Patient-controlled Analgesia Demand Research Articles

Modified versus traditional subcostal anterior quadratus lumborum block for postoperative analgesia after laparoscopic nephrectomy: a randomized-controlled study.

To examine the ramifications of both the modified and traditional subcostal anterior quadratus lumborum block (SQLB) on postoperative analgesia in individuals undergoing laparoscopic nephrectomy. Forty-six individuals slated for elective laparoscopic nephrectomy under general anesthesia were randomly assigned to acquire either traditional or modified SQLB using 20mL of 0.5% ropivacaine. The primary outcome was intravenous morphine-equivalent intake during the first 24h following surgery. Secondary outcomes included sensory block dermatomes, numerical rating scale (NRS) scores, the total number of patient-controlled analgesia (PCA) demands, rescue analgesic use, and complications related to opioids and nerve block. The modified SQLB group had significantly lower morphine-equivalent consumption compared to the traditional SQLB group within the initial 24h after surgery (23.1 ± 4.3 vs. 34.7 ± 6.8mg, P < 0.001). The modified SQLB also resulted in a greater number of dermatome segments of sensory block at 5, 10, and 15min after block (P < 0.05), lower NRS pain scores at rest and during coughing at 6, 24, and 48h (P < 0.001), and reduced usage of rescue analgesics as well as total PCA demands (P < 0.05). No significant differences were observed in the incidence of complications related to opioids or the nerve block procedure between the two groups. Ultrasound-guided modified SQLB confers significantly superior analgesic advantages over the traditional SQLB for patients undergoing laparoscopic nephrectomy, culminating in a marked reduction in postoperative opioid consumption and more efficacious pain management.

Walking Epidural in Labor Analgesia: A Comparative Study of Ropivacaine with Fentanyl and Without Fentanyl

Background: Labor pain and child birth entail a number of physiological consequences that may lead to deleterious effects on the mother and fetus. Implication of a neuraxial technique is being appreciated in labor. Fetal prognosis and maternal consent and its satisfaction are key to labor analgesia. Method: The primary objectives were to determine the visual analog scale (VAS), total duration of labor analgesia, patient-controlled analgesia demand, sensory and motor block, and hemodynamics. The secondary objectives were to determine obstetrics parameters such as maternal satisfaction, cervical dilation, membrane, APGAR score, and complications such as hypotension, bradycardia, and vomiting. A randomized prospective comparative, interventional study including 50 parturients was conducted, where they were divided into two equal groups of 25 each, and epidural analgesia was given by 0.2% ropivacaine with 2 mcg/ml fentanyl and 0.2% ropivacaine without fentanyl. Observation and Results: Analgesia was more in the RF group compared to the R group. The maternal satisfaction was more in the RF group than in the R group. Clinical hemodyamics, VAS score, Bromage score, and APGAR score were appreciable in the RF group as compared to the R group. Conclusion: We concluded that 0.2% ropivacine with fentanyl gives more analgesia and maternal satisfaction than ropivacine alone.

Transcutaneous electrical acupoint stimulation to reduce opioid consumption in patients undergoing inguinal hernia repair: protocol for a randomized controlled trial

BackgroundThe purpose of this study is to evaluate the efficacy and safety of transcutaneous electrical acupoint stimulation (TEAS) in the postoperative treatment of patients undergoing inguinal hernia repair compared with sham and no treatment group.MethodsThis study is a protocol for a three-armed, single-blinded, placebo-controlled randomized controlled trial. Ninety participants scheduled for inguinal hernia repair will be randomly assigned to the TEAS group (n = 30), sham group (n = 30), and control group (n = 30). The TEAS group will receive treatment using four portable coin-sized electro-stimulators at both local and distal acupuncture points. The sham group will receive sham treatment with mock electrostimulation. The treatment groups will receive mixed frequency stimulation (alternating at 2 and 100 Hz every 3 s) in continuous mode for 30 min at intervals of 2 h for 24 h postoperatively. The control group will receive postoperative pain control using patient-controlled analgesia (PCA) device. The primary outcome is the total morphine dose received in the postoperative period (mg) using PCA 24 h after surgery. The number of PCA demands (i.e., times the button will be pressed) and delivered bolus doses, score on the Visual Analogue Scale, opioid-related side effects, the requirement for supplemental medications, score on the Hospital Anxiety and Depression Scale (HADS), and blood levels of stress hormones cortisol and prolactin.DiscussionThe results of this trial will determine whether TEAS with intensified stimulation protocol is a safe and effective option for reducing analgesic consumption and postoperative pain.Trial registrationISRCTN76428396. Registered on 05 October 2020. https://www.isrctn.com/ISRCTN76428396

Ultrasound-Guided Comparison of Psoas Compartment Block and Supra-Inguinal Fascia Iliaca Compartment Block for Pain Management in Pediatric Developmental Dysplasia of Hip Surgeries.

