Routine Analgesia Research Articles

Background Infusion during Intravenous Patient-Controlled Analgesia: The New Routine Analgesia?

To the Editor:—Congratulations to the authors for this excellent study. Some comments: The equal analgesic effectiveness in both epidural analgesia (EDA) and intravenous patient-controlled analgesia (PCA) in this study 1is surprising. Our own and others experiences have demonstrated superior dynamic pain relief during EDA versus intravenous PCA, 2,3also after abdominal aortic surgery. 4The authors have improved analgesic effectiveness of intravenous PCA by a background infusion, with an initial dosage of 80 μg/h fentanyl plus 40 μg on demand. Calculations result in a possible cumulative fentanyl consumption of approximately 2 mg/24 h. The intravenous infusion of fentanyl (75 μ g/h) induces ventilatory disturbances, and in some patients severe respiratory insufficiency or apnea. 5The additional use of a background infusion during intravenous PCA increases the risk of respiratory depression about five-fold. 3Therefore background infusion during intravenous PCA is not recommended for routine postoperative analgesia on the ward, especially in patients with higher risk. 6Increased dosages of opioids may induce sleep disturbances, fatigue, and disability 7, which all are undesired side effects after high-risk surgery. These doubts do not refer to special study conditions, but to routine analgesia on the ward.Two questions: how high was the fentanyl consumption during intravenous PCA and EDA at days 1, 2, and 3? Did side effects from fentanyl occur?

A Pain Monitoring Program for nurses: effect on the administration of analgesics

Both physicians and nurses are responsible for adequate pain management. The aim of this study was to assess pain management behavior of physicians and nurses, and to evaluate the effects of a Pain Monitoring Program for nurses on the extent to which nurses administer analgesics. The Pain Monitoring Program consisted of two components: educating nurses about pain, pain assessment and pain management; and implementing daily pain assessment by means of a numeric rating scale. Several outcomes were distinguished to evaluate the administration of analgesics by nurses: the prescribed analgesics by physicians, the administered analgesics by nurses, and the discrepancy between the ordered and the administered analgesics. The effects of the Pain Monitoring Program on these outcomes were measured in a quasi-experimental design with a non-equivalent control group. In total, 703 patients participated: 358 patients in the control group and 345 in the intervention group. Patients were interviewed twice, i.e. at the beginning and at the end of hospitalization. Results of the control group showed that at the first interview 70% of the patients were prescribed analgesics by physicians and only 74% of those patients were actually administered analgesics by nurses. Consequently, 50% of the patients in pain received analgesics. The administered analgesics was in absolute agreement with the prescribed analgesics in 60% of the patients with routine analgesics and in 85% of the patients with PRN analgesics. The relative difference between ordered and administered routine analgesics was small, namely 15% for opioids and 20% for non-opioids. Similar results of the control group were found for the second interview. In addition, the results showed that the Pain Monitoring Program was effective in improving nurses' administration of analgesics. At the first interview more patients received analgesics that were prescribed on a PRN basis and the doses of administered routine non-opioids including PRN increased. At the time of the second interview, more patients received weak opioids. The Pain Monitoring Program was especially effective in patients with moderate to severe pain. However, the discrepancy between the analgesics ordered by physicians and actually administered by nurses did not change as a result of the Pain Monitoring Program. Based on this study it can be concluded that the use of a simple method such as a numeric rating scale together with pain education for nurses is effective in improving the administration of analgesics by nurses. These are important results because nurses play an essential role in helping patients to cope with their pain. Because the Pain Monitoring Program (PMP) was effective in a heterogeneous population in multiple care settings, the possibility of implementing the PMP in routine nursing practice should be considered.

