PCA Device Research Articles

Data-based program management of system-wide IV smart pump integration.

Smart pump bidirectional interoperability offers automated infusion programming and documentation that can improve patient safety and workflow efficiency. This technology has been poorly implemented across US hospitals, and there is little guidance on the tracking or monitoring of interoperability systems. The purpose of this report is to describe the successful implementation of intravenous (IV) smart pump interoperability in a large health system. Bidirectional IV smart pump interoperability and compliance monitoring were implemented across a large Midwestern health system using ICU Medical's Plum 360 and LifeCare PCA devices and Smith Medical's MedFusion 4000 Syringe Pump devices. The hospital system's experience in implementing and monitoring IV smart pump compliance using automated reports and a dedicated medication safety integration nurse is described. Compliance trends suggest that the implementation of IV smart pump interoperability has achieved a reduction in programming outside of the dose error reduction system, manual overrides, and IV medication administration error rates. The monitoring of smart pump compliance has had demonstrated benefits in investigating usability concerns, recognizing system errors, and identifying increased needs for nurse training. This program can serve as an example for other healthcare systems adopting IV smart pump interoperability.

Postoperative opioid consumption data repository incorporated in electric medical record based on PCA device data extraction program.

Postoperative opioid consumption data repository incorporated in electric medical record based on PCA device data extraction program.

Place of the paravertebral block in post-operative analgesia in thoracic surgery

The thoracic epidural analgesia (TEA) remains the standard gold for analgesic support in thoracic surgery, there is an interesting alternative to epidural analgesia, which is the paravertebral block (PVB). The aim in our study was to assess the value of performing a PVB in the management of postoperative pain in thoracic surgery compared to TEA. Methods: 80 patients were randomized to receive either epidural analgesia (n = 38, 10 cc bupivacaine 0.5% + 10 ϒ Sufentanyl then 10 cc Bupivacain 0.1% + 10 ϒ Sufentanyl via a PCA device) or PVB analgesia loss of resistance technique (n = 40, 10 cc bupivacaine 0.5% + 10 ϒ Sufentanyl via a PCA device). All patients received standard general anesthesia. The peri-operative parameters studied include standard measurement, EVA scale at rest and mobilization, use of morphinics. Results: there is a significant difference between the two groups and the incidents of puncture were significantly more important for the APDT group. The postoperative pain assessment by EVA did not show a significant difference between TEA and PVB Conclusion: the comparison of PVB to TPDA did not find significant difference in the efficacy of analgesia and the side effects. The BPV could be proposed as a first intention for postoperative analgesia in thoracic surgery.

Operation, Effectiveness, and Limitations of Continuous Serratus Anterior Plane Blocks for Thoracoscopic Surgery in Adults.

PurposeThis randomized, double-blind study evaluated the effectiveness and limitations of continuous serratus anterior plane block (cSAPB) by comparing the effect of cSAPB to patient-controlled intravenous analgesia (PCIA) on postoperative acute pain after thoracoscopic surgery in adults.Patients and MethodsSixty-six patients who underwent elective video-assisted thoracoscopic surgery (VATS) were randomly allocated to cSAPB or PCIA groups (n=33 per group) after surgery. For the cSAPB group, patients were treated by an initial does of 20 mL ropivacaine (0.375%), followed by continuous infusion at a rate of 5 mL/h of ropivacaine (0.2%) and a patient-controlled bolus of 5 mL ropivacaine (0.2%). PCIA started with an initial does of 0.03 µg/kg sufentanil, followed by a basal infusion of 0.03 µg/kg/h sufentanil and a patient-controlled bolus of 0.03 µg/kg sufentanil. Visual analog scale (VAS) and other items were examined postoperatively. The area under the curve of VAS-time (AUCVAS-time) at rest and on coughing in the first 24 hours postoperatively were primary outcomes.ResultsAt the first 24 hours postoperatively, patients in the cSAPB group exhibited a smaller AUCVAS-time at rest (44.0±17.1 vs 68.9±11.8 cm·h, P<0.001) and AUCVAS-time on coughing (67.1±8.8 vs 78.0±12.5 cm·h, P<0.001) compared with those in the PCIA group. The differences in means of VAS score at rest were more than 1.0 cm between the two groups, however, on coughing they were less than 1.0 cm at each observation point. Additionally, patients in the cSAPB group had a longer time to first patient-controlled bolus (15.8±7.6 vs 10.6±8.6 hours, P=0.011). Furthermore, a higher rank of satisfaction was recorded with patients in the cSAPB group.ConclusioncSAPB using PCA devices might be superior to traditional intravenous continuous analgesia, particularly with an advantage of pain relief at rest following VATS operation. Meanwhile, cSAPB lacks a satisfactory analgesic effect on cough.

