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 172,036 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Patient-controlled iv delivery of opioids for postoperative pain management is a popular alternative to the traditional im route of administration. However, occasional patients receiving opioids in this manner develop severe respiratory depression. The purpose of this paper is to determine the incidence of, and factors contributing to, the development of this complication. To do this, the Office of Medical Quality Improvement retrospectively searched for reports of respiratory depression in a database compiled from the charts of approximately 1600 patients who had received PCA at the University of Alberta Hospitals in 1992. Eight cases of serious respiratory depression were detected. Factors associated with the occurrence of respiratory depression included the concurrent use of a background infusion, advanced age, concomitant administration of sedative/hypnotic medications, and pre-existing sleep apnoea syndrome. No cases were attributed to operator error or equipment malfunction. In conclusion, the risk of respiratory depression with patient-controlled opioid administration is similar to that observed when opioids are delivered by the traditional im or spinal routes. The safe and effective use of patient-controlled analgesia depends upon knowledgeable medical and nursing staff, clearly defined nursing policy and procedures, and frequent patient follow-up.
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PMID:Respiratory depression associated with patient-controlled analgesia: a review of eight cases. 790 32

Despite intravenous patient-controlled analgesia's (IV-PCA) increasing popularity, the psychological and pharmacological factors upon which patient satisfaction with IV-PCA are based are unknown. Sixty-eight women scheduled for abdominal hysterectomy completed a series of questionnaires measuring emotional distress, locus of control, perceived support, and optimism before their surgery. Postoperative ratings of pain intensity, emotional distress, anticipated recovery time, nightmares, and satisfaction with IV-PCA were taken 1 and 3 days after surgery. A nurse observer rated perceived anxiety, estimated recovery, and satisfaction with IV-PCA. Cumulative and hourly IV-PCA use and dose/demand ratio were obtained. Degree of dissatisfaction with IV-PCA was significantly correlated with pain intensity, nightmares, patient's perceptions of support, expectations of recovery, preoperative anxiety, and postoperative depression. Dose/demand ratio and hourly analgesic usage were significantly related to pre- and postoperative emotional distress factors. Perioperative management of anxiety, perceptions, and expectations may prove valuable in improving pain control and satisfaction with IV-PCA.
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PMID:Psychosocial and pharmacologic predictors of satisfaction with intravenous patient-controlled analgesia. 831 18

In a prospective, randomized, double-blinded study, 23 patients who had undergone Caesarean delivery under epidural anaesthesia were assessed to evaluate the effectiveness of patient-controlled epidural analgesia (PCEA) with fentanyl compared with a single dose of epidural morphine for postoperative analgesia. Group A (n = 11) received epidural fentanyl 100 micrograms intraoperatively then self-administered a maximum of two epidural fentanyl boluses 50 micrograms (10 micrograms.ml-1) with a lockout period of five minutes for a maximum of two doses per hour. Group B (n = 11) received a single bolus of epidural morphine 3 mg (0.5 mg.ml-1) intraoperatively and received the same instructions as Group A but had their PCA devices filled with 0.9% NaCl. Patients were assessed up to 24 hr for pain, satisfaction with pain relief, nausea and pruritus using visual analogue scales (VAS). The treatments for inadequate analgesia, nausea and pruritus as well as time to first independent ambulation were recorded. The ventilatory response to carbon dioxide challenge was measured at four and eight hours. Pain relief, satisfaction with pain relief, and the use of supplemental analgesics were similar in both groups. The mean 24 hr dose of epidural fentanyl used by group A patients was 680 micrograms. Pruritus was less common in Group A patients at the 8 and 24 hr observation periods (P < 0.0125). Both groups experienced the same degree of nausea and clinically unimportant respiratory depression. We conclude that PCEA with fentanyl provides analgesia equal to a single dose of epidural morphine and may be suitable for patients who have experienced considerable pruritus after epidural morphine administration.
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PMID:A comparative study of patient-controlled epidural fentanyl and single dose epidural morphine for post-caesarean analgesia. 851 20