BackgroundThe aim of this study was to compare psoas compartment block (PCB) and supra-inguinal fascia iliaca compartment block (SFIB) in terms of pain management and the need for additional systemic analgesia in the perioperative phase of developmental dysplasia of the hip (DDH).Materials and MethodsSixty pediatric patients were randomized into the PCB group and the SFIB group. The Numeric Rating Scale (NRS) pain scores were used to assess postoperative pain during the initial 24 h after extubation. Sufentanil consumption, patient-controlled analgesia (PCA) demands, and complications were also recorded.ResultsThe NRS pain scores were significantly lower in the PCB group than in the SFIB group at 0, 4, 8, 12, and 24 h after extubation (all P < 0.01). Postoperatively, 13.8% of patients in the PCB cohort received additional administration of sufentanil, in contrast to 63.3% of the SFIB cohort (P < 0.01). In the PCB group, 0 (0-0) mcg/kg sufentanil was administered, while in the SFIB group 0.1 (0-0.2) mcg/kg (P < 0.01). In addition, the PCB group had fewer PCA demands than the SFIB group within the initial 24 h (P < 0.01). It took less operating time to achieve SFIB as compared to PCB (P < 0.01). No adverse events related to two techniques were recorded.ConclusionsPCB provided a better perioperative pain management in pediatric patients with the DDH surgeries compared to SFIB. It also reduced the need for supplementary systemic analgesia.

Exploratory study of VVZ-149, a novel analgesic molecule, in the affective component of acute postoperative pain after laparoscopic colorectal surgery

Study objectiveVVZ-149 is a small molecule that inhibits the glycine transporter type 2 and the serotonin receptor 5-hydroxytryptamine 2A. In the present study, we investigated the efficacy and safety of VVZ-149 as a single-use injectable analgesic for treating moderate to severe postoperative pain after colorectal surgery. DesignRandomized, parallel group, double-blind Phase 2 clinical trial (NCT02489526). Setting3 academic institutions in the United States. Patients60 patients undergoing laparoscopic colorectal surgery. InterventionsA continuous 8-h intravenous infusion of VVZ-149 Injections (n = 40) or placebo (n = 20) administered after emergence from anesthesia. MeasurementsThe outcome measures included pain intensity (PI), opioid consumption via patient-controlled analgesia (PCA), and rescue dosing provided “as needed”. Early rescue dosing with opioids postoperatively was associated with preoperative negative affect (anxiety, depression, and pain catastrophizing), enabling it to be used as an indirect measure of the affective component of pain. Efficacy outcomes were compared between treatment groups based on preoperative negative affect and early rescue dosing of opioids. Main resultsPostoperative PI was non-significantly lower in patients receiving VVZ-149 compared to those receiving placebo. The VVZ-149 group had a 34.2% reduction in opioid consumption for 24 h post-dose, along with fewer PCA demands. Somnolence and headache was higher in the intervention group. For patients characterized by high levels of preoperative negative affect, the VVZ-149 group experienced a significant pain reduction and 40% less opioid use compared to the placebo group. ConclusionsVVZ-149 resulted in a non-significant reduction of postoperative pain during the first 8 h after surgery. Post hoc analysis indicates that VVZ-149 may benefit patients with negative affect who otherwise have higher postoperative opioid use. Registration numberwww.clinicaltrials.gov, ID: NCT02489526.

Patient-controlled analgesia and morphine consumption in sickle cell anemia painful crises: A new protocol.

The sudden and rapidly increasing severity of pain in sickle cell anemia painful crises frequently requires the use of strong opioids. Patients require continuous administrations of various doses (increased/decreased) within the following hours. This study aims to retrospectively evaluate the effects of a structured protocol based on standardized Visual Analogue Scale (VAS) and Patient-controlled analgesia (PCA) patient demand count on morphine consumption in painful crises. A total of 177 painful crises of 93 patients who were administered morphine using the PCA method according to appropriate analgesia protocol between 2004-2018 were evaluated in this study. The demographic data, hemoglobin chromatography and genotypes, painful episode follow-up time, VAS scores before and after treatment, and daily morphine consumption of the patients were recorded. Morphine consumption during the crisis according to age groups and sex were compared. Of the patients, 57% were homozygous hemoglobin type SS (HbSS). Mean morphine consumption with PCA method was 56.9±35.4 mg (min-max: 10-232 mg) and mean follow-up time was 3.4±2.1 days (min.-max.: 1-11). VAS scores were significantly lower after treatment (6.8±2.3 pre-treatment; 0.8±0.6 post-treatment) (p<0.05). To our knowledge, our study is the first structured protocol based on VAS and PCA demand data. We believe lower morphine dosage using PCA protocol according to the rapidly changing pain levels of the patients will provide effective analgesia. Prospective studies with fewer limitations will more effectively demonstrate the effectiveness of this protocol.

