Method Of Postoperative Pain Control Research Articles

Inadvertent Epidural Administration of Atracurium and Lidocaine Mixture: A case report

Epidural administration of opioid and/or local anesthetics during general anesthesia is widespread method for postoperative pain control. Despite of its availability, inadvertent administration of non-epidural medications into epidural space can be associated with serious neurologic sequelae. We report a case of accidental epidural atracurium injection.

The Effect of the Initiating Time of Patient Controlled Analgesia on the Onset of Postoperative Analgesic Effect

Background: Patient controlled analgesia (PCA) is now a widely accepted method of postoperative pain control. It usually begins at postanesthetic care unit, but it takes time to achieve satisfactory level. We have studied the differences in the onset of analgesic effects between starting PCA preoperatively and starting PCA postoperatively. Methods: Forty patients for subtotal gastrectomy were randomized to two groups. In group I, we started PCA at postanesthetic care unit, in group II, PCA was begun immediately after the induction of anesthesia. We visited each patient and measured 10 cm-visual analgue scale (VAS) score at 3, 6, 9, 12 and 15 hours after the end of operation. We also measured the time taken from the end of operation to extubation. Results: There were no differences in VAS score between two groups on 3 hour. But at 6, 9, and 12 hour, VAS score was significantly lower in group II (P

The Effect of Epidural Patient-Controlled Analgesia on the Frequency and Progress of Postoperative Side Effects

Background: Epidural PCA (patient controlled analgesia) is a well known postoperative pain control method. However its side effects are not well understood. This study will look into the frequency and progress of the side effects of the epidural PCA using bupivacaine and fentanyl mixture after gynecological surgery. Methods: About 100 female patients undergoing lower abdominal gynecologic surgery under the general anesthesia were studied regarding the side effects such as failure of pain control, nausea, vomit, sedation, pruritus, motor block and hypotension. Visual analogue scale (VAS) was used for the measurement of pain at rest and cough. The frequency and the progress of the side effects were also recorded at 2, 6, 12, 24, 36 and 48 hours after the surgery. The relationship between the insertion site of epidural PCA catheter and motor block, hypotension and the use of rescue drug were also analyzed. Results: VAS scores at cough were 12 to 21 point higher than at rest. Nausea and motor block were more severe than other side effects. The group having epidural PCA catheter inserted in the upper lumbar epidural space showed more severe motor block than the group having it inserted in the lower thoracic epidural space. Conclusions: The frequency of nausea and motor block were relatively higher than other side effects. So it is necessary to take a careful observation and an immediate treatment for these side effects in postoperative pain management using epidural PCA. Also the severity of motor block depends on the insertion site of epidural PCA catheter. Lower thoracic epidural space is considered to be a better insertion site than upper lumbar epidural space in reducing the motor block side effect.

Prospective Randomized Clinical Trial Comparing Patient-Controlled Intravenous Analgesia With Patient-Controlled Epidural Analgesia After Lumbar Spinal Fusion

A prospective, randomized, double-blind clinical trial was conducted. To compare the efficacy of patient-controlled analgesia (PCA) with that of patient-controlled epidural analgesia (PCEA) in terms of overall patient satisfaction with postoperative pain management after lumbar spine fusion. In numerous surgical disciplines, PCEA and PCA have proved to be effective methods of postoperative pain control. The literature states that with PCEA, less opioid use is required during the immediate postoperative period to maintain equivalent pain control compared to PCA. Continuous epidural infusion has been assessed in spine fusion patients, but PCEA has not been evaluated. Furthermore, this is the first prospective randomized clinical trial to assess overall patient satisfaction while stratifying patients for both anxiety level and preoperative opioid use. For this study, 74 patients were assigned randomly to one of two treatment groups, with PCA and PCEA administered in a double-blind manner for a 3-day postoperative course. All the patients received both PCA and PCEA delivery systems. Assessment was by a blinded, independent observer. Overall patient satisfaction with pain management was assessed by a visual analog scale at the end of postoperative day 3. Secondary measures included: three scales from the Functional Independence Measure instrument; opioid quantity; side effects; and length of hospital stay. Thirty-eight patients were randomized to PCA, and 36 were randomized to PCEA. No baseline variable differences between the groups were observed. The results showed no difference between the groups on the following measures: overall patient satisfaction with pain management, ambulation, and length of stay. The PCA patients used significantly more opioid than the PCEA patients. Both postoperative analgesic regimens provided good overall patient satisfaction. The only clinical advantage of PCEA over PCA for spine fusion patients was the lower amount of opioid consumed, although the PCEA group experienced significantly more side effects than the PCA group. There were no other significant differences. Therefore, patient or physician preference could select either postoperative pain management delivery system.