The EEG alterations attributed to senescence are the complex result of functional as well as organic factors, such as normal physiological aging, pathological process which results in cognitive deterioration, and/or psychological phenomena including depression. The aim of this study is to clarify which factors influence which EEG features and to evaluate the relationship between the clinical and electrophysiological indices. For simplicity, this study focused on the major three factors that are important in dealing with senescence; 1) normal, physiological aging; 2) dementia; 3) depression. A total of 191 subjects participated in this study. The subject groups were classified into 9 groups based on their age and pathology. Two healthy elderly groups (N = 60; between the ages of 60 and 80 years; subclassified according to their social activity), a healthy young volunteers' group (N = 30; between the ages of 20 and 39), a healthy middle-aged volunteers' group (N = 30; between the ages of 40 and 59), four subject groups of dementia of Alzheimer's type [DAT] classified according to the severity of dementia (total number of subjects = 44), depressive elderly subjects (N = 12), and one group of subjects who are older than 80 years (N = 15). The depressive subjects were diagnosed as major depression with their main symptom being psychomotor retardation which resembles the clinical picture of early dementia. The EEGs change with age. This well-approved fact is also confirmed in this study based on ANOVA. Within the same age groups, there were little differences in EEGs regardless of the quality of their social activities. More slow activity, more 20-32Hz fast activity, and less 13.5-20.0Hz beta activity were seen in the socially-inactive group than in the socially-active group (multiple range test based on Tukey's method). The fact that no tendency of increases in slow and fast activities accompanied by a decrease of alpha activity were seen in the socially-active group suggest that having such tendency in their EEG features may be indicative of underlying pathological process that are qualitatively different from normal physiological aging. The moderate grade of those change may not yet cause clinical impairment noticeable as dementia, but appear as less social activity. The EEGs of depressed elderly differed from the socially-inactive elderly as well as the mild dementia particularly in beta frequency bands. There were no significant differences between the socially-inactive elderly and the mild dementia. The tendency of an increase of slow activity and a decrease of alpha activity was seen as the clinical severity of dementia increases. However, these changes reached at the statistically significant level only in the extremely demented subject group. To extract the feature indices of the EEGs, PCA was applied. Five principal components were descriptive of 88% of the data. The EEG features summarized by these components could differentiate the socially-active elderly and the socially-inactive elderly, and the depressed group was distinctively differed from other groups. Interestingly PCA showed the similarity between the socially-inactive elderly and the mild dementia, and the similarity between the middle-aged and the young volunteers. Except for the extreme dementia, subgroups of DAT patients according to the clinical severity did not show distinctive differences in EEG features. The correlation among the EEG derivations was investigated using cluster analysis. The result indicated that the interhemispheric electrophysiological correlation diminishes along with the advancement of the pathological process of the brain. This study indicated that the EEG indices derived from the multivariate analyses are more informative in regard to the relationship among EEG variables as well as these spatial relationship than evaluating the changes in each frequency band alone.
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PMID:[Analytic study on EEG features of aging with/without psychiatric disorders: focussing at the alterations in the EEGs of the healthy, depressive and demented elderlies]. 855 25

The use of patient-controlled analgesia with alfentanil (PCA-alfentanil) as a form of pain relief for dressing procedures in patients during the acute phase of their burn injuries was investigated. Five ASA 1 and 2 patients with 10-30 per cent total body surface area (TBSA) thermal burns, had PCA-alfentanil for their dressing procedures after standard fluid resuscitation. One patient who did not receive a loading dose and a background infusion of alfentanil had unsatisfactory pain relief. Four patients had good pain relief after a loading dose of IV alfentanil 1 mg followed by a continuous background infusion of 200-800 micrograms/h. Demand dose ranged from 200 to 400 micrograms and lockout time ranged from 1 to 3 min. The total dose of alfentanil delivered ranged from 0.8 to 4.48 mg and duration of the dressings ranged from 30 to 60 min. All patients were mildly sedated, calm, communicative and cooperative during dressing procedures. None of them experienced hypotension or respiratory depression. One patient experienced nausea but no vomiting, no other adverse effects of alfentanil were noted. From the pilot study, PCA-alfentanil may be an effective form of pain relief for dressing procedures in patients during their acute phase of burn injuries. The optimal PCA-alfentanil setting has yet to be determined.
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PMID:Use of patient-controlled analgesia with alfentanil for burns dressing procedures: a preliminary report of five patients. 872 67

1. Prevent predictable pain, such as occurs postoperatively. Anticipatory pain management is particularly important in the elderly, who frequently attempt to "tough it out" without much analgesia. 2. Assume the patient is in pain if the situation is potentially painful, even without verbal complaints. Confused elders may be unable or unwilling to verbalize pain. For example, a confused 90-year-old woman with an acute hip fracture should be treated for pain, even if she does not complain of it. Elders, especially if demented, may not have the usual external "pain behaviors." 3. Do not routinely use antiemetics, especially phenothiazines. The incidence of postoperative nausea and vomiting is probably less in the elderly, and antiemetics are strongly anticholinergic and poorly tolerated in the frail elderly. 5. Do not use IM narcotics at all, except as "rescue analgesia" or when acute pain has subsided. Their high peak, low trough profile leads to a respiratory depression, excess pain cycle which is poorly tolerated in the elderly IV, or even oral, morphine is better tolerated. 6. Use multiple modalities for analgesia; for example, intercostal nerve block and epidural opioids, or IV-PCA and IV NSAIDs. This will enhance analgesia and reduce narcotic toxicity. This is especially important in frail elders, who often tolerate systemic narcotics poorly. 7. Use site-specific analgesia. Certain operative sites, such as the upper extremity, are especially amenable to local nerve blocks. Others, such as thoracotomy, are especially painful and need potent analgesia. For upper-extremity surgery, consider interscalene nerve block and NSAIDs. For thoracotomy, use extrapleural, intercostal nerve block and epidural narcotics. Local bupivacaine and NSAIDs work well after inguinal herniorrhaphy. For knee surgery, consider intra-articular morphine and NSAIDs. 8. Whenever possible, add a scheduled parenteral, rectal, or oral NSAID, in order to spare narcotics, enhance analgesia, and decrease inflammatory mediators. Unless the patient has a contraindication or there is a strong concern about hemostasis or peptic ulceration, NSAIDs should generally be administered. The major concern in frail elders is acute renal failure; therefore, ensure good hydration and avoid use of NSAIDs if renal function is diminished. NSAIDs should be used on a scheduled (not prn) basis.
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PMID:Postoperative pain management in the frail elderly. 885 47