Patient-Controlled Analgesia in High-Risk Populations: Implications for Safety

We aim to (1) identify the benefits and risks of patient-controlled analgesia and (2) analyze the risks of using various modalities of PCA among patients with traumatic injuries, sleep apnea, chronic pain, or neuropathies. An oral sufentanil PCA system may be as effective as an intravenous PCA. The overall incidence of PCA device error is less than 1%. While IV PCA may not be more effective than nurse-administered opioid among trauma patients, thoracic epidural analgesia may improve outcomes. Patients with obstructive sleep apnea or obesity are at increased risk of opioid-induced respiratory depression (OIRD). Patients with chronic pain or opioid tolerance, who may require higher opioid dosing, benefit from close monitoring. Continuous pulse oximetry and capnography can improve detection of OIRD. Risk of nerve injury after nerve block may be higher among patients with peripheral neuropathy, but this risk may be decreased with lower local anesthetic total dose or concentration. PCA, whether in intravenous, neuraxial, or peripheral nerve form, can have a significant role in postoperative analgesia. Regardless of technique, use of a PCA method should account for the potential risks to the patient, particularly in the presence of comorbidities such as sleep apnea, polytrauma, chronic pain, and preexisting neuropathy.

Sufentanil Sublingual for Acute Post-Operative Pain: A Systematic Literature Review Focused on Pain Intensity, Adverse Events, and Patient Satisfaction.

ContextPain is commonly experienced among patients after surgical procedures. Clinical pain management after surgery is far from being successful. Patients may control postoperative pain by self-administration of intravenous opioids using devices designed for this purpose (patient-controlled analgesia or PCA). PCA devices have been developed including the sufentanil sublingual tablet system (SSTS). A systematic review of the use of SSTS for postoperative pain is needed to identify an alternative method of pain management.ObjectivesTo systematically review literature to establish the efficacy and the safety of PCA with SSTS used in the treatment of moderate-to-severe acute post-operative pain in a hospital setting.MethodsEmbase, MEDLINE, Google Scholar, and Cochrane Central Trials Register were systematically searched in December 2019 for studies examining SSTS for pain in adult after surgical procedures. The methodological quality of the studies and their results were appraised using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist and specific measurement properties criteria, respectively.ResultsSixteen studies evaluating SSTS were included for a total of 2311 patients. All participants in the SSTS group reported NRS ≤ 4 within 24 h after surgery. Patient satisfaction was high, with a minimum of 70% satisfaction among patients treated with SSTS. The most common adverse events (AEs) overall for SSTS 15 and 30 mcg were nausea, vomiting, and headache. AEs observed in the studies were generally consistent with those associated with opioids and the postsurgical setting.ConclusionsSSTS is an important system for the management of moderate-to-severe acute pain in a hospital setting. SSTS is well tolerated, with no unexpected adverse events (AEs) and no clinically meaningful vital sign changes. These data confirm the safety and tolerability of the SSTS. Successful pain management resulted in a high level of acceptance of the SSTS by patients with high satisfaction for the method of pain control.

Comparative study between: Epidural bupivacaine versus Patient Controlled Analgesia for postoperative pain control in total knee arthroplasty