A randomized control trial using intraoperative dexmedetomidine during Roux-en-Y gastric bypass surgery to reduce postoperative pain and narcotic use

BackgroundDexmedetomidine (DMET), a selective a2-adrenergic agonist, is an opioid-sparing adjuvant sedative that avoids respiratory depression and has been shown to be beneficial in bariatric surgery patients. Although benefit has been shown, prior studies have not evaluated the pain control effects of a single intraoperative bolus. ObjectivesTo evaluate the postoperative effects of a single intraoperative dose of DMET. SettingsUniversity Hospital, United States. MethodsThis is a prospective, randomized, double-blinded study registered with clinicaltrials.gov (#NCT02604940). Patients undergoing laparoscopic Roux-en-Y gastric bypass surgery were randomized and given either a placebo or an intraoperative DMET bolus, where 1 mg/kg was delivered over 10 minutes at the time of surgical closure. Measured outcomes included the following: postoperative pain scores, patient-controlled analgesia (PCA) opioid consumption, PCA demand bolus attempts, duration of postanesthesia care unit (PACU) stay, and vital signs. Descriptive statistics were recorded as frequencies and compared using Χ2 analysis, and a Welch's 2-sample t test was used to compare continuous variables. ResultsForty-six participants undergoing laparoscopic Roux-en-Y gastric bypass surgery were randomized into placebo (n = 20) or DMET (n = 26) groups. There were no statistical differences in age (45.1 versus 43.2 yr, P = .522), sex (80% versus 81% female, P = .948), and body mass index (46.1 versus 45.6 kg/m2, P = .818) between the 2 groups. There were no statistically significant differences in vital signs (heart rate, blood pressure, oxygen saturation, and respiration rate) between DMET and placebo groups in the preoperative and intraoperative period. During the initial 4 hours in the PACU postoperatively, mean heart rate (70 ± 12 versus 86 ± 14, P < .001), systolic blood pressure (107 ± 17 versus 148 ± 16, P < .001), and diastolic blood pressure (56 ± 15 versus 79 ± 13, P < .001) were significantly lower in the DMET-treated group compared with placebo. During the initial 4 hours in the PACU, mean self-reported pain scores were significantly lower in the DMET-treated group (3.6 ± 2.8) compared with the placebo group (6.7 ± 3; P = .005). The lower pain scores occurred with no significant difference in the mean opioid dosage received in the PACU between DMET-treated (2.66 ± 2.02 mg) and placebo (3.7 ± 2.3 mg; P = .09) groups. Also, there was no statistically significant difference in the total number of PCA attempts for opioids between the DMET-treated and placebo groups (P = .49). ConclusionsA single bolus of DMET (1 mg/kg delivered over 10 min) administered at the time of surgical closure did not reduce immediate PACU usage of opioids but significantly reduced reported pain scores and caused a significant decrease in the number of attempts made by patients; this is a trend of decreased attempts over time (P = .04) in the DMET group. The trend of the mean total medication used over time indicates that there is neither an increasing nor decreasing trend for the DMET group, but there is an increasing trend in the total used over time for the placebo group. There was no statistically or clinically significant bradycardia, hypotension, hypoxia, respiratory depression intraoperative duration, or PACU stay. Reduced single bolus dosing of DMET required for analgesia in bariatric surgery patients is optimal from physiologic, level of care, and cost perspectives.

