Method Of Postoperative Pain Control Research Articles

Prediction of postoperative pain using path analysis in older patients

Effective postoperative pain management is important for older surgical patients because pain affects perioperative outcomes. A prospective cohort study was conducted to describe the direct and indirect effects of patient risk factors and pain treatment in explaining levels of postoperative pain in older surgical patients. We studied patients who were 65 years of age or older and were scheduled for major noncardiac surgery with a postoperative hospital stay of at least 2 days. The numeric rating scale (0 = no pain, 10 = worst possible pain) was used to measure pain levels before surgery and once daily for 2 days after surgery. Path analysis was performed to examine the association between predictive variables and postoperative pain levels. Three hundred fifty patients were studied. We found that preoperative pain level, use of preoperative opioids, female gender, higher ASA physical status, and postoperative pain control methods were the strongest predictors of postoperative pain as measured on the first day after surgery. Younger age, greater preoperative symptoms of depression, and lower cognitive function also contributed to higher postoperative pain levels. Pain levels on the second day after surgery were strongly predicted by preoperative pain level, use of preoperative opioids, surgical risk, and pain and opioid dose on postoperative day 1. However, younger age, female gender, higher ASA physical status, greater preoperative symptoms of depression, lower cognitive function, and postoperative pain control methods indirectly contributed to pain levels on the second day after surgery. Although preoperative pain and use of preoperative opioids have the strongest effects on postoperative pain, clinicians should be aware that other factors such as age, gender, surgical risk, preoperative cognitive impairment, and depression also contribute to reported postoperative pain. Based on significant statistical correlations, these study results can contribute to more effective postoperative care for those patients having the risk factors studied here. Preoperative treatment/intervention based in part on factors such as preoperative pain, use of preoperative opioids, and depression may improve postoperative pain management.

Postoperative Analgesia: Comparing Continuous Epidural Catheter Infusion of Local Anesthetic and Opioid and Continuous Wound Catheter Infusion of Local Anesthetic

Continuous wound infusion has been investigated as a method of postoperative pain control and its efficacy has been demonstrated when compared to saline infusion. The objective of this study was to compare the quality of postoperative analgesia, the use of opioids as rescue analgesia, patient satisfaction, and the incidence of complications between epidural catheter infusion of local anesthetic and opioids and continuous wound infusion of local anesthetic. Thirty-eight patients undergoing elective laparotomy under general anesthesia, randomly divided into two groups, participated in this study. Group I (GI) received postoperative patient-controlled epidural analgesia (PCEA) with continuous infusion of ropivacaine and fentanyl, while Group II (GII) receive postoperative patient-controlled continuous wound catheter infusion of ropivacaine. In the postoperative period, the following parameters were assessed: quality of analgesia through the Visual Analogue Scale; use of rescue opioids; and adverse effects driving patient satisfaction. Decreased pain at rest and with movements (p < 0.05) and lower consumption of rescue opioids (p < 0.05) were observed in GI in all intervals evaluated, as well as greater patient satisfaction in the post anesthesia care unit (PACU). The incidence of complications was similar in both groups except for pruritus which prevailed in GI between 6 (p < 0.05) and 24 (p < 0.001) postoperative hours. Postoperative analgesia with opioids and local anesthetics via PCEA was superior to the patient-controlled local anesthetic infusion into surgical wound. The incidence of side effects was similar in both groups.

Effect of patient education in post-operative patients using patient controlled analgesia

AbstractPatient controlled analgesia (PCA) is an effective method of postoperative pain control. Patients are required to operate the device in order to control their pain and it is therefore important that they receive an adequate explanation of its use.This study compared a group of patients who received intensive pre- and postoperative counselling on the use of PCA with a group who received the usual explanation from anaesthetists.No difference in pain control, as measured by nurse recorded pain scores, was detected but some evidence of a reduced incidence of side effects of therapy, particularly nausea and vomiting, was observed in the counselled group. Patients' overall satisfaction with post-operative pain relieving treatment was increased in the group who had been counselled.The study indicates that improved patient education leads to a more satisfied patient who is less likely to have unanswered concerns about the use of PCA and who might be less likely to experience side effects associated with this therapy.