Outcome of Total Knee Arthroplasty Depending on Post-operative Pain Control Methods

Background: Rehabilitation physical therapy after a total knee arthroplasy (TKA) is important for the functional prognosis of the surgery and the methods of postoperative analgesic control could have influence on physical therapy. Therefore we compared surgical outcome of TKA patients receiving intravenous patient-controlled analgesia (IPCA) and epidural patient-controlled analgesia (EPCA) for pain control. Methods: Forty four patients scheduled for a TKA were randomly allocated into two groups. The IPCA group received intravenous PCA (fentanyl 30/ml, ketorolac 3 mg/ml, 0.5 ml/15 min/0.5 ml) after general anesthesia and the EPCA group received epidural PCA (0.1% bupivacaine, fentanyl 3/ml, 3 ml/15 min/3 ml) after combined spinal epidural anesthesia for an operation. Pain score and side effects were checked at 6, 24, 48, and 72 hours after the operation. Range of motion (ROM) was evaluated at discharge, 1 and 3 months after the operation. Results: The EPCA group showed better analgesia and ROM than the IPCA group but the advantage on ROM did not last up to the 3 month follow up. Nausea/vomiting and sedation was more in the IPCA group, and backache, paresthesia and motor weakness of the lower limbs were more in the EPCA group. However, all side effects were tolerable for the patients. There was 31.8% of epidural catheter dislodgement or occlusion. Conclusions: Better analgesia with epidural PCA resulted in a better functional prognosis, but more effort would be needed to manage an epidural catheter.

What's new in pediatric paravertebral analgesia

Paravertebral nerve block is a very effective method of postoperative pain control that is ideal for certain unilateral operative procedures in which bilateral blockade is not necessary. The quality of the block may be superior to that seen with epidural analgesia. Paravertebral nerve blockade in children has primarily involved the use of postoperative infusions of local anesthetic via indwelling catheters for renal and thoracic surgery. Its use has thus been mostly limited to the inpatient population. Recently, bolus injections into the paravertebral space have been shown to be effective in adults undergoing outpatient surgery, yet experience with this technique in children is limited. This article briefly reviews the current use of paravertebral blockade in children and using case illustration, specifically outlines the use of paravertebral blockade for outpatient inguinal surgery in children. It also includes a description of the many benefits of the technique in this population. Copyright 2002, Elsevier Science (USA). All rights reserved.

The efficacy of continuous cryotherapy on the postoperative shoulder: A prospective, randomized investigation

This prospective, randomized investigation evaluated the efficacy of cryotherapy on subjective responses after both open and arthroscopic procedures on the shoulder. Seventy patients were randomly assigned to one of two study groups: (1) continuous cryotherapy group and (2) age-matched control group. Visual analog scales were used to assess subjective responses on postoperative days 1, 7, 14, and 21. On day 1, patients receiving cryotherapy reported significantly less pain during sleep and significantly more comfort in bed and rated their sleep as more restful than the control subjects. During days 7 through 21, cryotherapy subjects reported a significant reduction in frequency and intensity of pain, as well as less pain during shoulder rehabilitation, than the control subjects. These results indicate that cryotherapy is an effective method for postoperative pain control because it decreases the severity and frequency of pain and allows a return to normal sleep patterns while increasing overall postoperative comfort and satisfaction. (J Shoulder Elbow Surg 2001;10:522-5.)

The Effect of the IV-PCA (Intravenous-Patient Controlled Analgesia) on the Recovery Index

Background: It is well known that intravenous patient controlled analgesia (IV-PCA) is an effective method to reduce the magnitude of postoperative pain. However, we do not know the appropriate time to start the IV-PCA. To determine the appropriate time to minimalize the sympathetic stimulation and shorten the awakening time after general anesthesia, experiments to indicate whether starting an infusion of the IV-PCA before the end of an operation has a minimal hemodynamic change and similar recovery index compared with the control group were done. Methods: Seventy-eight patients scheduled for a total abdominal hysterectomy were randomly allocated to two groups. In the IV-PCA group (n=37), we started the infusion of the IV-PCA before the end of the operation and in the control group (n=4l) which received no IV-PCA, we did not use the IV-PCA as a postoperative pain control method. We measured heart rate, blood pressure, postanesthesia recovery score every 10 minutes for 60 minutes and awakening time at the post-anesthesia care unit. Results: The postanesthesia recovery scores on arrival, 10, 20, 30, 40 and 50 minute after arrival at the post-anesthesia care unit were lower in the IV-PCA group than in the control group. In addition the awakening time after vaporizer-off and at the post-anesthesia care unit was longer in the IV-PCA group than in the control group. Conclusions: We conclude that starting the infusion of the IV-PCA before the end of the operation is not effective in early recovery and awakening. (Koreaa J Anesthesiol 2001; 41: 318-323)

Use of an orbital epidural catheter to control pain after orbital implant surgery.