Laparoskopik Kolesistektomi Sonrası Parasetamol ve İbuprofenin Postoperatif Analjezik Etkilerinin Karşılaştırılması

Objective: Non-steroid anti-inflammatory drugs (NSAIDs) and paracetamol (P) are frequent constituents of multimodal postoperative analgesia. The aim of this study was to compare analgesic effects of intravenous (IV) paracetamol and ibuprofen (IB) administered intraoperatively and in repeated doses postoperatively to the patients who underwent laparoscopic cholecystectomy. Material and Methods: A total of 40 patients with class of American Society of Anesthesiologists (ASA) I-III who underwent laparoscopic cholecystectomy were randomized into Groups-P and IB in this randomized, prospective and double-blind study. After anesthesia induction and initiation of the surgery, Group-P patients received 1 g IV paracetamol and Group-IB patients received 800 mg IV ibuprofen. At skin closure, 1.5 mg/kg of IV tramadol was administered. For postoperative analgesia, a patient-controlled analgesia (PCA) pump with tramadol was used. During the first 24h postoperatively, Group-P patients received 1 g of IV paracetamol and Group-IB patients received 400 mg of IV ibuprofen at every 6h. Patients with visual analog pain scale (VAS) scores ≥ 4 received rescue analgesia. The groups were compared for postoperative first 24h VAS scores, PCA demand, total tramadol dose, and rescue analgesic requirement. Results: Compared with Group-P, Group-IB had significantly lower VAS-awakening, VAS-post-anesthesia care unit (PACU) and VAS- 6th h scores. Postoperative rescue analgesic requirement was lower in Group-IB than in Group-P at all timepoints, most notably in the PACU. Conclusion: Compared with paracetamol, intraoperative and repeated postoperative doses of ibuprofen substantially decreased the pain scores and rescue analgesic requirement. As a component of multimodal analgesia, IV ibuprofen is an effective option for postoperative pain management.

Prediction of Patient-Controlled Analgesic Consumption: A Multimodel Regression Tree Approach.

Several factors contribute to individual variability in postoperative pain, therefore, individuals consume postoperative analgesics at different rates. Although many statistical studies have analyzed postoperative pain and analgesic consumption, most have identified only the correlation and have not subjected the statistical model to further tests in order to evaluate its predictive accuracy. In this study involving 3052 patients, a multistrategy computational approach was developed for analgesic consumption prediction. This approach uses data on patient-controlled analgesia demand behavior over time and combines clustering, classification, and regression to mitigate the limitations of current statistical models. Cross-validation results indicated that the proposed approach significantly outperforms various existing regression methods. Moreover, a comparison between the predictions by anesthesiologists and medical specialists and those of the computational approach for an independent test data set of 60 patients further evidenced the superiority of the computational approach in predicting analgesic consumption because it produced markedly lower root mean squared errors.

A comparative study of intravenous patient-controlled analgesia with tramadol alone and tramadol plus dexmedetomidine for major lower abdominal surgery

Background: Different techniques are used to provide postoperative pain relief to the patients. The patient-controlled analgesia (PCA) has come out as promising option. The main advantage of it is a stable plasma concentration of analgesic drug and the control of medication in patients' hand. Morphine has been used extensively for postoperative analgesia, but almost no respiratory depression makes tramadol equally popular for postoperative analgesia. Alpha-2 agonist-like dexmedetomidine can have additive analgesic effect. The above background was the base of planning this study to evaluate the effect of dexmedetomidine added to tramadol for postoperative analgesia. Materials and Methods: This prospective study was conducted in sixty female patients undergoing lower abdominal surgery. All patients were given spinal anesthesia for surgery. When effect of spinal anesthesia wear off and the patient had verbal rating score (VRS) more than three PCA was started. In Group T, all patients received tramadol 1 mg/kg followed by PCA tramadol. In Group D, all patients received tramadol 1 mg/kg and dexmedetomidine 0.5 mcg/kg followed by PCA having combination of tramadol and dexmedetomidine. VRS for pain, total consumption of tramadol, and side effects were recorded for 24 h postoperatively. Results: VRS for pain was comparable in both the groups. PCA demand and total dose of tramadol were less in group who received tramadol with dexmedetomidine. There was no significant difference in occurrence of side effects. Conclusions: The combination of dexmedetomidine with tramadol reduces the tramadol requirement for postoperative analgesia.

The effect of tramadol plus paracetamol on consumption of morphine after coronary artery bypass grafting