Routine analgesia use forneonates in intensive care

Routine analgesia use forneonates in intensive care

New amide local anesthetics for obstetric use

Summary The introduction of stereo-specific levorotary isomers of amide local anesthetics, ropivacaine and levobupivacaine, for clinical use is important. This is because these drugs have a wider margin of safety, but similar blocking properties to the currently available formulation of racemic bupivacaine, although at a higher cost. However, it is noteworthy that modifications in clinical practice, such as the use of appropriate test doses and fractionation of the induction dose, have made epidural use in obstetrics a very safe procedure even before the introduction of these new drugs 50 Thus, because of their greater cost, it is difficult to predict what role, if any, these amides will assume in obstetric practice without a cost-benefit analysis. From the standpoint of systemic toxicity, the anticipated benefit of these drugs during routine epidural analgesia for labor is questionable because of the widespread use of very dilute concentrations of local anesthetic by continuous infusion. Their use, in theory, may be more beneficial to women having a cesarean section where relatively higher volumes and concentrations of local anesthetics are required for satisfactory sensory and motor block. Nonetheless, in no circumstance should a greater margin of safety be relied on a substitute for proper technique.

Guías de práctica clínica de la Sociedad Española de Cardiología en la angina inestable/infarto sin elevación ST

This paper up-dates the Clinical Guidelines for Unstable Angina/Non Q wave Myocardial Infarction of the Spanish Society of Cardiology. Due to the increased efficacy of adequate management in the early phases, it has been considered necessary to include recommendations for the pre Hospital and Emergency department phase. Prehospital management. Patients with thoracic pain compatible with myocardial ischemia should be transferred to Hospital as quickly as possible and an ECG tracing performed. Initial management includes rest, sublingual nitroglycerin and aspirin. In the Emergency department. Immediate clinical attention and accessibility to a defibrillator should be available. If ECG tracing discloses ST elevation reperfusion strategy is to be implemented immediately. If no ST elevation is present, the probability of myocardial ischemia and risk factor evaluation is essential for adequate management. A simplified risk stratification classification is presented, that also determines the most adequate site for admission: Coronary Care Unit if high risk factors are present, Cardiology ward for the intermediate risk patient and ambulatory treatment if low risk. Management in Coronary Care Unit. Includes routine ECG monitoring and analgesia. Antithrombotic and anti ischemic treatment include new indication for GP IIb-IIIa and Low molecular weight heparins. Coronary arteriography and revascularisation are recommended, if refractory or recurrent angina, left ventricles dysfunction or other complications are present. Management in the ward is based on adequate chronic medical treatment, risk stratification, and secondary prevention strategy. Coronary arteriography before discharge must be considered in the light of the result of non-invasive tests.

Infectious complications of epidural anaesthesia and analgesia

Clinically overt infections of the epidural catheter skin entry site occur in approximately 5% of patients after a few days; deep catheter tract infections occur in approximately 5% of patients after more prolonged epidural analgesia. This indicates that potentially serious epidural infectious complications are ever-present risks of epidural anaesthesia and analgesia. This review focuses on risk factors and guidelines for routine epidural analgesia that may minimize the risks of serious infectious complications.

Intrathecal Morphine

A prospective, randomized, double-blind study. To evaluate the efficacy and safety of three different dosages of intrathecal morphine sulfate for postoperative analgesia after lumbar spinal fusion. Analgesia and respiratory depression after intrathecal morphine sulfate injection are dose related. The optimal dose to use for major spinal surgery is not known. Sixty patients undergoing posterolateral lumbar fusion with or without decompression were divided randomly into 3 groups of 20 patients each. Anesthesia, monitoring, and surgery were similar for all patients. Just before closing of the wound, morphine sulfate was injected into the dural sack under direct visualization. Patients in groups 1-3 received 0.2 mg, 0.3 mg, and 0.4 mg morphine, respectively. Routine analgesia, consisting of diclofenac, was prescribed to use if necessary. Measurements were made and compared between the groups at zero hours (on admission to the Intensive Care Unit), 6 hours, 12 hours, 18 hours, and 24 hours after surgery. At zero hours and at 12 hours after surgery, pain levels were similar in groups 2 and 3, but were significantly higher in group 1 (P < 0.05). The respiratory rate was significantly lower in group 3 than in the other two groups (P < 0.05), and the arterial CO2 tension (PaCO2) was consistently higher in group 3. PaCO2 decreased in all three groups over the first 24 hours. Pruritus and nausea did not differ among the three groups. For adult patients undergoing posterolateral lumbar fusion, 0.3 mg (0.004 mg/kg) is probably the optimal dose of intrathecal morphine to manage pain.

