Postsurgical Pain Relief Research Articles

Internet-Based Monitoring and Benchmarking in Ambulatory Surgery Centers

Each year the number of surgical procedures performed on an outpatient basis increases, yet relatively little is known about assessing and improving quality of care in ambulatory surgery. Conventional methods for evaluating outcomes, which are based on assessment of inpatient services, are inadequate in the rapidly changing, geographically dispersed field of ambulatory surgery. Internet-based systems for improving outcomes and establishing benchmarks may be feasible and timely. Eleven freestanding ambulatory surgery centers (ASCs) reported process and outcome data for 3,966 outpatient surgical procedures to an outcomes monitoring system (OMS), during a demonstration period from April 1997 to April 1999. ASCs downloaded software and protocol manuals from the OMS Web site. Centers securely submitted clinical information on perioperative process and outcome measures and postoperative patient telephone interviews. Feedback to centers ranged from current and historical rates of surgical and postsurgical complications to patient satisfaction and the adequacy of postsurgical pain relief. ASCs were able to successfully implement the data collection protocols and transmit data to the OMS. Data security efforts were successful in preventing the transmission of patient identifiers. Feedback reports to ASCs were used to institute changes in ASC staffing, patient care, and patient education, as well as for accreditation and marketing. The demonstration also pointed out shortcomings in the OMS, such as the need to simplify hardware and software installation as well as data collection and transfer methods, which have been addressed in subsequent OMS versions. Internet-based benchmarking for geographically dispersed outpatient health care facilities, such as ASCs, is feasible and likely to play a major role in this effort.

RELIEF OF POST SURGICAL PAIN BY PATIENT CONTROLLED EPIDURAL ANALGESIA (PCEA) WITH BUPRENORPHINE AFTER COMBINED SPINAL-EPIDURAL ANESTHESIA

S227 Combined spinal-epidural anesthesia (CSEA) offers the advantage of rapid and profound anesthesia with the capability of providing epidural analgesia for the management of post surgical pain. The present study evaluated the safety and efficacy of patient controlled epidural analgesia (PCEA) with buprenorphine following CSEA. METHOD: Eighty adult patients of ASA class I-II who were scheduled for lower abdominal and lower extremity surgeries were divided into 2 equal groups: Group A received CESA with 17G epidural needle inserted at L3-4 interspace through which 25G Whittaker needle was introduced into the subarachnoid space and hyperbaric bupivacaine 0.2mg/kg was injected. After injection the Whittaker needles were removed and epidural catheter was placed. Group B received epidural anesthesia with 2% lidocaine via indwelling catheter inserted at L3-4. After surgery when the patient first complained of pain PCEA was given by Graseby-9300 pump with loading dose 5 ml, continuous infusion 0.5ml/hr and PCA dose 1 ml (lock out interval 20 min.) of buprenorphine 0.0015% in bupivacaine 0.15%. Vital signs, pain intensity by VAS, frequency and dose of PCEA, and adverse effects were recorded for 24 hr. postoperatively. RESULT: The demographic data were comparable between the 2 groups. The analgesic effect, dose of epidural drugs used and the adverse effect profile were very similar for the 2 groups without significant difference (Table 1 and Table 2). The incidence of adverse effects were noticeably low.Table 1: PCEA dose and Pain scoreTable 2: Adverse EffectsDISCUSSION: Our study showed that PCEA with buprenorphine can be used safely to provide effective relief of post surgical pain after CSEA.