Abstract Introduction Effective postoperative pain control in total knee arthroplasty is important, especially with starting physiotherapy and early ambulation, which enhances recovery and reduces hospital length of stay. The risk of postoperative complications, such as deep venous thrombosis and nosocomial infections, has also been shown to decrease with early mobilization. Aim The aim of this study is to assess the analgesic efficacy of epidural bupivacaine compared with intravenous patient controlled analgesia (opioid and NSAIDs) during postoperative period in total knee arthroplasty. Patients Forty patients, ranging in age from 20 to 70 yr, scheduled to receive total knee replacements with spinal anesthesia were randomly assigned to this study. Methods patients received epidural bupivacaine 0.125% alone in (group epa) or iv nalbuphine 50mg, ketorolac 60mg via pca device. The quality of postoperative analgesia was assessed by the anesthesiologist according to Visual Analogue Score (VAS), Cortisol level 24 hours preoperative and 2 hours postoperative for stress response. Results The efficacy of both epidural Bupivacaine and i.v nalbuphine &amp; ketorolac via PCA device in controlling pain after total Knee arthroplasty however PCA was slightly less efficient especialy during the 12 hr after surgery. We found that one of the main draw backs of epidural analgesia using bupivacaine were arterial hypotension and urinary retention which required catheterization of many patients for voiding of urine. Results were comparable between the 2 groups and were against group EPA, Serum cortisol levels were elevated 2h post-surgery in all patients. This elevation is in accordance with the well-established stress response to surgery. Furthermore, cortisol levels were significantly less elevated in the group EPA, compared with group PCA. Conclusion The results of the study revealed both Epidural bupivacaine and systemic opioids combined with NASID via PCA device are effective of pain control post TKA.

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

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

The nature, magnitude, and reporting compliance of device-related events for intravenous patient-controlled analgesia in the FDA Manufacturer and User Facility Device Experience (MAUDE) database

ABSTRACTBackground: The aim of this study is to determine the characteristics, magnitude, and the quality of reporting of mandated events involving intravenous patient-controlled analgesia (IV-PCA) devices in the Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database; a postmarket surveillance system.Methods: We utilized a mixed-methods approach to systematically characterize structured data and text narratives associated with IV-PCA events submitted to MAUDE between 1 January 2011 and 12 September 2016.Results: Of 1,430 IV-PCA events reported during the study period, 6.4% were adverse events (AEs) as identified via structured data fields in the MEDWATCH forms. Upon qualitative review of the narrative texts, 11.0% of events were associated with an unfavorable clinical outcome, which was 71% higher than the incidence of the adverse outcomes reported using the structured data fields. Device-related issues, which were mostly preventable, accounted for 86.9% of events. Of 65 reportable events submitted by manufacturers, 18.5% did not comply with reporting requirements as mandated by law.Conclusion: Patients on IV-PCA continue to experience serious complications as a result of preventable errors. Multi-modal interventions including educational training and the development and adoption of PCA devices with improved safety features are needed to improve safety.

Abstract PR343

Background & Objectives: Providing satisfactory and safe analgesia is a major challenge for elder patients with hip fractures.The aim of this study was to compare the analgesia efficacy and safety between continuous fascia iliaca block analgesia (CFIB) and patient-controlled intravenous analgesia (PCIA)in elder patients undergoing hip fracture surgery. Materials & Methods: 32 patients (ASA II-III, ages 66-90 years old) scheduled for hip fracture surgeries were randomized into two groups. Patients of Group CFIB were placed a fascia iliaca catheter under ultrasound guidance and 30mL 0.33% ropivacaine was injected via the catheter before standardized general anesthesia. After surgery, a continuous infusion of 0.15% ropivacaine at rate of 2mL/h via the catheter, and a bolus of 30ml 0.15% ropivacaine was injected every 24h for 3 days after surgery. Patients of Group PCIA received standardized general anesthesia and intravenous patient-controlled analgesia using sufentanil for 3 days after surgery Results: There was no difference in pain intensity during movement (dynamic VAS) and rest (static VAS) before a bolus injection between the two groups 24h, 48h and 72 h after surgery. After a bolus injection, both the static and dynamic VAS decreased in Group CFIB, but only the VAS in 24h postoperatively was found difference, and compared to Group PCIA, only the static VAS was found difference. There was no difference in analgesic rescue between the two groups. Fewer side effect and better cooperation were found in Group CFIB. In Group PCIA, three patients removed the PCA devices because of nausea and vomiting. And a delirium and a respiratory depression in post anesthesia care unit respectively were found.Conclusion: These preliminary results showed similar analgesia efficacy between continuous fascia iliaca block and patient-controlled intravenous analgesia. Fewer side effect and better cooperation were found in continuous fascia iliaca block. Further studies are needed.

