The primary end points were static and dynamic visual analogue scores (VAS) and postoperative pain scores. Secondary observations were postoperative morphine consumption at 8 h, 24 h and 48 h, and patient satisfaction.Results:Group A showed greater analgesic effects at 12 h (P < 0.02), 24 h (P < 0.03), 36 h (P < 0.008) and 48 h (P < 0.007) when compared to the other two techniques, as pain scores were less in group A as compared to group B and C. The requirement of postoperative intravenous morphine (mg) was 18 ± 12.82, 22.92 ± 9.88, 41.56 ± 8.83 for groups A, B and C after 48 h (P < 0.001).Conclusion:Continuous wound infiltration is an effective postoperative pain control technique with minimal side effects, after spinal surgery.

Influences of gender on postoperative morphine consumption.

Gender related differences on morphine consumption during postoperative period following abdominal surgeries. Four hundred and fifty ASA I & II patients of either sex (male =231, female = 219), between the age group of 18-65 y undergoing elective intra abdominal surgeries under general anaesthesia were included for the study. Patients with preexisting pain either acute or chronic preoperatively were excluded from the study. Anaesthesia and analgesia protocol during surgery was standardized. Postoperatively, a loading dose was given to achieve the visual analogue scale (VAS) of ≤30 and subjects were connected to patient control analgesia (PCA) pump containing 0.4 mg/ml of morphine configured to deliver a bolus dose (1 mg) with a 5 min lock-out period. The total analgesic requirements along with VAS (visual analog scale) score were analysed between males and females in the first 24 h postoperatively. All demographic data and between group comparisons were analysed with student t-test. Within group comparisons were done by using one-way-ANOVA test and Tukey's Honestly significant Difference test. During the first 24 h, males consumed significantly higher amount of morphine (34.35 ± 6.68 mg) when compared to females (26.78 ± 7.14 mg), p < 0.001. We conclude that men require more morphine in the postoperative period than women.

Is s-ketamine with or without magnesium sulphate an alternative for postoperative pain treatment? Randomised study

Is s-ketamine with or without magnesium sulphate an alternative for postoperative pain treatment? Randomised study

Recovering from an interruption: Investigating speed−accuracy trade-offs in task resumption behavior.

Interruptions are disruptive because they take time to recover from, in the form of a resumption lag, and lead to an increase in the likelihood of errors being made. Despite an abundance of work investigating the effect of interruptions on routine task performance, little is known about whether there is a link between how quickly a task is resumed following an interruption (i.e., the duration of the postinterruption resumption lag) and the likelihood that an error is made. Two experiments are reported in which participants were interrupted by a cognitively demanding secondary mental arithmetic task while working on a routine sequential data-entry task. In Experiment 1 the time-cost of making an error on the primary task was varied between conditions. When errors were associated with a high time-cost penalty, participants made fewer errors and resumed the primary task more slowly than when errors were associated with a low time-cost penalty. In Experiment 2 participants were prohibited from resuming the primary task quickly by a 10-s system lockout period following the completion of the interrupting task. This lockout period led to a significant reduction in resumption errors because the lockout prohibited fast, inaccurate task resumptions. Taken together, our results suggest that longer resumption lags following an interruption are beneficial in terms of reducing the likelihood of errors being made. We discuss the practical implications of how systems might be designed to encourage more reflective task resumption behavior in situations where interruptions are commonplace. (PsycINFO Database Record (c) 2013 APA, all rights reserved).

A Hard Road: Driving Local Action against Alcohol Related Problems in a Rural Town

Context is important in developing strategies to address alcohol related violence. Knowledge of local conditions is critical to action in rural areas. The aim of this study was to gather information about context specific alcohol related problems experienced by frontline workers in a regional centre to inform the local alcohol action plan. Frontline workers were invited to participate in one of five focus group discussions that investigated problems experienced as a result of other people’s alcohol use. Alcohol related problems were more frequently associated with time periods than any single group in the community. Social media was used to incite arguments between groups in different venues during the lock-out periods. The focus groups identified that the location of licensed premises and a taxi rank; and previous relationships between protagonists were the key contextual factors causing alcohol related problems. A second taxi rank was identified as a useful local management strategy. Supply reduction was suggested as a key factor in long term solutions to alcohol related problems in rural towns. The local liquor accord did not want to reduce supply of alcohol by closing late night venues earlier. Local action to reduce alcohol related problems will be limited to pragmatic solutions because supply reduction is unacceptable to those in the business of selling alcohol.