L’obésité, l’analgésie péridurale et l’incision sous-costale sont des facteurs de risque de désaturation postopératoire

This study was designed to determine the incidence of oxygen desaturation after upper abdominal surgery during the first 48 hr on general surgical wards and also to identify risk factors for oxygen desaturation. This descriptive study was conducted in 206 patients not expected to receive supplemental oxygen postoperatively who were undergoing upper abdominal surgery in a tertiary care university hospital. Desaturation was classified either as constant, i.e., oxygen saturation < 90% for > three minutes or < 85% once or as episodic, i.e., when oxygen saturation is decreased by > or = 5% below baseline for one to two minutes ten times or more during the night period. Possible risk factors were elderly patients (> 70 yr), obesity (body mass index [BMI] > 25 kg.m(-2)), smoking, surgical time > 180 min, postoperative pain control methods, intraoperative blood loss, and site of incision. Of the 206 patients enrolled, 171 were retained for analysis. Desaturation occurred in 65 patients (38%). Forty-eight of these had constant hypoxemia with nadir oxygen saturation values ranging from 71-89%. The remaining 17 patients experienced nocturnal episodic hypoxemia. After multivariate analysis, the three factors that correlated with postoperative desaturation were BMI > 25 (adjusted odds ratio [OR] 3.06; 95% confidence interval (CI) 1.38-6.79; P = 0.006), subcostal incision (OR 2.68; 95%CI 1.34-5.38; P = 0.005), and neuraxial opioids (OR 2.44; 95%CI 1.21-4.91; P = 0.013). Oxygen desaturation is common after upper abdominal surgery, and the risk factors are obesity, a subcostal incision, and neuraxial opioid administration.

Pain Control After Total Knee Arthroplasty: A Prospective Study Comparing Local Infiltration Anesthesia and Epidural Anesthesia

Postoperative pain control after total knee arthroplasty (TKA) is a well-known clinical problem. Efforts to treat it with the use of local anesthesia have been made, but the results have been contradictive. In the late 1990s, an infiltrated solution of ropivacaine/ketorolac/adrenaline was shown to be effective for this purpose, and this technique has since spread over the world. The purpose of this study was to compare the local infiltration anesthesia technique with epidural anesthesia, which has been the most widely used technique in Sweden.Eighty-five patients received either local infiltration anesthesia or epidural anesthesia for postoperative pain relief. Postoperative morphine consumption, range of motion, walking ability, patient satisfaction, hospital stay, and time in the recovery room were measured. The groups were followed equally. The patients in the local infiltration anesthesia group were mobilized 24 hours earlier. On postoperative day one, 22 of 33 patients in the local infiltration anesthesia group could get in and out of bed without assistance. Only 1 of 31 patients in the epidural anesthesia group could manage this. On postoperative day two, 28 of 33 patients in the local infiltration anesthesia group could walk without assistance, compared to 5 of 31 in the epidural anesthesia group. Seventy-six percent of the local infiltration anesthesia patients were "very satisfied" with their postoperative pain control method, compared to 40% of the epidural anesthesia patients.The local infiltration anesthesia technique is better for postoperative pain relief in TKA than epidural anesthesia. It offers equal pain relief, faster mobilization, and more satisfied patients. No negative side effects were seen during the study.

