Medication Requests Research Articles

A clinical comparison of ropivacaine 0.75%, ropivacaine 1% or bupivacaine 0.5% for interscalene brachial plexus anaesthesia

In order to compare interscalene brachial plexus block performed with ropivacaine or bupivacaine, 45 healthy, unpremedicated patients, undergoing elective shoulder surgery, were randomly allocated to receive interscalene brachial plexus anaesthesia with 20 mL of either ropivacaine 0.75% (n = 15), ropivacaine 1% (n = 15), or bupivacaine 0.5% (n = 15). Readiness for surgery (loss of pinprick sensation from C4 to C7 and inability to elevate the limb from the bed) was achieved later with bupivacaine 0.5% (28 ±15 min) than with ropivacaine 1% (10±5 min) (P = 0.005) and ropivacaine 0.75% (15±8 min) (P=0.0005). No differences in success rate were observed between the three groups; however, seven patients receiving bupivacaine 0.5% required intra-operative analgesic supplementation (fentanyl 0.1 mg intravenous) compared with one patient receiving ropivacaine 0.75%, and two patients treated with ropivacaine 1% (P=0.02). The time from the block placement to first request for pain medication was similar in the three groups (10.7 ± 2 h, 11 ± 2.4 h, and 10.9 ± 3.9 h after 0.75% and 1% ropivacaine or 0.5% bupivacaine, respectively). We conclude that interscalene brachial plexus block performed with 20 mL of either 0.75% or 1% ropivacaine allows for a prolonged post-operative pain relief, similar to that provided by bupivacaine 0.5%, with short onset time of surgical anaesthesia.

Spinal Anesthesia Using Hyperbaric 0.75% Versus Hyperbaric 1% Bupivacaine for Cesarean Section

Although 0.75% hyperbaric bupivacaine is commonly administered to provide spinal anesthesia for cesarean section in the United States, in some countries, only the 1% hyperbaric solution of spinal bupivacaine is available. The aim of this study was to compare 0.75% with 1% hyperbaric spinal bupivacaine for cesarean section. In this prospective study, 50 patients undergoing elective cesarean section were randomized to receive a spinal anesthetic with either 1.5 mL of 0.75% bupivacaine (n = 25) or 1.125 mL of 1% bupivacaine (n = 25). There were no statistically significant differences in patient demographics, time to onset of block, or intraoperative pain. All patients had a successful block for surgery. The time from injection of the spinal anesthetic to first request for pain medication in the postanesthesia care unit was longer in the women who received 0.75% bupivacaine (4.3 vs 3 h; P < 0.05). Six women (24%) who received 1% bupivacaine versus one woman (4%) who received 0.75% bupivacaine complained of postoperative backache (P < 0.05). In addition, postdural puncture headache occurred in four women, all of whom received 1% bupivacaine (P = 0.04). In conclusion, our data suggest that 0.75% bupivacaine results in fewer postoperative problems and offers several significant benefits compared with the 1% concentration. Implications: Although 0.75% bupivacaine is usually used to provide spinal anesthesia for cesarean section in the United States, a more concentrated solution is popular in Europe. In this study, we compared 0.75% bupivacaine with 1% bupivacaine when administered for cesarean section and found that the 0.75% solution offers several significant benefits. (Anesth Analg 1998;87:1099-1104)