PATIENT CONTROLLED EPIDURAL ANALGESIA (PCEA) WITH BUPRENORPHINE AND DROPERIDOL IN CHILDREN

S228 Epidural administration of droperidol has been shown to enhance the analgesic effect of epidural morphine with reduced adverse effects in adults [1]. Epidural buprenorphine is being used to provide postsurgical pain control [2]. The present study assessed whether the addition of epidural droperidol would influence the effect of epidural buprenorphine by Patient Controlled Epidural Analgesia (PCEA) in pediatric patients. METHOD: Forty children of ASA class I-II and age 5-11 who were scheduled for lower extremity surgeries received placement of epidural catheter at L2-4 after ketamin 5 mg/kg I.M. Epidural anesthesia was maintained with 1.5% lidocaine. After surgery when patients were fully awake and complained of pain they were divided in double blind and randomized fashion innnto 2 equal groups with Group A receiving PCEA of buprenophine 0.0012% in bupivacaine 0.1% and Group B receiving PCEA of buprenorphine 0.0012% + droperidol 0.005% + bupivacaine 0.1%. The PCEA was administered by Graseby-9300 pump with a loading dose of 0.1 ml/kg, continuous infusion of 0.05 ml/kg/hr and a PCA dose of 0.05 ml/kg with a 30 min lock out interval. Vital signs, pain intensity assessment by faces pain scale [3], sedation by Ramsay scale [4], frequency and dose of PCEA and adverse effects were recorded for 24 hr. post operatively. RESULT: The demographic data of the 2 groups were comparable without significant difference. Both groups obtained effective pain relief with an average value of the summed VAS 1.7 for Group A and 1.5 for Group B. However, Group B had significantly lower number of PCEA doses 1.44 +/- 0.18 vs 2.65 +/- 0.38) and less total 24 hr. dose used than those of Group B (13.23 +/- 3.26 ml vs 20.38 +/- 5.35 ml) (p<0.01). This seems to indicate that there is a potentiating effect of the epidural buprenorphine analgesia by droperidol. The incidence of nausea/vomiting was found to be 5/20 in Group A vs 1/20 in Group B. Patients in Group B showed a higher sedation score of 3.7 +/- 0.62 vs 2.7 +/- 0.45 in Group A (p<0.05). Urinary retention was not assessed due to the use of indwelling Foley catheters in some of the patients and there was no other significant adverse reactions observed. DISCUSSION: The addition of epidural droperidol appears to potentiate the analgesic effect and reduce the adverse effect of epidural burenorphine which can be used safely to provide effective relief of post surgical pain by PCEA method in children.

Postoperative pain relief, from the patients5 and the nurses' point of view

In this prospective, consecutive study, 191 patients were interviewed before and after surgery (orthopaedic, gynaecological, abdominal and urological operations) about their attitude to and the quality of received pain relief, respectively. In addition, nurses working in the surgical units involved in the study were asked to answer a questionnaire covering attitudes to postoperative pain and pain treatment. Of the patients, 47% were in pain at the time of the postsurgical interview, 10% had not any analgesic prescribed at all and 15% had received less than prescribed. In 36% of the cases there was a discrepancy between the amount of analgesic prescribed by the surgeon and the amount prescribed by the anaesthetist. In 80% of the patients the pain outlasted the first postoperative day, but only 64% would always tell the staff if they had pain. Seventeen per cent of the patients had never been asked about their postoperative pain status. Preoperative pain had a significant correlation to postoperative pain. Although the results are not impressive, they do constitute some improvement compared to previously published studies. Fifty-one nurses (71% of the total nursing staff) answered the questionnaire. Of these, 63% were sometimes in doubt about the physicians' prescriptions, 55% would occasionally refuse to give analgesics for various reasons, and 37% were not satisfied with the routines of pain control in their ward. Knowledge of pain treatment and communication between surgeons, anaesthesiologists, nurses and patients must be improved to make postsurgical pain relief adequate.

The role of the perispinal route for postsurgical pain relief

Summary Excellent postsurgical pain relief is no longer a privilege for patients nursed in the intensive care unit or the post anaesthetic care unit. The discovery of opioid receptors in the spinal cord has opened new horizons in the treatment of postoperative pain. Nevertheless, we still lack the ideal opiate to provide long-lasting pain relief of fast onset without the risk of life-threatening side-effects. This has resulted in more attention being focused in the first place on combined regimens with local anaesthetic drugs and also on other adjuvant agents allowing for significant dose reductions of both opioid and additives. The trend towards combinations of opioids with low concentrations of local anaesthetics has received growing interest due to the unanswered question of whether analgesia obtained with continuous administration of lipophilic opioids is a true spinal cord effect or the result of the drug being redistributed through the plasma to supraspinal levels. Nevertheless, continuous and PCA administration are the techniques of the future rather than the renewed interest in bolus injections of morphine. There should be no doubt that the perispinal route offers other beneficial effects besides pain relief, but that for these the use of local anaesthetics is essential. Most probably opioids have no effect on platelet aggregation, neither do they accelerate bowel motility. Local anaesthetics may induce a better quality of analgesia. However, future studies, making more distinction between pain at rest and pain during activity and stressing the site of operation, are mandatory to determine the optimal concentration and dose of local anaesthetic drugs required to improve the quality of opioid-induced analgesia. The definite place of α 2 -adrenergic agonist drugs in postsurgical pain relief, whether used alone or in combined regimens, still remains unclear. The increasing popularity of continuous spinal anaesthesia will undoubtedly promote the use of this route for prolonged analgesia into the postoperative period.