Study of objectiveTo compare the effects of oral tramadol+paracetamol combination on morphine consumption following coronary artery bypass grafting (CABG) in the patient-controlled analgesia (PCA) protocol. DesignA prospective, double-blind, randomized, clinical study. SettingSingle-institution, tertiary hospital. PatientsFifty cardiac surgical patients undergoing primary CABG surgery. InterventionsAfter surgery, the patients were allocated to 1 of 2 groups. Both groups received morphine according to the PCA protocol after arrival to the coronary intensive care unit (bolus 1 mg, lockout time 15 minutes). In addition to morphine administration 2 hours before operation and postoperative 2nd, 6th, 12th, 18th, 24th, 30th, 36th, 42th, and 48th hours, group T received tramadol+paracetamol (Zaldiar; 325 mg paracetamol, 37.5 mg tramadol) and group P received placebo. Sedation levels were measured with the Ramsay Sedation Scale, whereas pain was assessed with the Pain Intensity Score during mechanical ventilation and with the Numeric Rating Scale after extubation. If the Numeric Rating Scale score was ≥3 and Pain Intensity Score was ≥3, 0.05 mg/kg morphine was administered additionally. MeasurementsPreoperative patient characteristics, risk assessment, and intraoperative data were similar between the groups. Main resultsCumulative morphine consumption, number of PCA demand, and boluses were higher in group P (P<.01). The amount of total morphine (in mg) used as a rescue analgesia was also higher in group P (5.06±1.0), compared with group T (2.37±0.52; P<.001). The patients who received rescue doses of morphine were 8 (32%) in group T and 18 (72%) in group P (P<.001). Duration of mechanical ventilation in group P was longer than group T (P<.01). ConclusionTramadol+paracetamol combination along with PCA morphine improves analgesia and reduces morphine requirement up to 50% after CABG, compared with morphine PCA alone.

Effect of endovenous lidocaine on analgesia and serum cytokines: double-blinded and randomized trial

Study ObjectiveThis trial aimed to compare postoperative analgesia, opioid consumption, duration of ileus and hospital stay, and cytokine levels in patients undergoing laparoscopic cholecystectomies who received intravenous lidocaine in comparison with a control group. DesignProspective, longitudinal, double-blind, and randomized study. SettingOperating room and postoperative recovery area. PatientsForty-four American Society of Anesthesiologists I and II patients older than 17 years, undergoing laparoscopic cholecystectomy, under general anesthesia. InterventionsThe first group received intravenous lidocaine during the procedure until 1 hour postoperatively, whereas the second group received saline. Both groups received dipyrone and morphine patient-controlled analgesia. MeasurementsPain was assessed by Visual Numeric Scale at rest and when coughing at different times after the end of the surgery. Blood samples were taken at the end of procedure and 24 hours later. The total morphine patient-controlled analgesia demand, the time for the first flatus, and the length of hospital stay were also recorded. Main ResultsGroups were similar in relation to sex (P= .2), age (P= .5), weight (P= .08), and length of surgery (P= .6). No differences were observed regarding the intensity of postoperative pain between the groups, either at rest (P= .76) or when coughing (P= .31), in morphine consumption (P= .9), and in the duration of ileus (P= .5) or length of hospital stay (P= .9). The inflammatory markers interleukin (IL)-1 (P= .02), IL-6 (P< .01), interferon-γ (P< .01), and tumor necrosis factor α (P< .01) showed significant reduction in the lidocaine group against the placebo group, except IL-10 (P= .01), that, because of its anti-inflammatory effects, increased its concentration. ConclusionsIntravenous lidocaine was not able to reduce postoperative pain, opioid consumption, and duration of ileus or length of hospital stay. However, its anti-inflammatory effect was noticeable.

Effects of acupuncture on post-cesarean section pain.

Post-operation pain is a very subjective phenomenon. The aim of this study was to find out the effects of acupuncture or electro-acupuncture on post-cesarean pain. Sixty women, who had had spinal anesthesia during cesarean section at the Department of Obstetrics of China Medical University Hospital, were randomly assigned to the control group, the acupuncture group, and the electro-acupuncture group. After the operation, we applied subjects with acupuncture or electro-acupuncture on the bilateral acupuncture point, San Yin Jiao (Sp6), and the patient controlled analgesia (PCA). The first time of requesting morphine, the frequency of PCA demands in 24 hours, and the doses of PCA used were recorded double blindly. In addition, monitoring the subjects' vital signs, the opioid-related side effects, and the pain scores was done. The results showed that the acupuncture group and the electro-acupuncture group could delay the time of requesting morphine up to 10 - 11 minutes when compared with the control group. The total dose of PCA used within the first 24 hours was 30% - 35% less in the acupuncture group and the electro-acupuncture group when compared with the control group, which was indicated in statistical significance. However, there was no significant difference between the acupuncture group and the electro-acupuncture group. The electro-acupuncture group's and the acupuncture group's pain scores were lower than the control group's within the first 2 hours. Both were statistically significant. However, two hours later, there were no significant differences of the visual analogue scale (VAS) scores between either of the treatment groups and the control group. Finally, the incidence of opioid-related side effects, such as dizziness, was less in the acupuncture group and electro-acupuncture group than in the control group. This study shows that the application of acupuncture and electro-acupuncture could definitely delay the time of requesting pain relief medication after cesarean section and decrease the PCA doses used within the first 24 hours.