A Comparison of Three Methods of Pain Control for Posterior Spinal Fusions in Adolescent Idiopathic Scoliosis

Retrospective cohort study. To compare the efficacy of patient-controlled analgesia (PCA) with morphine alone, a single preoperative intrathecal morphine injection and PCA (IT/PCA), and epidural catheter infusion without PCA (EPI) for postoperative pain control after posterior spinal fusion (PSF) and segmental spinal instrumentation (SSI) in adolescent idiopathic scoliosis (AIS). Postoperative pain control after PSF and SSI in AIS can be managed in different ways. EPI provides for a longer period of pain relief but is reliant on the correct placement and maintenance of the catheter in the epidural space. A single preoperative intrathecal morphine injection also provides for long acting analgesia. No direct comparison of these 3 methods of postoperative pain control has been reported. An IRB-approved retrospective chart review was performed at 2 institutions from 1997 to 2005. The medical record was reviewed to determine pain scores after surgery at multiple time periods. The 3 groups were compared using Student t test and chi and significance was defined as P < 0.05. There was no statistical difference in the gender, age, magnitude of curve, or number of levels fused in the IT/PCA (N = 42), PCA (N = 41), or EPI (N = 55) groups. Postoperative pain scores were lowest in the IT/PCA group in the first 8 hours (P < 0.05) but the pain scores in the EPI group were then lower through 24 hours (P < 0.05). Total morphine use (mg/kg) was lower in the IT/PCA group compared with the PCA group at 12 hours and 24 hours (P = 0.0001). Return to solid food ingestion was quickest in the EPI group (2.0 days) followed by the IT/PCA (2.6 days) and PCA alone (3.2 days) (P < 0.002). Respiratory depression and transient neurologic change occurred most frequently in the EPI group (EPI 11/55 pts vs. 1/42 IT/PCA vs. 0/41 PCA P < 0.001). Pruritus was greatest in the epidural group (11/55 P < 0.05). There were no intraoperative somatosensory-evoked potential changes or permanent neurologic injury recorded in any group. An EPI controls postoperative pain for the longest period of time and allows for a quicker return to consumption of solid foods. However, a single preoperative intrathecal morphine injection controls the pain equally for the first 24 hours with less pruritus and with less adverse events thus requiring less nursing and physician intervention after PSF and SSI in AIS. All methods were safe with no neurologic injury recorded.

Perioperative Complications of Liver Resection in the Elderly with Hepatocellular Carcinoma: A Comparison with Younger Patients

Liver resection surgery in patients with hepatocellular carcinoma is a high-risk procedure with an in-hospital mortality rate around 5%. Patient age and volume of blood loss were found to be independent predictive factors of long-term outcomes in previous studies. We sought to clarify the age-related differences in the perioperative complications during the whole admission for liver resection surgery. This retrospective study included 210 patients scheduled for elective liver resection from July 2006 to July 2008. The characteristics of the patients, intraoperative events, and postoperative complications were retrieved from medical charts, anesthesia records stored in a computer database, and the quality assurance system in our department. The patients were divided into two groups: Group A, aged 60 years or older ( n = 91); and Group B, aged younger than 60 years ( n = 119). Postoperative complications and intraoperative parameters were compared using the Student's t test for continuous data, and χ 2 test for categorical data. Correlations of age with blood loss, operation time, urine output, length of intensive care unit stay, total admission time, and intubation time were examined with the Pearson's correlation. Analysis of variance was used to investigate the endotracheal intubation time with different postoperative pain control methods. No differences in intraoperative blood loss, total operation time, urine output during surgery, in-hospital death, difficulty of operation, and incidence of massive blood loss and oliguria were found between the two groups. The length of intensive care unit stay and total admission time were significantly longer in the elderly group ( p = 0.04 and 0.01, respectively). There was a higher incidence of postoperative respiratory complications in the elderly as revealed by a longer intubation time in Group A than in Group B ( p = 0.03). In contrast to some surgeries for emergency conditions such as long bone fracture or acute abdomen, the perioperative complications in the elderly receiving elective liver resection surgery did not differ markedly from those of younger patients. However, elderly patients would benefit even more if comprehensive postoperative care or newly improved therapies can be provided to lessen the incidence of perioperative respiratory complications.