COMPARISON OF A SUBHYPNOTIC DOSE OF PROPOFOL WITH LOW-DOSE DROPERIDOL FOR PREVENTING PONV AFTER DESFLURANE ANESTHESIA

S25 Introduction: Controversy exists regarding the choice of prophylactic antiemetics in outpatients undergoing laparoscopic procedures with an inhalation-based anesthetic technique [1]. Therefore, a prospective, randomized, placebo-controlled, single-blind study was designed to compare the antiemetic effectiveness of a subhypnotic dose of propofol (0.5 mg/kg iv) and low-dose of droperidol (0.625 mg iv) when administered at the end of surgery under desflurane anesthesia. Methods: Ninety-six healthy consenting females undergoing laparoscopic cholecystectomy were assigned to one of three study groups. Anesthesia was induced with midazolam, 2 mg iv, fentanyl, 100 [micro sign]g iv, propofol, 2 mg/kg iv, and rocuronium, 0.6 mg/kg iv, and was maintained with desflurane 3-8% in combination with nitrous oxide 65% in oxygen. Supplemental fentanyl, 50 [micro sign]g iv boluses, were administered for persistent hypertension (MAP>30% of baseline value) or tachycardia (HR >100 bpm). Muscle relaxation was maintained with rocuronium, 0.15 mg/kg iv boluses. At skin closure, one of three study drugs was administered: (1) saline 5 ml iv, (2) propofol, 0.5 mg/kg iv, or (3) droperidol 0.625 mg iv. The times from discontinuation of desflurane/N2 O to awakening, orientation and home-readiness were recorded. The incidences of postoperative nausea and vomiting (PONV) and requests for antiemetic rescue medication were evaluated during the first 24 hours after surgery. Data were analyzed using ANOVA for continuous variables and Chi-square test for discrete variables, with p-values <0.05 considered statistically significant. Results: There were no differences among the groups with respect to demographic characteristics or the need for adjunctive drugs. The early recovery times were 30-40% longer in the propofol group compared to the saline and droperidol groups (Table 1). The droperidol group had the lowest incidence of PONV and the shortest time to home-readiness (Table 1).Table 1Conclusions: Low-dose droperidol (0.625 mg) given at the end of surgery is an effective prophylactic antiemetic after desflurane anesthesia and can contribute to an earlier discharge home after laparoscopic cholecystectomy. Administration of a subhypnotic dose of propofol (0.5 mg/kg) delayed emergence from desflurane anesthesia without reducing emetic symptoms in the postoperative period.

Effects of State Humor, Expectancies, and Choice on Postsurgical Mood and Self‐Medication: A Field Experiment1

It was hypothesized that repeated exposure to humorous material reduces distress, pain, and medication following surgery. This hypothesis was tested in a field experiment by randomly assigning 78 postsurgical patients to either a control group or 1 of 8 experimental groups formed by the factorial crossing of type of videotape (humorous vs. serious), perceived control (choice vs. no choice), and expectation (positive vs. none). Multivariate analyses of variance disclosed that humor reduced requests for minor medication, combined with expectations to reduce pain, but increased use of heavy analgesic when patients were deprived of choice. Although more research needs to be done, the findings suggest that hospital patients benefit from humorous and distracting material when exposure is voluntary.