Evaluation of Simethicone for the Treatment of Postoperative Abdominal Discomfort in Infants

Study Objective: To determine whether abdominal discomfort is a cause for distress symptoms in infants following administration of inhalational anesthesia, and to evaluate the effectiveness of simethicone in treating this discomfort. Design: Randomized, double-blinded study. Setting: Large tertiary care, university-based medical center. Patients: 175 ASA physical status I and II infants under 28 months of age who underwent an inhalational anesthetic for a variety of procedures that were expected to cause relatively little pain. Interventions: Children were assessed for the presence of postoperative abdominal discomfort, and, if evident, were randomly given either simethicone or placebo in a double-blinded fashion. Measurements and main results: Abdominal discomfort was measured using the Faces Legs Activity Cry and Consolability (FLACC) Behavioral Pain Scale. Scores were recorded pre-drug; at 10, 20, and 30 minutes following drug administration; and at discharge. If discomfort had not resolved within 15 minutes after the drug was given, routine analgesics or other medications were administered. Abdominal girth was measured preoperatively, on admission into the postanesthesia care unit (PACU), and at discharge. 21% of infants exhibited symptoms of abdominal discomfort postoperatively. Younger infants were at greater risk for this condition. 36 infants were given either placebo or simethicone, and of these, infants who received simethicone were comfortable earlier and required fewer rescue medications compared with placebo. There were no differences in ability to tolerate oral fluids prior to discharge or in the length of stay in the PACU. Conclusions: Simethicone is a safe and inexpensive medication that may provide anesthesiologists with an effective treatment choice for suspected postoperative abdominal discomfort in infants.

The prophylactic use of diclofenac (Voltarol) suppositories in perineal pain after episiotomy. A random allocation double-blind study

One hundred and ten patients who had episiotomies to aid normal vaginal delivery without epidural analgesia were = allocated at random to receive either diclofenac (n 56) or = placebo (n 54) suppositories. Pain after episiotomy was assessed at 24 and 48 hours using a combination of a visual analogue scale, a modified pain score and a review of additional analgesia required. All patients in both groups were allowed routine hospital analgesia on request. Our data suggests that very few patients suffered severe pain, even in the placebo group. However, the prophylactic use of diclofenac suppositories significantly reduced perineal pain in the first 24 hours, although the difference was less marked by 48 hours. Overall additional analgesia requirement was correspondingly less in the diclofenac group.

A Method for Reconstruction of Large Full-Thickness Defects of the Bony Thorax

Wide resection in 12 cases of malignant or potentially malignant lesions of the chest wall resulted in full-thickness loss of skeleton and frequently of overlying soft tissues (defect greater than or equal to 15 cm in its smallest diameter or at least 90% of the sternum resected). In reconstruction of the defect, steel bars were used to replace lost ribs and a double layer of Marlex mesh for intercostal spaces. Soft-tissue coverage and primary closure were accomplished with current plastic surgical procedures and good stability of the chest wall was achieved. Protracted respiratory support was required in only one case. Postoperative pain was managed with epidural anesthesia and routine analgesics. Functionally and cosmetically satisfactory long-term results were obtained, with no infection and no need for removal of prosthetic material. The overall 5-year and 10-year actuarial survival rates were 60% and 37.5%. If lesions are radically resectable, the extent of thoracic wall resection need not be restricted because of inability to close the defects.

Epidural fentanyl and perineal pain in labour.