Intrathecal morphine combined with intravenous patient-controlled analgesia is an effective and safe method for immediate postoperative pain control in live liver donors

The healthy condition of living donors makes their tolerance to pain particularly low, and clinicians are often challenged to come up with an analgesic technique that is effective yet ensures donor safety. This study compared, in donor right hepatectomy, the efficacy and safety of preoperative intrathecal morphine (ITM) combined with intravenous patient-controlled analgesia (IV-PCA) with IV-PCA alone. Forty adult patients were randomly allocated into 2 groups: ITM+IV-PCA group (n = 20) and IV-PCA-only group (n = 20). Patients in the ITM+IV-PCA group received morphine sulfate (400 microg). The visual analog scale (VAS) at rest and when coughing and supplementary meperidine and IV-PCA (fentanyl) consumption were assessed at 2, 4, 6, 8, 10, 12, 18, 24, 30, 36, 42, 48 56, 64, and 72 hours after surgery. Also, side effects such as sedation, dizziness, nausea, vomiting, pruritus, and respiratory depression were evaluated. The ITM+IV-PCA group showed significantly less pain at rest and when coughing for up to 30 hours and 24 hours, respectively. Cumulative postoperative consumption of meperidine and IV-PCA (fentanyl) were significantly less in the ITM+IV-PCA group. The incidence of side effects were comparable between the 2 groups except for pruritus; its incidence was significantly higher in the ITM+IV-PCA group during the first 24 hours, but no treatment was required due to its mild severity. The results of our study suggest that preoperative ITM combined with IV-PCA may be considered as an effective and safe pain management regimen in living liver donors who have characteristics of low tolerance to pain and postoperative coagulation derangement.

Parents' understanding of information regarding their child's postoperative pain management.

Unlike information provided for research, information disclosed to patients for treatment or procedures is largely unregulated and, as such, there is likely a considerable variability in the type and amount of disclosure. This study was designed to examine the nature of information provided to parents regarding options for postoperative pain control and their understanding thereof. One hundred eighty-seven parents of children scheduled to undergo a surgical procedure requiring inpatient postoperative pain control completed questionnaires that elicited information regarding their perceptions and understanding of, and satisfaction with, information regarding postoperative pain management. Results showed that there was considerable variability in the content and amount of information provided to parents based on the method of postoperative pain control provided. Parents whose child received patient-controlled analgesia were given significantly (P<0.025) more information on the risks and benefits compared with those receiving nurse controlled or intravenous-prn analgesia. Approximately one third of parents had no understanding of the risks associated with postoperative pain management. Parents who received pain information preoperatively and who were given information regarding the risks and benefits had improved understanding compared with parents who received no or minimal information (P<0.001). Furthermore, information that was deemed unclear or insufficient resulted in decreased parental understanding. These results demonstrate the variability in the type and amount of information provided to parents regarding their child's postoperative pain control and reinforce the importance of clear and full disclosure of pain information, particularly with respect to the risks and benefits.

Postoperative pain management

Intravenous patient-controlled analgesia (i.v. PCA) for parenteral postoperative pain control is considered standard therapy as patients can individually titrate the amount of analgesic as needed. Iontophoretic patient-activated transdermal systems (IPATS) are a new non-invasive pre-programmed method for postoperative pain control. By pressing the dosing button a 40 microg dose of fentanyl is delivered over a 10 min period via iontophoresis through the intact skin. Several comparative randomized controlled trials have demonstrated that IPATS provide postoperative pain control equivalent to i.v. PCA with morphine. Thus, IPATS is a new method in the management of acute postoperative pain which increases patient mobility and reduces time and effort of care as well as the risk of programming errors. In this review the efficacy, pharmacokinetics, handling and process cost-effectiveness of IPATS are discussed.