At Law: Sledding in Oregon

On 8 November, voters in Oregon made their state first in nation to legalize physicians' directly helping patients to die. By a 32,000 vote margin (51 to 49 percent) they approved Measure No. 16, which removes criminal penalties for physicians who prescribe drugs to enable people to take their own lives. Eight days later, a jury in Saskatchewan found Robert Latimer guilty of second degree murder for killing his severely handicapped daughter Tracy.[1] Though circumstances in that case seem a world away from new Oregon law, changes in community and professional norms inherent in Oregon act may well push law beyond its enacted confines with profound consequences for future Latimer-type cases. Ballot Measure 16 Oregon was third state to have a Death with Dignity Act on its election ballot in this decade. Initiative measures with same names were defeated in Washington State in 1991 and California in 1992, both by 54 to 46 percent, despite repeated polls that show strong public support for physician assistance to bring a speedy and pain-free death. Analyzing those prior votes, proponents concluded that die electorate wanted stronger safeguards and more limited power for physicians. Giving doctors a lesser role than had neighboring states' proposals (which allowed active euthanasia), Oregon act legalizes physician-assisted suicide but leaves patients to perform final act. The law applies only to residents of Oregon eighteen years of age or older who have the ability to make and communicate health care decisions, including communication through persons familiar with [their] manner of communicating if those persons are available [section] 1.01 (6)]. To be qualified to receive a lethal prescription, person must also be suffering from a terminal disease, which is defined as incurable and irreversible disease that has been medically confirmed and will, within reasonable medical produce death within six (6) months [section] 1.01(12)]. Beyond these requirements, statute contains four principal safeguards. First, attending physician must convey information not only about diagnosis and prognosis and risks and results of taking prescribed medication, but also the feasible alternatives, including, but not limited to, comfort care, hospice, and pain control [section] 3.01 (2)]. The physician must ask patient to notify next of kin of his or her plans but may not deny request for medication because a patient declines or is unable to do so [section] 3.05]. Second, a consulting physician must confirm that patient has a terminal illness, is capable, and has made a voluntary and informed decision [section] 3.02]. Third, if either attending or consulting physician thinks patient suffers from a psychiatric disorder, including causing impaired judgment, patient must be referred for counseling. Lethal medication may then not be prescribed until a licensed consultant rules out such a disorder or depression [section] 3.03]. Finally, a person wishing to commit suicide must make a series of oral and written requests to that effect. At least fifteen days must elapse between initial oral request and one that immediately precedes writing of prescription, and sometime between two oral requests - and no less than forty-eight hours before prescription - patient must execute a written request for medication, witnessed by at least two people who can attest to patient's apparent decisionmaking capacity and voluntary, uncoerced decision. Mirroring advance directive statutes, Oregon law proscribes attending physician's being a witness, and at least one of witnesses must be disinterested, in sense of not being a relative, someone entitled to a portion of estate, or an owner or employee of a health care facility where patient resides or receives care [section] 2. …

A comparison of regularly dosed oral morphine and on-demand intramuscular morphine in the treatment of postsurgical pain

A randomized, placebo-controlled, double-blind clinical trial was conducted to compare the use of regularly dosed po morphine and on-demand in morphine in 47 patients undergoing total hip arthroplasty. Patients were randomized to receive either 20 mg (initial dose) of regularly dosed morphine (every four hours po) plus breakthrough pain medication on-demand consisting of both 10 mg morphine po and placebo im, or an equivalent regularly dosed oral placebo (every four hours) with breakthrough pain medication consisting of oral placebo and 5-10 mg morphine im. Subsequent to each request for breakthrough pain medication, the next regularly dosed oral solution was increased by 5 mg (or equivalent volume of placebo) to a maximum of 40 mg po Q4H. Time-averaged pain scores were lower on both postoperative day 1 and 2 in the group receiving regularly dosed morphine po (P < 0.05). Fewer patients requested breakthrough pain medication on both days in the oral morphine group. The incidence of nausea and vomiting, and of decreased respiratory rates were similar in both groups. Regularly dosed oral morphine is inexpensive and should be compared to other methods of opioid delivery.

Requests for medications during chemical dependency rehabilitation as a predictor of relapse.

This study tested an aspect of the low-frustration-tolerance hypothesis by investigating the relationship between nonprescription medication requests by chemical-dependency patients, while in treatment, and their relapse rate. Subjects were 200 adult, chemically dependent patients admitted to a 28-day inpatient treatment program. The number of requests for nonprescription medications for subjective and objective symptoms were recorded for all patients during the course of their treatment, and these patients were followed for 1 year after treatment to determine if they had remained abstinent. Results were consistent with the predictions of the low-frustration-tolerance hypothesis. Patients who requested more medications for subjective symptoms during treatment were less likely to remain abstinent for 1 year after treatment.

Preoperative self-efficacy and postoperative behaviors

Preoperative instruction has been found to decrease postoperative complications; however, the mechanisms through which preoperative instruction exerts its effects remain unknown. In this study, the relationship between preoperative self-efficacy and postoperative behaviors was investigated. Subjects were 68 cholecystectomy patients. Subjects' scores on the efficacy expectations subscale were related significantly to postoperative deep breathing, ambulation, and recall of expected events; scores on the outcome expectations subscale were related significantly to postoperative requests for pain medication. Self-efficacy theory provided a link between self perceptions and behavior and may be the mechanism through which preoperative instruction exerts its effects.