61 * PCA for PVI: first report of successful use of patient controlled analgesia for AF ablation

Background: General anaesthesia (GA) is the gold standard for AF ablation (AFA) but approximately 50% of cases are performed under conscious sedation (CS). Compared to GA, CS is associated with inferior clinical results, In addition, pateints frequently experience pain and anxiety. However, financial and logistical restrictions mean that universal use of GA is unlikely in the foreseeable future. Accordingly, a pressing need exists to develop an alternative to current CS regimes. Technique: Remifentanil is a potent ultra-short-acting synthetic opioid with has rapid onset and offset. The remifentanil patient controlled analgesia (PCA) system is an established technique on labour wards with a good safety profile and high patient satisfaction. In both AF ablation and labour, recurring short episodes of intense visceral pain are interspersed with less painful periods. We performed a safety and feasibility study of PCA for PVI and provide our experience of our initial six cases, the first such cases to be reported. Methods: After IV paracetamol and midazolam premedication, patients received a background Remifentanil infusion (0.05-0.07mcg/kg/min) with 20mcg boluses on demand via the PCA with 2 minute lockout. An anesthetist and anaesthetic assistant were present throughout and blood pressure sedation level and respiratory parametres were closely monitored. Results: 5 of the 6 patients male with a mean age of 60.3 years (range 47-71). 3 were redo procedures and 5 had persistent AF. Two patients underwent electrical cardioversion. The mean remifentanyl dose was 864.5 mcg (403-1411) with an infusion time of 145.2 (96-180) minutes. Median PCA demands were 11 (2-59) against 6.5 (2-22) delivered. Mean midazolam dosage was 2.4mg (1.5-3.5). No serious complications occurred. Mild was treated with ondansetron. Using a 10cm Visual Analogue Scale (10=best) operators and patients scored the technique very favourably. Although patients did report some pain, 3 reported only a single episode, and 2 more reported between 0-15 minutes of pain. The most frequently reported site of pain was the groin, relating to insertion, manipulation or removal of venous sheaths. In response we extended the remifentanyl provision to cover these events. All patients reported that they would have PCA for a future PVI and those who had previously experienced CS stated a preference for PCA. Conclusion: This first report is encouraging that PCA may be a safe and effective alternative to CS achieving high satisfaction ratings from both clinicians and patients. After further protocol refinement we plan a multi-centre trial and would welcome expressions of interest. | Mean scores (range) | Comfort | Anxiety | Worst Pain | |:------------------- | ------------- | ------------- | ------------- | | Patient | 7.8 (2.6-9.3) | 7.8 (4.7-9.5) | 4.8 (1.3-8.3) | | Nurse | 8.8 (7.6-9.5) | 7.9 (5.4-9.4) | 9.0 (6.4-9.9) | | Cardiologist | 9.2 (8.4-9.9) | 9.5 (9.0-9.8) | 8.4 (5.0-9.6) | | Anesthetist | 8.5 (7.0-9.6) | 8.0 (5.0-9.4) | 7.0 (5.2-9.1) |

Scheduled intravenous acetaminophen reduces postoperative narcotic analgesic demand and requirement after laparoscopic Roux-en-Y gastric bypass

BackgroundIntravenous (IV) acetaminophen has the potential to reduce postoperative narcotic analgesic requirement but this has not been reported in bariatric surgery. As lower dosages could reduce undesirable narcotic side effects, we investigated the opioid-sparing effect of concomitant IV acetaminophen in bariatric surgery. MethodsWe performed a retrospective review of our electronic medical records of laparoscopic Roux-en-Y gastric bypasses (LRYGB) performed for severe obesity between 2011 and 2013. We identified 183 patients that received scheduled IV acetaminophen in addition to morphine sulfate (MSO4) patient-controlled analgesia (PCA). A cohort of 229 patients from the preceding 2 years who were treated with MSO4 PCA but not acetaminophen was used as a historical control. Patient demographic characteristics and narcotic use data were extracted from electronic medical records. Student’s t test or linear regression was used as appropriate (P< .05). ResultsDuring the first 24-hour postoperative period after LRYGB, narcotic analgesic demand (total PCA demand including nondelivery of narcotic due to lock-out) was reduced by 25% with the concomitant use of IV acetaminophen (40.5 versus 30.9 average pushes; P<.05). During the same period, narcotic analgesic dosage requirement was cut down by 20% in the study group (average of 29.9 versus 24.1 mg of MSO4; P<.05). Linear regression analysis confirmed that these changes were independent of age, gender, and body mass index distribution, or type 2 diabetes mellitus. ConclusionScheduled IV acetaminophen reduces the demand for and the requirement of narcotic analgesia after LRYGB. We provide new evidence in support of the routine use of multimodal analgesia that includes scheduled IV acetaminophen in the initial 24-hour period after bariatric surgery.