The Safety of Concurrent Administration of Opioids via Epidural and Intravenous Routes for Postoperative Pain in Pediatric Oncology Patients

Supplementation of epidural opioid analgesia with intravenous opioids is usually avoided because of concern about respiratory depression. However, the choice of adjunct analgesic agents for pediatric oncology patients is limited. Antipyretic drugs may mask fever in neutropenic patients, and nonsteroidal anti-inflammatory agents may exert antiplatelet effects and interact with chemotherapeutic agents. We examined the safety of concurrent use of epidural and intravenous opioids in a consecutive series of 117 epidural infusions in pediatric patients and compared our findings to those reported by other investigators. We observed a 0.85% rate of clinically significant respiratory complications. The single adverse event was associated with an error in dosage. In our experience, the supplementation of epidural opioid analgesia with intravenous opioids has been a safe method of postoperative pain control for pediatric patients with cancer.

A national survey of postoperative pain managements in hospitals from the national health insurance database

Background: A postoperative pain management has been considered as an important issue in surgery. However, any systematic information or standard method about it has not been so far provided for clinicians in Korea. This study aims to analyze the current practices of in-hospital postoperative pain controls and suggest clinical implications. Methods: A descriptive statistical analysis was adopted to review a nationwide distribution of postoperative pain control methods for the types of patients, surgery, hospitals, specialties, and analgesia. The data is based on the medical claims database of Health Insurance Review Agency (HIRA), which covers all reimbursement claims from hospitals in Korea. All inpatient surgery cases implemented during one year were included in the analysis. Results: It was reported that 1,539,662 cases out of total 1,891,596 inpatient surgery cases were associated with one or more types of analgesia in 2005. The most frequent type of inpatient surgery was bone surgery (24.4%). In all cases related with analgesia, bone surgery took the highest percentage of 28.6%. It was also revealed that the most frequently used postoperative pain management was oral or external use of NSAID (non steroidal anti-inflammatory drug), which was 75.0% of all analgesia treatments. An epidural PCA (patient controlled analgesia), IV PCA (intra-venous patient controlled analgesia) and epidural opioid bolus were 0.2%, 0.2% and 0.1%, respectively, of all analgesia treatments. Conclusions: The results would certainly be useful to develop a clinical practice guideline in postoperative pain management to enhance patient outcomes. (Korean J Anesthesiol 2008; 55: 458∼66)

Periprostatic Nerve Blockage Reduces Postoperative Analgesic Consumption and Pain Scores of Patients Undergoing Transurethral Prostate Resection

Introduction: To evaluate the effects of periprostatic bupivacaine administration on pain control and analgesic consumption after transurethral prostate resection (TURP). Materials and Methods: The study included 40 male patients with benign prostatic hyperplasia who underwent TURP, and they were divided randomly into two groups. All patients were operated under general anesthesia. The study group patients (n = 20) received periprostatic bupivacaine (0.5% 20 ml) injection (group I), and the control patients (n = 20) received only saline (NaCl 0.9% 20 ml) injection (group II). All injections were performed bilaterally into the periprostatic areas immediately after the TURP procedure via the transperineal route. In the postoperative period, all patients (groups I and II) received tramadol using a patient-controlled analgesia device. Postoperative pain was assessed and recorded using the visual analog scale (VAS) at postoperative hours 1, 2, 3, 4, 5, 6, 7, 8, 12, 16, 20, 24, and 48. Total tramadol consumptions and additional analgesic requirements were also recorded and compared between groups. Results: There was no difference in demographic data between the two groups (p > 0.05). VAS scores of the patients at hours 1, 3, 4, 5, 7, 8, and 12 were found to be significantly lower in group I than in group II (p < 0.05). Total tramadol consumption and patient-controlled analgesia demands of groups I and II were 153.5 ± 52.4 vs. 465.0 ± 55.1 mg and 17.1 ± 7.7 vs. 77.8 ± 7.5 mg, respectively (p < 0.001). No side effect was observed regarding bupivacaine injections. Conclusions: Periprostatic bupivacaine administration was a useful and safe method for postoperative pain control and reduced analgesic consumption in patients undergoing TURP.