Cytolytic vaginosis

Cytolytic vaginosis, a not uncommon condition, is frequently misdiagnosed because it is confused with Candida. Many practitioners rely on their clinical judgment alone rather than the use of high-quality microscopes and the results of a wet smear. Compounding the problem of misdiagnosis is that patients assume that their symptoms are caused by a yeast infection, which results in telephone requests for medication from their physicians instead of an office consultation. Cytolytic vaginosis is characterized by pruritus, dyspareunia, vulvar dysuria, and cyclical increase in symptoms more pronounced during the luteal phase. Diagnostic criteria include a high risk of suspicion; the absence of Trichomonas, Gardnerella, or Candida on wet smear; an increased number of lactobacilli; a paucity of white blood cells; evidence of cytolysis; and the presence of discharge; and a pH between 3.5 and 4.5. Treatment entails use of sodium bicarbonate douches.

Epidural nalbuphine for analgesia following caesarean delivery: dose-response and effect of local anaesthetic choice

The analgesic profile of epidural nalbuphine for postoperative pain relief and the impact of local anaesthetic choice upon this profile was investigated in 58 patients undergoing elective Caesarean delivery under epidural anaesthesia. Patients were randomized to receive either lidocaine 2% with 1:200,000 epinephrine or 2-chloroprocaine 3% for perioperative anaesthesia, followed by either 10, 20, or 30 mg of epidural nalbuphine administered at the first complaint of postoperative discomfort. Postoperative analgesia was quantitated on a visual analogue (VAS) scale, and by the time from the epidural opioid injection until the first request for supplemental pain medication. The duration of analgesia after lidocaine anaesthesia followed by 10, 20 or 30 mg nalbuphine was 77 (53-127) min, 205 (110-269) min, and 185 (116-241), respectively (median, 95% confidence interval, P less than 0.01, 20 and 30 mg vs 10 mg). Following 2-chloroprocaine anaesthesia, VAS remained consistently elevated: the median duration of analgesia was only 30-40 min and did not differ among the three doses of nalbuphine. Side-effects consisted only of somnolence, and were noted only following lidocaine anaesthesia. Somnolence was observed in 0, 20% and 50% of those receiving 10 mg, 20 mg and 30 mg of nalbuphine respectively (NS). No evidence of respiratory depression was noted in any patient. It is concluded that 20 or 30 mg of epidural nalbuphine provides analgesia for only two to four hours following Caesarean delivery with lidocaine anaesthesia, but anaesthesia with 2-chloroprocaine resulted in minimal or no analgesia from this opioid. Nalbuphine appears to be a disappointing agent for epidural use after Caesarean delivery.

Transdermal Scopolamine Decreases Nausea and Vomiting Following Cesarean Section in Patients Receiving Epidural Morphine

Kotelko, D. M.; Rottman, R. L.; Wright, W. C.; Stone, J. J.; Yamashiro, A. Y.; Rosenblatt, R. M. Author Information

The effect of epinephrine in local anaesthetic on epidural morphine-induced pruritus.

The severity of epidural morphine-induced pruritus was evaluated following the addition of epinephrine to the local anaesthetic solution used for Caesarean section anaesthesia. The local anaesthetic solutions used were: Group I--0.5 per cent bupivacaine plain--20 patients. Group II--0.5 per cent bupivacaine with 1:400,000 epinephrine--25 patients. Group III--0.5 per cent bupivacaine with 1:200,000 epinephrine for the 3 ml "test dose" followed by 0.5 per cent bupivacaine plain for anaesthesia--21 patients. The severity of the pruritus, as measured by completion of a visual analogue "itch scale" and by requests for medication for pruritus, was statistically significantly greater in both groups in which epinephrine was added. This effect was not dose-related, as the "test dose" group (15 micrograms epinephrine) experienced the most severe itch. This latter difference was also statistically significant (p less than 0.05).