The surgical placement of orbital implants for eviscerations, enucleations, and secondary implantations can cause severe postoperative pain that may not be relieved with high doses of narcotics. We analyzed the effectiveness of a method for postoperative pain control in orbital implant surgery using an orbital epidural pain catheter connected to a patient-controlled analgesia bupivacaine hydrochloride pump. One hundred nineteen patients undergoing orbital hydroxyapatite implant surgery received placement of an orbital epidural catheter for the infusion of local anesthetics at the conclusion of their surgery. Patients were asked to gauge their level of comfort into the following 3 categories: total, some, or no pain relief in the first week after surgery. A separate numerical grading scale was used to further quantitate pain. Blood samples were collected in 4 patients to assess the systemic levels of bupivacaine. Most patients (88.2%) responded with total or some pain relief, with only 11.8% suffering severe pain. The mean numerical pain score was 2.8, within a range of 0 (no pain) to 10 (severe pain). The average plasma bupivacaine level in the 4 patients in whom this was measured was 0.38 microg/mL, which is well below the toxic level of 4.0 microg/mL. Furthermore, there were only 5 minor complications caused by the catheters, ie, 1 retrobulbar hemorrhage and 4 catheters that did not work. No permanent problems arose from any of the complications. The orbital epidural pain catheter is an effective means to achieve postoperative pain control after orbital implant surgery. The simple technique of insertion and management of the catheters was well tolerated in our patient population.

Clinical Experience of Postoperative Pain Control

Background : We prospectively studied 615 patients who received postoperative pain control (epidural analgesia or intravenous patient controlled analgesia) to evaluate pain relief, side effects and complications. Methods : All study patients receiving postoperative pain control were assessed three times a day by the pain control resident for pain relief, using a visual analogue scale. The presence of side effects and complications was assessed. Results : Over 1year, 615 patients (65.9% women, aged 46.9±16.4yr) were studied. General surgery, gynecology and obstetrics in the department; and lower abdomen, upper abdomen and perineum in the operation site were order of decreasing frequency. The most common site of epidural puncture level was T12-L1 in the epidural analgesia. The average pain score using VAS in all groups was less than 3.0 and the degree of satisfaction in postoperative pain control was rated as good on 88% of the patients. Nausea occurred in 9.1% of all patients, vomiting in 6.3%, pruritis in 0.9%, urinary retention in 2.6%, hypotension in 3.2%, but there was no case of respiratory depression. Dislodgement of the epidural catheter occurred in 0.5% of all patients. Conclusions : Postoperative epidural fentanyl/bupivacaine infusions and IV PCA are an effective method of postoperative pain control with a low incidence of side effects. We believe that, with appropriate patient observations and careful drug selection and with the use of epidural catheters placed appropriately for the proposed surgery, that high quality postoperative pain control can be offered. (Korean J Anesthesiol 1997; 32: 281∼288)

Postoperative pain control in paediatric ambulatory herniorrhaphy and orchiopexy using atraumatic intraoperative instillation of bupivacaine in comparison with rectal application of acetaminophen: a double-blind study

Herniorrhaphy and orchiopexy are increasingly performed on an outpatient basis in paediatric surgery. In such cases, postoperative analgesia should receive special attention so that the hospital stay need not be unnecessarily prolonged due to side effects of the analgesic agents, such as sedation, respiratory depression or vomiting. Therefore, the present study is a randomized double-blind investigation to assess the effectiveness of atraumatic intra-operative instillation of bupivacaine in the surgical site and the rectal application of acetaminophen as a postoperative analgesic following herniorrhaphy and orchiopexy. Male patients between the ages of 3 and 6 yr who were scheduled to receive ambulatory herniorrhaphy or orchiopexy were included in the study. One hundred children in each of the herniorrhaphy and orchiopexy groups were treated respectively with acetaminophen or with bupivacaine as the postoperative analgesic. Atraumatic intraoperative instillation of bupivacaine into the surgical site proved to be significantly superior as a postoperative analgesic in both the herniorrhaphy and orchiopexy groups as compared to rectal application of acetaminophen (χ 2 test: herniorrhaphy group P < 0.05; orchiopexy group P < 0.001). For herniorrhaphy and orchiopexy in childhood, local atraumatic instillation of bupivacaine during surgery into the wound bed is a simple, easy to use and reliable method for post-operative pain control with no side effects.