Continuous intralesional infusion combined with interscalene block was effective for postoperative analgesia after arthroscopic shoulder surgery

The purpose of this study was to compare the efficacy of postoperative pain control by intravenous patient-controlled analgesia (IV) and by continuous intralesional infusion of a local anesthetic (IL) with or without an interscalene block (ISB) after arthroscopic shoulder surgery. We allocated 84 patients to 4 groups according to analgesic method: IV, ISB-IV, IL, and ISB-IL. Postoperative pain, side effects, and supplementary analgesics were recorded at 1 hour and then every 8 hours for 48 hours. The interscalene block (groups ISB-IV and ISB-IL) was found to be effective at relieving pain and at reducing supplementary analgesic amounts at 1 and 8 hours postoperatively (P < .05). Patients in group ISB-IL had less pain at 16 and 48 hours postoperatively than those in the other groups (P < .05). Continuous intralesional infusion (groups IL and ISB-IL) was superior in reducing analgesic-related side effects (P < .05). This study suggests that a combination of an interscalene block and continuous intralesional infusion of a local anesthetic is an effective and safe method of postoperative pain control after arthroscopic shoulder surgery.

The Use of a Continuous Interscalene Brachial Plexus Block for Pain Control following Shoulder Surgery

Background: Pain following shoulder surgery is usually severe and difficult to control using conventional postoperative pain control maneuvers. Therefore, we investigated the pain control efficacy, PONV (postoperative nausea vomiting) and complications by the use of a continuous brachial plexus block in patients who had undergone shoulder surgery. Methods: Thirty three shoulder surgery patients were enrolled in this study. According to the Borgeatimodified lateral technique, 30 ml of 0.37% ropivacaine were injected into the patients, which was followed by insertion of a continuous brachial plexus catheter into the plexus sheath. The operation was then conducted under general anesthesia, and postoperative pain was evaluated in the recovery room 12, 24, 36, and 48 hr after surgery. In addition, nausea and vomiting was calculated using the visual analogue scale (VAS) and sedation was evaluated using the modified Ramsay score. A total of 400 ml of 0.2% Ropivacaine was administered at a rate of 8 ml/hr to control the postoperative pain for 2 days. In addition, other neurological complications were investigated, and the catheter tips were cultured after they were removed to determine if any infection had occurred. Results: The postoperative pain scores were below 2 on the 10 cm VAS, and the level of nausea and vomiting was also satisfactorily (＜ 2/10 cm VAS). In addition, the mean sedation score of the patients in the recovery room was 2. There were complications including motor weakness (24%), dyspnea (15%), Hornorisyndrome (9%), postauricular numbness (9%) and metallic taste (3%), however, there were no patients who complained of n eurological symptoms after one month of follow-up, and no signs of infection were found when the results of catheter tip cultures were evaluated. Conclusions: The use of a continuous interscalene brachial plexus block is a feasible method of postoperative pain control for patients who undergo major shoulder surgery. (Korean J Anesthesiol 2007; 53: 733∼9)

The Effect of Preoperative Epidural Analgesia with Intravenous Patient-controlled Analgesia (IV-PCA) for Postoperative Pain Control in Bone Fusion and Pedicle Screw Fixation