Perineal pain during the course of routine epidural analgesia with bupivacaine was treated with a 10-ml top-up of either bupivacaine 25 mg, fentanyl 100 micrograms or fentanyl 100 micrograms plus bupivacaine 10 mg, in 46 women in the first stage of labour. Only fentanyl plus bupivacaine produced consistently reliable analgesia which was quicker in onset and longer in duration (140, SD 26 minutes) than either fentanyl (114, SD 26 minutes) or bupivacaine (99, SD 44 minutes) alone. Side effects, itching and drowsiness, which were not troublesome, were more frequent in the groups given fentanyl.

Epidural Morphine Treatment of Pain in Guillain-Barre Syndrome

The discovery of specific opiate receptors in the spinal cord and brain formed the anatomic rationale for the subsequent use of both epidural and intrathecal narcotics to control pain.¹The efficacy of spinally administered narcotics in treating postoperative and chronic pain conditions is widely accepted.²The pain in these chronic disorders is usually caused by tissue compression, or neural invasion from either primary or metastatic neoplasms. There are no reports in the literature about the efficacy of spinally administered narcotics in the treatment of the pain associated with inflammatory peripheral neuropathies. We describe a patient with Guillain-Barré syndrome who had severe dysesthetic pain unresponsive to routine analgesics and other therapeutic maneuvers, who was successfully managed with epidural morphine sulfate. <h3>REPORT OF A CASE</h3> A 20-year-old man with no known previous medical problems, presented with three days of increasing weakness of his extremities associated with paresthesias. He was

Naloxone Reversal of Mild Neurobehavioral Depression in Normal Newborn Infants after Routine Obstetric Analgesia

To investigate the presence of subtle narcotic depression following maternal narcotic analgesia, we have evaluated the effects of naloxone versus placebo in a double-blind parallel group study in 43 normal term newborn infants whose mothers had received routine narcotic analgesia within six hours prior to delivery. Infants were given either an intramuscular injection of 20 μg/kg naloxone or 0.20 ml/kg placebo after determination of the one-minute Apgar score, and the following measurements were compared: Apgar scores at one and five minutes, capillary blood gas values at one, 60, 120, and 240 minutes, and neurobehavioral assessments at one, 4, and 24 hours. No adverse effects from naloxone were observed. Neither Apgar scores nor capillary blood gas determinations differed significantly between the two groups. Response to sound was significantly higher in the naloxone group at 24 hours. The alertness score was significantly higher for the naloxone group at one and four hours; the general assessment score for the naloxone group was significantly higher at four and 24 hours. Average scores of naloxone and placebo groups were also different at four and 24 hours of age. These data demonstrate that maternal narcotic analgesia may produce subtle changes in alertness and general behavior not reflected by Apgar scores or respiratory status, potentially reversible by administration of naloxone shortly following delivery.

Sleep-Related Periodic Headache and Imipramine

Six adult patients, 4 women and 2 men, afflicted with chronic, severe, periodic, sleep-related headaches experienced a sustained, significant reduction in the frequency and severity of attacks. These patients had been relatively refractory to routine analgesics and ergot derivative therapy.

FIBROCHONDROMA IN AN INFANT FOUR WEEKS OLD

The early age of the patient—4 weeks at the time the tumor was surgically removed—makes this case of unusual interest. The tumor made its appearance at about the age of 3 weeks and had such a rapid growth that, although the diagnosis was suspected, we were inclined to delay surgical intervention because of the age. <h3>REPORT OF A CASE</h3> The infant was born Oct. 12, 1941, of a white primipara aged 20. Delivery was normal and spontaneous with the occiput in the right anterior position, the duration of labor being about twelve hours. Routine analgesia induced with a barbiturate and a small amount of ether were employed during the second stage. There was no evidence of birth trauma to the child or the mother; force had not been used, and there was no laceration of the perineum, the vaginal mucosa or the cervix. No episiotomy had been done, and no