Patient-controlled analgesia

Patient-controlled analgesia (PCA) is now one of the preferred methods of postoperative pain control after surgery. Many routes have been used to administer PCA, but intravenous drug delivery is most commonly used. This article discusses advantages and limitations of PCA and how some of the limitations can be addressed.

Transabdominal versus retroperitoneal incision for abdominal aortic surgery: Report of a prospective randomized trial

The purpose of this study was to perform a randomized, prospective trial that compares the transabdominal with the retroperitoneal approach to the aorta for routine infrarenal aortic reconstruction. From August 1990 through November 1993, patients undergoing surgery for abdominal aortic aneurysm (AAA) disease or aortoiliac occlusive disease (AIOD) were asked to participate in a randomized trial comparing the transabdominal incision (TAI) to the retroperitoneal incision (RPI) for aortic surgery. One hundred forty-five patients were randomized, with 75 (41 with AAA and 34 with AIOD) in the TAI group and 70 (40 with AAA and 30 with AIOD) in the RPI group. There were no significant differences between the groups in terms of age, sex, postoperative pain control (epidural vs patient-controlled analgesia), or comorbid conditions, except for a higher incidence of chronic obstructive pulmonary disease in the TAI group (21 vs 8 patients). The incidence of intraoperative complications was similar for both groups. After surgery, the incidence of prolonged ileus (p = 0.013) and small bowel obstruction (p = 0.05) was higher in the TAI group. Overall, the RPI group had significantly fewer complications (p < 0.0001). The overall postoperative mortality rate (two deaths) was 1.4%, with both occurring in the TAI group (p = 0.507). The RPI group also had significantly shorter stays in the intensive care unit (p = 0.006), a trend toward shorter hospitalization (p = 0.10), lower total hospital charges (p = 0.019), and lower total hospital costs (p = 0.017). There was no difference in pulmonary complications (p = 0.71). In long-term follow-up (mean 23 months), the RPI group reported more incisional pain (p = 0.056), but no difference was found in incisional hernias or bulges (p = 0.297). We conclude that the RPI approach for abdominal aortic surgery is associated with fewer postoperative complications, shorter stays in the hospital and intensive care unit, and lower cost. There is, however, an increase in long-term incisional pain. Current methods of postoperative pain control seem to decrease the incidence of pulmonary complications.

Patient-controlled analgesia: a new method for old.

Patient-controlled analgesia (PCA) has successfully made the transition from a research tool for the investigation of pain, to a wider clinical utility as method of pain control. Reliable and sophisticated PCA systems have been commercially available for some time. The technique has been most commonly used for control of postoperative pain, but has also been successfully used during labour, after burns, in acute painful medical conditions and in terminal care. It is generally more effective than the traditional methods of postoperative pain control but not automatically so. The choice of opioid, the settings chosen for demand dose and the lockout interval will greatly influence the effectiveness of this method of analgesia. Psychological variables are also important in predicting the efficacy of PCA.

Efficacy of subarachnoid morphine in a community hospital.

Two hundred seventy-five patients who underwent major surgery and received subarachnoid morphine for postoperative pain relief were prospectively studied to establish the benefits of its routine use in a community hospital. Seventy-nine percent of all patients had a satisfactory analgesic-free interval of 18 hours, and postoperative analgesics were unnecessary for the first 24 hours in 56% of all patients. Pruritus developed in 26% of all patients, 16% experienced nausea, vomiting, or both, and 4% experienced urinary retention. There were no cases of respiratory depression. Ninety-two percent of all patients were managed on the medical/surgical floors without incident, and 90% of the patients were satisfied with their results. It was shown that, when there are properly trained floor nurses, subarachnoid morphine (0.1-0.4 mg) can be an effective, safe, and simple method for postoperative pain control in a community hospital.

New techniques in postoperative analgesia

New and more efficient techniques of postoperative pain management have been recently introduced. Patient-controlled intravenous (and perhaps subcutaneous) administration of analgesics is an improvement over traditional intramuscular injection. Its efficacy, safety, and high acceptance by patients, surgeons, and nurses make this technique increasingly popular for routine management of postoperative pain. Epidural or intrathecal administration of narcotic agents, although more efficient in controlling pain than intravenous infusion, should probably be reserved for indications such as major thoracic and abdominal procedures. Spinal administration requires more routine surveillance and, when inadequately managed, has the potential for serious side effects and complications. Clinical investigations currently in progress are aimed at finding more successful and safer methods of postoperative pain control. The best methods will likely involve a multifaceted therapeutic approach rather than the simple effect of one "magic bullet."