Background: Postoperative pain control following bone fusion and pedicle screw fixation is insufficient with IV-PCA alone. Therefore, the effect of preoperative epidural analgesia in addition to IV-PCA was evaluated for postoperative pain control following bone fusion and pedicle screw fixation surgery. Methods: Eighty patients, scheduled to undergo bone fusion and pedicle screw fixation, were randomly assigned to two groups; the study (n = 40) or control groups (n = 40). After induction, the patient was turned into the prone position, and morphine 2 mg and 10 ml of 0.2% ropivacaine were injected into the L1/2 epidural space, after dye confirmation, under C-arm guidance for the study group, with 10 ml normal saline injected into the L1/2 epidural space for the control group. After induction, IV-PCA was applied in both groups. After the operation, the NRS (numerical rating scale) and side effects were evaluated immediately post-op, and at 24 and 48 hours after the operation. Results: In the study group, the NRS was more reduced for all periods compared with the control group, but the incidences of nausea/vomiting and pruritus were no different from the control group. Conclusions: It was concluded that preoperative epidural analgesia, in addition to IV-PCA, was a good postoperative pain control method following bone fusion and pedicle screw fixation. (Korean J Anesthesiol 2007; 52: 296~300)

A Prospective Randomized Study of Preemptive Analgesia for Postoperative Pain in the Patients Undergoing Posterior Lumbar Interbody Fusion

A prospective randomized clinical trial in preemptive analgesia for postoperative pain was conducted. To compare the efficacy of three preemptive analgesics combined with local anesthesia: continuous subcutaneous morphine (SC), continuous epidural morphine (ED), and diclofenac sodium (DS). Systemic opioids are known to be effective methods of postoperative pain control. The use of epidural morphine for postoperative analgesia has been a standard treatment in spinal surgery. Only a few studies in the literature have investigated the efficacy of preemptive analgesia using morphine. This is the first prospective randomized clinical trial to assess both subcutaneous and epidural continuous administration of opioids for preemptive analgesia. For this study, 73 patients were assigned randomly to one of three treatment groups: SC, ED, or DS. All patients underwent posterior lumbar interbody fusion with instrumentation. Pain management was assessed using the visual analogue scale (VAS). Usage of supplemental analgesics, the time to first request of them, and side effects were also investigated. Twenty-two patients were randomized to SC, 23 to ED, and 27 to DS. No baseline variable differences among the three groups were seen. The results showed no significant difference in analgesic effects among those three preemptive analgesics. Only immediately after surgery (at 0 hours), the VAS of the DS group was lowest among three groups. But the DS group took more supplemental analgesic drugs until 72 hours, and the time to first request of this group was shorter than that of the other two groups. High rates of minor side effects were seen in both the ED and DS groups. SC gave moderate analgesic effects as well as the other two groups with few adverse effects. DS provided a favorable effect immediately after surgery, but the effective time was short and the patient needed more supplemental drugs after that. ED did not give the expected effect, with comparatively high rates of side effects. Continuous epidural anesthesia did not seem to be suitable for preemptive analgesia. Continuous subcutaneous morphine brought some analgesic effects with a low rate of complications. It can be an attractive method for postoperative analgesia with technical ease.