Effect of pharmacists' clinical interventions on nonformulary drug use

The effect on drug costs of pharmacists' interventions in reducing the use of nonformulary medications was studied in a private teaching hospital. During a four-month period, nonformulary medication request forms and pharmacist consultation logs were reviewed to determine physicians' actions taken on requests for nonformulary medications. Cost avoidance of interventions (nonformulary medication cost) and the cost of pharmacist cost) and the cost of pharmacist time for the interventions were determined. The pharmacist was able to contact The pharmacist was able to contact the physician in 388 of 394 instances in which the use of a nonformulary medication was considered. Of 230 recommendations by pharmacists to change a nonformulary drug order to one for a formulary alternative, 64.8% (149) were accepted by physicians. Of pharmacists' recommendations that were accepted, 75.8% (113/149) were from decentralized areas, which was a significantly higher acceptance rate than that for the centralized areas (24.7% or 36/149). Cost avoidance resulting from acceptance of pharmacists' recommendations during the four-month study was $2,645, or $13,573 per year; this was more than the cost of pharmacist time required to perform interventions. Pharmacist interventions to decrease use of nonformulary drugs can be cost-effective and appear to be more successful in decentralized pharmacy service areas than in areas served by a central pharmacy.

Prevalence of Diphyllobothriasis

To the Editor.— I enjoyed reading the editorial Diphyllobothriasis (1981; 246:2483), if for no other reason than it reminded me of my recent reading of a similar fish tapeworm epidemic in New York City some years ago. 1 However, I disagree with the statement that the prevalence or increase of the infestation can be ascertained or judged by the number of requests for the latest specific medication received by the Centers for Disease Control (CDC), especially since there are and have been on the market a number of other effective antihelmintics. 2 The increase in the number of requests received by the CDC for niclosamide may reflect only an increase in awareness by the prescribing physicians in the possibility of obtaining this medication from a single source and not an increase in incidence or prevalence, since a good number of physicians continue to prescribe one or the other of the

A Continuing Pharmacy Education Program

A "nonequivalent control group" design was employed to measure the effectiveness of a continuing education program developed to enhance a communitypharmacist's ability to respond to requests for nonpre scription medication. Trained observers were used to unobtrusively measure the pharmacist's behavior before and after the educational event. Data analyses indicated a significant improvement in the partici pant pharmacists' abilities.

An Analysis of Policies Regulating Medication in the Schools

ABSTRACTThe administration and storage of prescribed medication in the schools is an area in which parents, physicians and school personnel need a close working relationship. Two hundred local school superintendents, randomly selected from throughout the United States, were requested to identify if their school district had a formal written policy regarding the storage and administration of prescribed drugs and, if so, to send a copy of this policy for analysis. The recommendations derived from the policies received were readily divisible into 12 categories: (1) physician's approval/request for the administration of medication, (2) parental or guardian's request and authorization to give medication, (3) functions of the school nurse, (4) container holding medication, (5) storage of medication, (6) person responsible for administration, (7) supply of medication kept at school, (8) log or written record of medication given, (9) unused medication, (10) delivery of medication to the school, (11) recording of information in student's cumulative folder, and (12) other. The large percentage of school districts responding that they do not have formal written policies to regulate the storage and administration of prescribed drugs in the schools, coupled with the few school districts which sent policies for analysis, provide clear evidence that a greater amount of attention is needed in this area.

Patients' Requests of an Outpatient Clinic

Three-hundred-twenty-five consecutive predominantly lower-class new patients at a psychiatric outpatient clinic rated the importance they attached to each of 14 categories of treatment needs or requests. Psychiatric residents subsequently rated the importance of each request for each patient at the conclusion of their initial assessment interview. Requests reflecting needs for intrapsychic therapy, clarification, and control of feelings were considered very important by approximately two thirds of the patients; needs for institutionalized contact, advice, and community triage by one half; and other requests for medication, reality contact, succorance, ventilation, confession, social intervention, administrative requests by a minority (one fourth to one third). Residents significantly underestimated the importance their patients attached to 10 of 14 requests. Factor analyses confirmed several systematic sources of disparity between patient and therapist perception of lower-class patient needs.