Increasing patient knowledge on the proper usage of a PCA machine with the use of a post-operative instructional card

ABSTRACTObjectives: The purpose of this study was to see if an instructional card, attached to the PCA machine following total hip arthroplasty describing proper use of the device, would positively affect subjects’ understanding of device usage, pain scores, pain medication consumption and satisfaction.Methods: Eighty adults undergoing total hip replacements who had been prescribed PCA were randomized into two study groups. Forty participants received the standard post-operative instruction on PCA device usage at our institution. The other 40 participants received the standard of care in addition to being given a typed instructional card immediately post-operatively, describing proper PCA device use. This card was attached to the PCA device during their recovery period. On post-operative day one, each patient completed a questionnaire on PCA usage, pain scores and satisfaction scores.Results: The pain scores in the Instructional Card group were significantly lower than the Control group (p = 0.024). Subjects’ understanding of PCA usage was also improved in the Instructional Card group for six of the seven questions asked.Conclusion: The findings from this study strongly support that postoperative patient information on proper PCA use by means of an instructional card improves pain control and hence the overall recovery for patients undergoing surgery. In addition, through improved understanding it adds an important safety feature in that patients and potentially their family members and/or friends may refrain from PCA-by-proxy. This article demonstrates that the simple intervention of adding an instructional card to a PCA machine is an effective method to improve patients’ knowledge as well as pain control and potentially increase the safety of the device use.

The Effect of Patient-controlled Analgesia on Intensity of Postoperative Pain in Abdominal Surgeries

surgeries. Patients and Methods: It was an interventional study conducted on thirty patients admitted to Amir-al-momenin Hospitalin Ahvaz , Iran, in 2009. About 60 patients participated in the current study. The patients were randomly divided into two groups. The intervention group used PCA devices and the control group received the routine pain relief protocol. Measurement tools were demographic characteristic questionnaire, check list of vital signs and adverse effects and visual analog scale (VAS). Vital signs, pain severity, drug consumption and adverse effects were assessed every six hours during 24 hours after surgery. Then data were analyzed by SPSS version 16, χ2, and t-test Results: There was a significant difference between the mean of pain severity and the amount of medications used by patients after surgery (P≤0.001). But there was no significant difference between vital signs and side effects between the two groups. Conclusions: These findings indicate the usefulness of PCA compared to the routine methods on pain relief after operation.Therefore this method can be recommended to alleviate postoperative pain.

Patient-controlled analgesia (PCA) following video-assisted thoracoscopic lobectomy: Comparison of epidural PCA and intravenous PCA

ObjectivesTo compare the efficacy and side effects of epidural patient-controlled analgesia (EPCA) with those of intravenous patient-controlled analgesia (IVPCA) in fast-track video-assisted thoracoscopic (VATS) lobectomy. Patients and methodsEPCA or IVPCA was chosen by patients and was started immediately following tracheal extubation in the wake of completion of VATS lobectomy. EPCA analgesia was carried out with the PCA device programmed to deliver a bolus dose of 3 mL of 0.1% bupivacaine combined with 1.2 μg/mL fentanyl, and continuous epidural infusion at a rate of 4 mL/hour through an epidural catheter placed at the T6-7 or T7-8 level. IVPCA was made possible by a patient controlled infusion pump programmed to deliver 0.1% morphine with a loading dose of 3 mg, and the controlled bolus of 1 mg, at a lockout interval of 5 minutes. A rescue dose of 5 mg intravenous morphine was available for all patients in postoperative care unit. Pain management was assessed with visual analog scale at rest (VAS-R) and during motion (VAS-M); side effects including nausea, vomiting, pruritus, dizziness and sleepiness were recorded and analyzed from postoperative Day 1 (POD1) to Day 3 (POD3). ResultsThis study included 105 patients. Satisfactory pain control was achieved, although 9/70 patients in the EPCA group and 5/35 patients in the IVPCA group needed rescue morphine in the recovery room. The VAS-R was significantly higher on POD1 than on POD2 or POD3 in both groups (p < 0.001). The VAS-R and VAS-M were comparable in both groups on POD1 and POD3 but significant lower VAS-M was seen in the EPCA group on POD2 (p = 0.008). Higher incidence of dizziness was found in the IVPCA group on POD1 (p = 0.044) but the EPCA group had a higher incidence of pruritus on POD2 (p = 0.024) and POD3 (p = 0.03). ConclusionOur results indicated that the necessity of pain control was higher on POD1 for VATS lobectomy. Both EPCA and IVPCA can provide an adequate, continuous and effective means for postoperative pain management and a lower VAS-M was found in EPCA on POD2.