Early postoperative patient-controlled analgesia ratio predicts 24-hour morphine consumption and pain in children undergoing scoliosis surgery

The identification of patients at risk for developing severe postoperative pain and/or opioid-related side effects is difficult due to a lack of sensitive indicators. The patient-controlled analgesia (PCA) ratio of demands to deliveries is a potential tool for early identification of patients who experience severe postoperative pain. The authors hypothesized that the PCA ratio is able to predict morphine requirement in the first 24 hours after scoliosis surgery. The authors performed a retrospective study of adolescents who had surgery for idiopathic scoliosis. They collected data describing PCA demands and deliveries, morphine consumption, numerical rating scale (NRS) pain scores, opioid related side effects, and duration of hospital stay. Spearman rank analysis assessed association among 4-hour PCA ratios, NRS pain score, and 24-hour morphine consumption. Patients were divided into groups on the basis of PCA ratios <1.5 and ≥1.5. Univariate analysis and multiple regression were used to identify independent factors predictive for increased 24-hour morphine. Mann-Whitney rank-sum and Fisher exact tests were used to compare data. p < 0.05 was considered statistically significant. One hundred forty-seven patients were included in the analysis, mean (SD) age and weight were 15 (1.8) years and 55 (27) kg, respectively. There was a significant positive correlation between the 4-hour PCA ratio and initial 24-hour cumulative morphine consumption (r = 0.33, p = 0.0002). Patients with a 4-hour PCA ratio ≥1.5 demonstrated a significantly greater initial 24-hour morphine consumption (p = 0.0002), greater pain scores at 24 hours after surgery (p = 0.02), a greater incidence of at least one opioid-related side effect within the initial 24 hours after surgery, and a longer duration of hospital stay (p = 0.04) compared with those patients with a 4-hour PCA ratio <1.5. PCA ratio ≥1.5, age, and patient sex were predictive for 24-hour morphine consumption. The authors have demonstrated that a PCA ratio of demands/deliveries ≥1.5 is predictive of increased opioid requirements and is associated with greater pain scores in the initial 24 hours after surgery, an increased incidence of opioid-related side effects, and duration of hospital stay.

A retrospective study of multimodal analgesic treatment after laparoscopic appendectomy in children

Laparoscopic appendectomy is a common emergency pediatric surgery procedure accompanied by substantial pain (pain scores >4 for >60% of the time) in 33% of these patients. We introduced a bundle of pain management interventions including local anesthetic infiltration at the incision site, intravenous (IV) opioids by patient-controlled analgesia (PCA), and scheduled doses of IV ketorolac and oral acetaminophen/hydrocodone. To evaluate the effect of these pain management interventions on pain control after laparoscopic appendectomy. We retrospectively studied pain in 206 children above 7years of age undergoing laparoscopic appendectomy from December 2011 to February 2012 at our institution.We extracted data on patient demographics, duration of anesthesia and surgery, intraoperative opioids, local anesthetic infiltration, surgical procedure reports, along with pain scores, postoperative PCA use, and opioid-related complications and hospital stays. Patients were divided into two groups - simple appendicitis without peritonitis and appendicitis with generalized peritonitis. The incidence of substantial pain when the multimodal regimen was used was 12%, which is significantly lower than earlier reports (Fisher's exact test P<0.001). Patients with generalized peritonitis experienced more pain, consumed more opioids, had more unmet PCA demands, and a higher incidence of respiratory depression compared with those with simple appendicitis. The multimodal regimen of local anesthetic infiltration, opioid by PCA, NSAIDs, and oral acetaminophen/hydrocodone reduced the incidence of substantial pain. Additional studies are required to identify subgroups of patients with minimal opioid requirements who can benefit from modifications of this regimen.