Requests for as-needed medications by asthmatic patients: Relationships to prescribed oral corticosteroid regimens and length of hospitalization

In a previous study, patient-coping styles, indexed by panic-fear symptomatology, were found to be associated with specific patterns of requesting as-needed (PRN) medications and treatments: Patients who tend to emphasize their symptoms (high panic-fear) requested PRNs frequently, even on days when their pulmonary function levels were essentially normal, while those who tend to minimize their symptoms (low panic-fear) requested PRNs infrequently, even on days when their pulmonary function levels were subnormal. In the present study, we found that patients who requested PRNs frequently spent more days in the hospital than those who requested PRNs only rarely. Intensive medication regimens (i.e., daily corticosteroids or alternate-day corticosteroids supplemented with TAO, cromolyn, or aerosolized steroids) were more often prescribed for patients requesting PRNs frequently than for those requesting PRNs rarely. These differences in patient management were attributable neither to differences in pulmonary function nor directly to differences in panic-fear rating. Thus, patient-coping styles can influence the treatment prescribed, and optimal management requires that individual patient-coping styles be considered in planning a regimen.

Panic-fear in asthma: Requests for as-needed medications in relation to pulmonary function measurements

Requests for as-needed medications and treatments (PRNs) by asthmatic patients scoring high, moderate, or low on the Asthma Symptom Checklist panic-fear category were studied for days when patients were matched at normal, intermediate, and subnormal levels of pulmonary function. Low panic-fear patients were the least likely to request PRNs regardless of the pulmonary function level. In contrast, high panic-fear patients often requested PRNs at each level of pulmonary function. Only moderate panic-fear patients made progressively more PRN requests on days when pulmonary functions were lower. These observations and others concerning the adverse influence of extreme panic-fear coping styles upon the treatment of asthma were discussed.

Second stage medical intervention and pain during childbirth

THE USE of medication as a medical intervention technique to alleviate pain during second stage labor has been a largely unexamined practice. Similarly the relationship between the administration of episiotomies or the use of forceps and changes in pain perception has scarcely been subjected to empirical investigation. Since the relief of the mother’s pain is at least one, if not “the prime function” [l] of an obstetrician during delivery, the relationship between pain and these 3 medical procedures requires more careful examination. The stated purpose of second stage medication is often the relief of pain [l, 21. Aiken and Cope [3] examined the comparative efficiency of two kinds of medication, promazine and Diazepam, in reaching this goal. Pain during labor, as reported by senior midwives, was reduced significantly more with promazine than with Diazepam. Brown et al. [4] separately checked the relationships between various dosages of oxytoxics or analgesics and pain reactions revealed by obstetrics reports. They found no significant relationship between dosage level and pain reactions for either type of medication. They then considered the possibility that differences in medication levels chosen by obstetricians might be attributable to patient requests for medication not reflected in obstetric reports of pain. It was impossible to assess directly this hypothesized relationship with their data, but the tentative conclusion, based on secondary evidence, was that no such relationship existed. The present study seeks to provide more direct evidence by including pain reports of the mother as well as the physician. The pain reports used here were from a population of women trained in prepared childbirth, and reports from the labor coach (usually the husband) and the childbirth educator were also obtained and analyzed. The approach taken in the present study is also more basic. Rather than assess the relative efficiency of two kinds of medication [3] or several dosage levels of one kind of medication [4], the question is whether medication per se yields pain reports different than reports in births where medication is absent. Since an episiotomy involves an incision in the muscular tissue of the perineum, the procedure might be expected temporarily to increase pain. Presumably the procedure would be no more painful than a tear, the alternative possibility. One researcher [5] found no differences in pain reported during the first perinatal week for women who had experienced an episiotomy vs those who had received a tear. The effect of an episiotomy on pain during labor has yet to be examined. The use of forceps may sometimes be required in childbirth. The effects of this procedure on pain reported