Morphine at “sub-analgesic” background infusion rate plus low-dose PCA bolus control pain better and is as safe as twice a bolus-only PCA regimen: A randomized, double blind study

Morphine for postoperative pain control is commonly titrated via intravenous patient-controlled analgesia (IV-PCA). An IV morphine background infusion is rarely used. We investigated whether analgesia is effectively attained and morphine consumption is reduced if PCA titration is coadjuvated by a continuous infusion protocol. Following colorectal cancer surgery, consenting patients were randomized to receive a minimal (“sub-analgesic”) dose of morphine 0.01mg/kg/h background infusion plus a 0.01mg/kg bolus (BI), or a 1.5mg bolus-only morphine (B0) (bolus ratio ∼1:2). Bolus lockout time was 7min in either case. All patients received 0.1mg/kg morphine before protocol initiation, and diclofenac 75mg intramuscularly b.i.d. during the study period, lasting 48h. Eighty-six patients (51 males, age 26–95 years) participated in the study. The total mean morphine consumption during the 48h was 25% lower in the BI than in the B0 group (P<0.05). Although the former applied the PCA device for boluses 19% less than the latter (P<0.05), their pain score was lower (P<0.05) most of the time, and they reported greater satisfaction (P<0.05) on a 10-scale numerical rating score. Pre- and postoperative vital signs were similar for both groups. No patient depicted hypoxemia or lapsed into deep sedation. Four BI and three B0 patients required treatment for postoperative nausea and vomiting. One BI patient had transient pruritus and one B0 69-year individual became disoriented 24h into treatment; either event subsided soon after stopping their respective regimen without the need for treatment. The main conclusions of the results are that very-low-dose background morphine infusion combined with small-dose PCA boluses may provide better pain relief, lower morphine consumption, and minimal complication rate as a 1.5mg PCA bolus-only protocol.

The role of magnesium in preventing postoperative hyperalgesia

Intraoperative remifentanil administration results in acute opioid tolerance that is manifested by increased postoperative pain, opioid requirement and specifically periincisional hyperalgesia. The aim of this study was to investigate the effect of magnesium in preventing remifentanil-induced hyperalgesia. This study was performed on 60 (ASA I-II) patients planned for abdominal hysterectomy. Sixty patients were randomized into two equal groups. Before anesthesia, saline solution was given to the patients in group I (control group), 50 mg/kg i.v. Magnesium in group II (magnesium group). Anesthesia was induced with 1 µg/kg remifentanil combined with 4-5 mg/kg thiopental and 0.5 mg/kg atracurium, maintained with 0.5 MAC sevoflurane and 0.4 µg/kg/min remifentanil in both groups. Sevoflurane concentration was titrated according to autonomic responses. Thirty minutes before the anticipated end of surgery, a 0.15 mg/kg bolus dose of morphine was intravenously. At the end of surgery, patients received tramadol i.v via a PCA device. Pain score, tramadol demand and delivery were assessed at 2, 4, 6, 12, 24 h after surgery. Total tramadol consumption were recorded for 24-48 h after surgery. Periincisional hyperalgesia was assessed by measuring pain threshold to pressure by using an algometer and electronic von Frey filaments before operation and at 28-48 h postoperatively. The pain scores and cumulative tramadol consumption were significantly lower in the magnesium group compared with the control group (p<0.05). Pressure and mechanical pain threshold were significantly less at 24-48 h postoperatively in control group than magnesium group. Magnesium administered preemptively reduced remifentanil-induced hyperalgesia.

Effects of preoperative oral melatonin medication on postoperative analgesia, sleep quality, and sedation in patients undergoing elective prostatectomy: a randomized clinical trial