Ilioinguinal-Iliohypogastric Nerve Block with Intravenous Dexketoprofen Improves Postoperative Analgesia in Abdominal Hysterectomies

Background and objectiveIn this study, our aim was to evaluate the effects of intravenous dexketoprofen trometamol with ilioinguinal and iliohypogastric nerve block on analgesic quality and morphine consumption after total abdominal hysterectomy operations. MethodsWe conducted this randomized controlled clinical study on 61 patients. The study was conducted in the operation room, post-anesthesia care unit, and inpatient clinic. We randomly grouped the 61 patients into control group (group C), block group (group B) and dexketoprofen-block group (group DB). Before the skin incision performed after anesthesia induction, we performed ilioinguinal iliohypogastric block (group C given saline and group P and DB given levobupivacaine). In contrast to group C and B, group DB was given dexketoprofen. We administered morphine analgesia to all patients by patient-controlled analgesia (PCA) during the postoperative 24hours. We recorded Visual Analogue Scale (VAS), satisfaction scores, morphine consumption and side effects during postoperative 24hours. ResultsWe found the DB group's VAS scores to be lower than the control group and block group's (p < 0.05) values at postoperative 1st, 2nd, 6th and 12th hours. VAS scores of group C were higher than of group B at postoperative first 2hours. Time to first PCA demand was longer, morphine consumption values were lower and satisfaction scores were higher in group DB than in the other two groups (p < 0.05). ConclusionsIlioinguinal-iliohypogastric nerve block with IV dexketoprofen increases patient satisfaction by decreasing opioid consumption, increasing patient satisfaction, which suggests that dexketoprofen trometamol is an effective non-steroidal anti-inflammatory analgesic in postoperative analgesia.

The Effect of EMLA Cream on Patient-Controlled Analgesia with Remifentanil in ESWL Procedure: A Placebo-Controlled Randomized Study

BackgroundTo alleviate stinging pain in the skin entry area and visceral discomfort in patients who are undergoing ESWL.ObjectivesThis study was designed to investigate the effectiveness of the EMLA cream in combination with remifentanil patient-controlled analgesia (PCA) in patients undergoing ESWL treatment.Patients and MethodsSixty patients were divided into two double-blind randomized groups. Those in the first group were administered 3-5mm of EMLA 5% cream on a marked area; the second group received, as a placebo, a cream with no analgesic effect in the same amount. All patients were administered a remifentanil bolus with a PCA device. Arterial blood pressure, oxygen saturation, and respiratory rate were recorded throughout the procedure; postoperative side effects, agitation, and respiratory depression were measured after. Visual Analogue Scale (VAS) scores were taken preoperatively, perioperatively, directly postoperatively, and 60 minutes subsequent to finishing the procedure.ResultsThere were no statistically significant differences in the frequency of PCA demands and delivered boluses or among perioperative VAS. No significant side effects were noted. Patient satisfaction was recorded high in both groups.ConclusionsEMLA cream offered no advantage over the placebo cream in patients undergoing ESWL with remifentanil PCA.

Decision tree-based learning to predict patient controlled analgesia consumption and readjustment

BackgroundAppropriate postoperative pain management contributes to earlier mobilization, shorter hospitalization, and reduced cost. The under treatment of pain may impede short-term recovery and have a detrimental long-term effect on health. This study focuses on Patient Controlled Analgesia (PCA), which is a delivery system for pain medication. This study proposes and demonstrates how to use machine learning and data mining techniques to predict analgesic requirements and PCA readjustment.MethodsThe sample in this study included 1099 patients. Every patient was described by 280 attributes, including the class attribute. In addition to commonly studied demographic and physiological factors, this study emphasizes attributes related to PCA. We used decision tree-based learning algorithms to predict analgesic consumption and PCA control readjustment based on the first few hours of PCA medications. We also developed a nearest neighbor-based data cleaning method to alleviate the class-imbalance problem in PCA setting readjustment prediction.ResultsThe prediction accuracies of total analgesic consumption (continuous dose and PCA dose) and PCA analgesic requirement (PCA dose only) by an ensemble of decision trees were 80.9% and 73.1%, respectively. Decision tree-based learning outperformed Artificial Neural Network, Support Vector Machine, Random Forest, Rotation Forest, and Naïve Bayesian classifiers in analgesic consumption prediction. The proposed data cleaning method improved the performance of every learning method in this study of PCA setting readjustment prediction. Comparative analysis identified the informative attributes from the data mining models and compared them with the correlates of analgesic requirement reported in previous works.ConclusionThis study presents a real-world application of data mining to anesthesiology. Unlike previous research, this study considers a wider variety of predictive factors, including PCA demands over time. We analyzed PCA patient data and conducted several experiments to evaluate the potential of applying machine-learning algorithms to assist anesthesiologists in PCA administration. Results demonstrate the feasibility of the proposed ensemble approach to postoperative pain management.