The use of glucocorticoids and non-steroidal anti-inflammatory drugs for preventive postsurgical pain relief

Summary For many years surgical pain has been wrongly considered as a minor prejudice. Surgery produces pain, inflammatory reaction and endocrine-metabolic changes known as the surgical ‘stress response’. These disorders are intimately interrelated and therefore adequate pain treatment is important. It will improve the patient's outcome by reducing the inflammatory reaction and the endocrine-metabolic changes. The advent of locoregional anaesthesia techniques and the discovery of morphine receptors in the spinal cord has been a real breakthrough, but proper postsurgical pain management still encounters problems related to efficacy, safety and practical execution. Recently new concepts about pain relief have arisen. In terms of efficacy, pre-emptive treatment of postoperative pain is essential. Furthermore, combined use of drugs and/or methods seems more likely to achieve the best results. Despite the popularity of spinal opioids for pain relief other drugs are still needed. NSAIDs are known to produce their effects by inhibition of prostaglandin synthesis. They have analgesic and anti-inflammatory properties. Therefore it seems logical that these drugs could play an important role in a highly inflammatory event such as a operation. Recent comprehensive studies have shown that NSAIDs could be of great use in postoperative pain relief after major surgery. Provided they are used preventively and in combination with opioids, they increase the duration and the quality of the analgesia. They also reduce the need for opioids (by about 30%). The fear of side-effects should not limit their use in the surgical patient, but precautionary measures should be taken into consideration in high risk patients. Steroids are also very potent anti-inflammatory drugs. Intravenous or peridural administration seems to have analgesic effects. The exact mechanism of action is unknown, but clinical results are impressive. When low doses of morphine (1 to 1.5 mg) combined with methylprednisolone (80 mg) are administered by the peridural route, 80% of all patients are pain free during the 3 days following surgery. Postoperative tiredness is reduced. The literature reveals accidents due to the spinal injection of corticoids, but only when administered intrathecally, repeatedly and/or using long-acting, preservative-containing drugs. No incidents have been reported using a preservative-free corticoid for a short period and injected into the peridural space. Further studies are necessary to determine the validity of this association. However, a 6-year long successful experience in more than 4000 patients and in all types of surgery, using a low dose of morphine (1 to 1.5 mg) with methylprednisolone (80 mg and thereafter 15 mg per bolus) injected into the peridural space, justifies further investigation.

Post-surgical pain relief with zero-order intravenous infusions of meptazinol and morphine: a double-blind placebo-controlled evaluation of their effects on ventilation

A double-blind, placebo-controlled study has been made of the analgesic and respiratory effects of constant rate infusions of meptazinol and morphine in 30 patients after abdominal surgery. Group I received meptazinol, loading dose 50 mg followed by i.v. infusion 0.5 mg.kg-1.h-1, Group II received morphine, loading dose 5 mg and then an infusion of 0.05 mg.kg-1.h-1, and Group III received saline. After recovery from inhalation anaesthesia (without opiates or a local anaesthetic) pain relief and chemoreceptor carbon dioxide tolerance were assessed before and at various times after starting the analgesic infusion. A similar degree of pain relief was found after 10 min in Groups I and II, which lasted until the end of observation period (20 h). Heart rate and systolic and diastolic blood pressures were lower in Group II than in Groups I and III, and respiratory rate fell in Groups I and II. After 6 h arterial carbon dioxide tensions (PaCO2) became significantly higher in Group II than Group III. The maximum percentage fall in mean tidal volume (VT) and expired minute volume (VE) from the preinjection values was significant in Groups I and II. End-tidal carbon-dioxide (PETCO2) and PaCO2 were significantly higher after 20 h of infusion in Group II compared to Group I. The slope of VE/PETCO2 (mean value of S) was increased in Group I and it was significantly reduced in Group II. Analysis of derived variables, such as the CO2 intercept (CO2I) and minute ventilation at 7 kPa (VE7), indicated a shift to the right of the slopes in Groups I and II, initially more so in Group I.(ABSTRACT TRUNCATED AT 250 WORDS)