Our intention was to assess the effectiveness of preoperative oral melatonin medication on sedation, sleep quality, and postoperative analgesia in patients undergoing elective prostatectomy. Fifty-two ASA I-II patients undergoing elective prostatectomy were included in this study, randomly divided into two groups. Patients received an oral placebo (n = 26) or 6 mg melatonin (n = 26) the night before and 1 h before surgery. All patients received a standard anesthetic protocol. At the end of surgery, all patients received tramadol i.v. via a PCA device. Extubation time, intraoperative fentanyl consumption, and recovery time were assessed at the end of the operation. Pain scores, tramadol consumption, and sedation scores were assessed at 1, 2, 4, 6, 12, 18, and 24 h postoperatively, and sleep quality and subjective analgesic efficacy were assessed at 24 h after surgery. There were no significant differences in demographic data between the groups. Extubation time and recovery time from anesthesia were significantly longer in the melatonin group (P < 0.05). Intraoperative fentanyl usage, pain scores, and tramadol consumption were significantly lower in the melatonin group (P < 0.05). The postoperative sleep quality of patients was significantly better in the melatonin group than in the control group (P < 0.05). Postoperative VAS of pain was significantly lower in the melatonin group compared with the control group at 1, 2, 4, 6, 12, 18, and 24 h postoperatively (P < 0.05). Subjective analgesic efficacy of patients was significantly different between groups (P < 0.05). The sedation scores were significantly higher in the melatonin group than in the control group at 1 h and 2 h after surgery (P < 0.05). Preoperative oral melatonin administration decreased pain scores and tramadol consumption and enhanced sleep quality, sedation scores, and subjective analgesic efficacy during the postoperative period.

Bacterial contamination of PCA and epidural infusion devices

Summary We prospectively audited the bacterial contamination of re-useable analgesia infusion pumps. In a one-month period, 112 samples from the handset and keypads of our analgesia infusion pumps were cultured for bacterial contamination. Forty-five percent of handset swabs and 46% of keypad swabs grew bacteria; the commonest organism being coagulase-negative staphylococcus. An additional cleaning step using 70% isopropyl alcohol wipes was introduced and the contamination rate was re-audited in 100 samples. The contamination rate was reduced to 6% of handset swabs and 4% of keypad swabs. A high initial rate of bacterial contamination of re-useable analgesia infusion pumps was significantly reduced by the implementation of a simple, additional cleaning procedure.

Adding Gabapentin to a multimodal regimen does not reduce acute pain, opioid consumption or chronic pain after total hip arthroplasty

Gabapentin (GPN) is effective in reducing post-operative pain and opioid consumption, but its effects with regional anesthesia for total hip arthroplasty (THA) are not known. We designed this study to determine whether (1) gabapentin administration reduces pain and opioid use after THA using a multimodal analgesic regimen including spinal anesthesia; (2) pre-operative administration of gabapentin is more effective than post-operative administration. After REB approval and informed consent, 126 patients were enrolled in a double-blinded, randomized-controlled study. Patients received acetaminophen 1 g per os (p.o.), celecoxib 400 mg p.o. and dexamethasone 8 mg intravenously, 1-2 h pre-operatively. Patients were randomly assigned to one of three treatment groups (G1: Placebo/Placebo; G2: GPN/Placebo; G3: Placebo/GPN). Patients received gabapentin 600 mg (G2) or placebo (G1 and G3) 2 h before surgery. All patients had spinal anesthesia [15 mg (3cc) of 0.5% hypobaric bupivacaine with 10 microg of fentanyl]. In the post-anesthetic care unit, patients received gabapentin 600 mg (G3) or placebo (G1 and G2). On the ward, patients received acetaminophen 1000 mg p.o. q6h, celecoxib 200 mg p.o. q12h and a morphine PCA device. Patients were interviewed 6 months post-surgery to determine the incidence and severity of chronic post-surgical pain. Mean+/-SD cumulative morphine (mg) consumption (G1=49.4+/-24.8, G2=47.2+/-30.1 and G3=56.1+/-38.2) at 48 h and pain scores at 12, 24, 36 and 48 h post-surgery were not significantly different among the groups [G1 (n=38), G2 (n=38) and G3 (n=38)]. Side effect profiles were similar across groups. Six months after surgery, the number of patients who reported chronic post-surgical pain (G1=10, G2=12 and G3=9) and the severity of the pain (G1=4.2+/-2.9, G2=4.1+/-2.2 and G3=4.9+/-2.2) did not differ significantly among the groups (P>0.05). A single 600 mg dose of gabapentin given pre-operatively or post-operatively does not reduce morphine consumption or pain scores in hospital or at 6 months after hip arthroplasty within the context of spinal anesthesia and a robust multimodal analgesia regimen.