Improving postoperative outcomes with epidural analgesia

THE ADVERSE EFFECTS of poorly managed postoperative pain are numerous. Unrelieved pain can interfere with recovery and contribute to a higher incidence of postoperative complications, such as wound infection and respiratory dysfunction. 1 Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997; 78: 606-617 Crossref PubMed Scopus (1723) Google Scholar , 2 Pasero C. Paice J.A. McCaffery M. Basic mechanisms underlying the causes and effects of pain. in: McCaffery M. Pasero C. Pain Clinical Manual. ed 2. Mosby, St. Louis, MO1999: 15-34 Google Scholar , 3 Pasero C. Portenoy R.K. McCaffery M. Opioid analgesics. in: McCaffery M. Pasero C. Pain Clinical Manual. ed 2. Mosby, St. Louis, MO1999: 161-299 Google Scholar A proliferation of research over the past 20 years has shown superior pain relief and improved functional outcomes following major surgery in patients who receive epidural analgesia with local anesthetics compared with traditional methods of postoperative pain management, such as intramuscular (IM) opioids and intravenous (IV) patient-controlled analgesia (PCA). 2 Pasero C. Paice J.A. McCaffery M. Basic mechanisms underlying the causes and effects of pain. in: McCaffery M. Pasero C. Pain Clinical Manual. ed 2. Mosby, St. Louis, MO1999: 15-34 Google Scholar , 4 Kehlet H. Modification of stress responses to surgery by neural blockade Clinical implications. in: Cousins M.J. Bridenbaugh P.O. Neural Blockade in Clinical Anesthesia and Management of Pain. Lippincott-Raven, Philadelphia, PA1998: 129-175 Google Scholar , 5 Kehlet H. Holte K. Effect of postoperative analgesia on surgical outcome. Br J Anaesth. 2001; 87: 62-72 Crossref PubMed Scopus (556) Google Scholar , 6 Pasero C. Epidural analgesia for postoperative pain management. Am J Nurs. 2003; 103: 43-45 Crossref PubMed Google Scholar Perianesthesia nurses have led the way in managing this excellent method of postoperative pain control by assisting with epidural catheter placement and titrating, maintaining, and discontinuing the therapy. The epidural route of administration is now accepted as an appropriate first-line route for the management of moderate-to-severe postoperative pain that is expected to last for at least 24 hours. 3 Pasero C. Portenoy R.K. McCaffery M. Opioid analgesics. in: McCaffery M. Pasero C. Pain Clinical Manual. ed 2. Mosby, St. Louis, MO1999: 161-299 Google Scholar , 6 Pasero C. Epidural analgesia for postoperative pain management. Am J Nurs. 2003; 103: 43-45 Crossref PubMed Google Scholar Chris Pasero is a Pain Management Educator and Clinical Consultant in El Dorado Hills, CA

An alternative method of wound pain control following hepatic resection: a preliminary study

Epidural analgesia is considered one of the optimal methods for provision of postoperative pain relief in patients recovering from major upper abdominal operations. Concerns regarding the potential risk of neurological complications prompted an evaluation of an alternative strategy using a continuous intermuscular bupivacaine (CIB) infusion combined with patient-controlled analgesia (PCA). Two fine-bore catheters are inserted in the deep intermuscular intercostal neuronal plane during abdominal wound closure, and a continuous infusion of bupivacaine 0.25% is commenced for 72 h postoperatively. Simultaneously, patient-controlled analgesia provided intravenous morphine on demand. The study comprised 10 consecutive patients undergoing liver resection in whom CIB infusion and PCA were employed. The feasibility, safety and efficacy of the technique were investigated, analysing postoperative pain scores, morphine requirements, spirometry and oxygen saturation. There were no postoperative deaths. Postoperative morbidity included one urinary tract infection, one minor chest infection and acute confusional episodes in two patients. Median pain scores and morphine requirements at 12, 24, 48 and 72 h postoperatively were satisfactory. Spirometry and oxygen saturation values also remained within the normal range. Preliminary experience with CIB infusion/PCA in the aftermath of major liver resection has demonstrated its simplicity and safety as an alternative method of postoperative pain control. Further study is required to investigate the role of CIB infusion/PCA as a practical alternative to epidural analgesia or PCA alone.

Hematoma block reduces narcotic pain medication after femoral elastic nailing in children.

Children with femur fractures can have severe pain after elastic nail fixation. The purpose of this paper is to test the effectiveness of an intraoperative hematoma block in controlling postoperative pain in children that underwent elastic nail fixation of isolated femur fractures. We compared 13 children who received an intraoperative bupivacaine hematoma block after elastic nail fixation of a femur fracture with a concurrent control group of 22 children with similar femur fractures that did not receive a hematoma block. The time to first narcotic dose after surgery was over 5 hours later in the hematoma block group versus the control group (P =.008). The hematoma block did not significantly lengthen the time of surgery. This study demonstrates that an intra-operative hematoma block is a simple, quick and effective method of postoperative pain control after elastic femoral nailing in children.