Etodolac: Analgesic effects in musculoskeletal and postoperative pain

Numerous clinical trials have shown etodolac to be an effective analgesic. The purpose of the present report is to review results of 14 studies that demonstrate the effectiveness of etodolac in a variety of painful conditions. Presented are the results of four postsurgical pain studies, one study of acute gouty arthritis and nine studies of acute musculoskeletal disorders: acute low back pain, acute painful shoulder, tendinitis and bursitis, and acute sports injuries. A single oral dose of etodolac (25, 50, 100, 200, or 400 mg) was compared with aspirin (650 mg) or a combination of acetaminophen (600 mg) plus codeine (60 mg) for the relief of pain up to 12 h following oral, urogenital or orthopedic surgery. In multiple dose studies of acute gouty arthritis and musculoskeletal conditions, etodolac 200 or 300 mg twice a day (b.i.d.) or 200 mg three times a day (t.i.d.) was compared with naproxen 500 mg b.i.d. or t.i.d., diclofenac 50 mg b.i.d. or t.i.d., and piroxicam 20 or 40 mg once a day (o.d.) administered over 5 to 14 days. The efficacy of etodolac was at least equal and in some ways superior to aspirin and acetaminophen plus codeine in the relief of postsurgical pain. In studies of acute gouty arthritis, significant improvement from baseline were seen for all efficacy parameters evaluated for both the etodolac- and naproxen-treated patients. All the present studies of musculoskeletal conditions have shown etodolac to be effective and comparable in analgesic efficacy to naproxen, diclofenac or piroxicam. In summary, etodolac therapy for pain following surgery, in acute gouty arthritis and in acute musculoskeletal conditions resulted in analgesia comparable to that provided by several well-established analgesic or anti-inflammatory agents.

Concomitant administration of diflunisal and codeine phosphate for the relief of postsurgical pain

Concomitant administration of diflunisal and codeine phosphate for the relief of postsurgical pain

Comparison of flurbiprofen and aspirin in the relief of postsurgical pain using the dental pain model

This single-dose, double-blind, randomized, placebo-controlled study evaluated the analgesic efficacy of both 25 and 50 mg of flurbiprofen (Ansaid, Upjohn) compared with 650 mg of aspirin and placebo in 164 patients who had undergone dental impection surgery. Using the highly sensitive dental pain model, flurbiprofen appears to be an effective, peripherally acting analgesic with a rapid onset of activity. In the current study, it was superior to aspirin in terms of peak effect and duration of action. Although flurbiprofen is much more potent than ibuprofen, its side-effect profile did not differ markedly from that of ibuprofen in this single-dose study.

Effect of epidural morphine on the Hoffman-reflex in man.

Four healthy, young subjects undergoing knee surgery with epidural anaesthesia were given epidural morphine for the relief of post-surgical pain. The Hoffman (H)-reflex was tested before and after the injection of morphine in the epidural space. The reflex was chosen as a monitor of the function of monosynaptic pathways in the spinal cord. Analogue scales for the measurement of pain revealed a satisfactory decrease of nociception after morphine injection, while the H-reflex was not significantly affected. This study may confirm that monosynaptic reflexes are not affected by epidural administration of morphine and that they are probably not involved in pain transmission.

Serum Levels following Epidural Administration of Morphine and Correlation with Relief of Postsurgical Pain

This study was undertaken to determine the serum levels of free morphine base resulting from the epidural administration of morphine, and to correlate these serum levels with analgesic effect. Results from twenty-one patients are presented. Following major surgery with bupivicaine or lidocaine conti

Serum levels following epidural administration of morphine and correlation with relief of postsurgical pain.

This study was undertaken to determine the serum levels of free morphine base resulting from the epidural administration of morphine, and to correlate these serum levels with analgesic effect. Results from twenty-one patients are presented. Following major surgery with bupivicaine or lidocaine conti

Postsurgical pain relief: Patients' status and nurses' medication choices

This study consisted of two interrelated parts. In the first part, the adequacy of pain relief in hospitalized post-surgical patients was assessed and described and in the second part ways in which nurses on the same units chose analgesic medications were examined and analyzed. Pain was considered a subjective experience. Patients were interviewed, and their charts reviewed on the third postoperative day. The sample included 109 patients in 5 central Illinois hospitals. After all patient interviews were completed, 121 nurses on the same units responded to a questionnaire which included clinical vignettes. Results of the patient interviews indicated that 75.2% of these patients were in moderate or marked pain distress and that a general question did not adequately assess pain. Chart review indicated that these patients were actually receiving less narcotic analgesics than they could receive. Nurses were overly concerned about the possibility of addiction; choices of analgesic medications seemed irrational; and knowledge of the drugs was inadequate. Moreover, these nurses indicated that complete pain relief after surgery was not their major goal. In 2 sets of identical vignettes where the only difference was the sex of the patient, nurses selected less medication for pain for female patients ( P < 0.001 and P < 0.025 respectively). Factors that nurses consider in administering and choosing postoperative analgesia are described.