Bacterial contamination of PCA and epidural infusion devices

We prospectively audited the bacterial contamination of re-usable analgesia infusion pumps. In a one-month period, 112 samples from the handset and keypads of our analgesia infusion pumps were cultured for bacterial contamination. Forty-five percent of handset swabs and 46% of keypad swabs grew bacteria; the commonest organism being coagulase-negative staphylococcus. An additional cleaning step using 70% isopropyl alcohol wipes was introduced and the contamination rate was re-audited in 100 samples. The contamination rate was reduced to 6% of handset swabs and 4% of keypad swabs. A high initial rate of bacterial contamination of re-usable analgesia infusion pumps was significantly reduced by the implementation of a simple, additional cleaning procedure.

(737): Continuous regional anesthesia of maxillary nerve: Clinical study of a new lateral approach to pterygopalatine fossa

The aim of the study was to assess the feasibility of continuous maxillary nerve block (CMNB) using a new technical approach for an indwelling catheter. After obtaining informed consent, 12 patients scheduled for maxillary carcinoma surgery were included in a prospective study. Before surgery an indwelling catheter was placed in the pterygopalatine fossa using lateral supra-zygomatic approach, according to previous anatomical study. Six ml of ropivacaine 7.5 mg/ml were injected. Difficulties and time to perform CMNB, side effects and complications were noted. General anesthesia (GA) was induced and maintained with propofol and remifentanil. Postoperative analgesia was started 30 min. before the end of surgery and performed with 5 ml ropivacaine 2 mg/ml. All patients received 5 ml of ropivacaine 2 mg/ml twice a day during 48 hours. In Post Anesthesia Care Unit morphine was titrated until stable pain control was achieved. An intravenous PCA device with morphine was started and continued in surgical ward during 48 hours. Pain level was analyzed with Visual Analogic Scale (VAS). In case of uncontrolled pain (VAS>4), patients received 1gr of paracetamol IV. Before nasal packing removal on 4th postoperative day 5ml of ropivacaine 7.5 mg/ml was injected into the catheter, GA was performed only if necessary. Results were compared with historic control group having maxillary carcinoma surgery without CMNB. Time to perform CMNB was 5min0.9 (meanSD), neither difficulty nor complication was noted. Eleven CMNB were achieved on first attempt. Remifentanil and paracetamol consumptions were significantly decreased in CMNB group. First paracetamol injection was significantly delayed in CMNB group. Only one patient in CMNB group needed GA for nasal packing removal because of early catheter removal. In conclusion CMNB via supra-zygomatic approach is easy and safe. CMNB improves per and post-operative analgesia and avoids GA for nasal packing removal. The aim of the study was to assess the feasibility of continuous maxillary nerve block (CMNB) using a new technical approach for an indwelling catheter. After obtaining informed consent, 12 patients scheduled for maxillary carcinoma surgery were included in a prospective study. Before surgery an indwelling catheter was placed in the pterygopalatine fossa using lateral supra-zygomatic approach, according to previous anatomical study. Six ml of ropivacaine 7.5 mg/ml were injected. Difficulties and time to perform CMNB, side effects and complications were noted. General anesthesia (GA) was induced and maintained with propofol and remifentanil. Postoperative analgesia was started 30 min. before the end of surgery and performed with 5 ml ropivacaine 2 mg/ml. All patients received 5 ml of ropivacaine 2 mg/ml twice a day during 48 hours. In Post Anesthesia Care Unit morphine was titrated until stable pain control was achieved. An intravenous PCA device with morphine was started and continued in surgical ward during 48 hours. Pain level was analyzed with Visual Analogic Scale (VAS). In case of uncontrolled pain (VAS>4), patients received 1gr of paracetamol IV. Before nasal packing removal on 4th postoperative day 5ml of ropivacaine 7.5 mg/ml was injected into the catheter, GA was performed only if necessary. Results were compared with historic control group having maxillary carcinoma surgery without CMNB. Time to perform CMNB was 5min0.9 (meanSD), neither difficulty nor complication was noted. Eleven CMNB were achieved on first attempt. Remifentanil and paracetamol consumptions were significantly decreased in CMNB group. First paracetamol injection was significantly delayed in CMNB group. Only one patient in CMNB group needed GA for nasal packing removal because of early catheter removal. In conclusion CMNB via supra-zygomatic approach is easy and safe. CMNB improves per and post-operative analgesia and avoids GA for nasal packing removal.