Evidence of pre-emptive analgetic effect of opioid would offer great potential benefit to patients with postoperative pain, a better pain relief with less opioid. The aim of this double blind randomised trial was to study the effect of intramuscular morphine premedication on postoperative pain. Forty-one patients undergoing total knee arthroplasty were randomly allocated to four groups. Two groups received epidural morphine, 4 mg immediately after operation and 3 mg ten hours later, and two groups the same volume of saline. All patients had access to intravenous PCA-fentanyl. One epidural morphine and one epidural saline group (PreEpiMo and PreMo, respectively) received morphine, 0.14 mg/kg i.m. as premedication. Pain was measured with a visual analogue scale (VAS). Respiration was monitored by means of pulseoximetry, arterial blood gas analysis and rate of breathing. Morphine premedication reduced postoperative pain in the immediate postoperative period in patients with epidural placebo (PreMo), but the effect was absent in patients with PreEpiMo. Epidural morphine (EpiMo) provided stable analgesia with reduced need of PCA-fentanyl. Two patients (10%) (one in EpiMo and one in PreEpiMo) developed respiratory depression requiring naloxone treatment. The dosage of epidural morphine used in this study was a likely explanation of this depression. Nausea, vomiting, itching and urinary retention were the most frequent side effects without significant differences between the groups. In conclusion, morphine premedication had a temporary rest effect on the postoperative pain. Epidural morphine provides a better analgesia than intravenous PCA-fentanyl.
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PMID:Does morphine premedication influence the pain and consumption of postoperative analgesics after total knee arthroplasty? 890 63

The results of this study show that postoperative patient-controlled pain therapy in children with piritramide is - in a similar way as with adults - a safe method involving a low incidence of side effects. A special pump parameter setting is required with larger bolus dose sizes and longer lockout intervals, not very different from the experience gained with adults, and which is based on other values than those recommended up to now with morphine for paediatric PCA. Side effects were rarely observed. The fear of respiratory depression constitutes no rational reason to deny the younger patients this form of analgesia provided that monitoring is guaranteed.
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PMID:On-demand analgesia with piritramide in children. A study on dosage specification and safety. 908 7

One hundred and twenty women undergoing gynaecological abdominal operations were randomized to receive either epidural bupivacaine 0.0625% + fentanyl 3.3 micrograms/ml infusion (Group EPI, n = 57), or patient-controlled intravenous morphine analgesia (Group PCA, n = 54) for postoperative pain relief. The groups were comparable in demographic data, types and duration of operation. Group EPI achieved significantly lower verbal rating scale of pain (VRS) at rest at 0, 4, 12, 16, 20, 28 and 40th postoperative hours. The VRS during cough were also significantly lower in Group EPI at 0, 4, 8, 12, 28 and 36th postoperative hours. None of the patients had respiratory depression or hypotension. Nausea/vomiting occurred in 52.6%/33.3% of patients in Group EPI and 52.7%/37.0% in Group PCA. Most patients (84.2% in Group EPI and 72.2% in Group PCA) rated their pain management as "good". We conclude that epidural infusion of bupivacaine 0.0625% and fentanyl 3.3 micrograms/ml provide better analgesia than patient-controlled intravenous morphine after gynaecological laparotomy.
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PMID:Epidural infusion of bupivacaine 0.0625% plus fentanyl 3.3 micrograms/ml provides better postoperative analgesia than patient-controlled analgesia with intravenous morphine after gynaecological laparotomy. 935 58

Patient-controlled analgesia has been proven to be an effective technique in postoperative pain management. The aim of our study was to evaluate PCA on general surgery wards. 311 patients and their nurses were questioned about their experiences in using PCA for postoperative pain management. Satisfaction with pain relief judged by both patients and nursing staff, incidence of negative side effects and technical problems were studied. The great majority of patients and nursing staff rated the quality of pain relief as being satisfactory. Incidence of negative side effects was extraordinarily low. There was no respiratory depression observed, technical problems hardly arose. Most of the patients coped very well with operating their PCA-pumps. We conclude that PCA is a safe and effective method in postoperative pain management on surgical wards. Under the condition of regular monitoring of pain intensity, of analgesic consumption, level of sedation and of side effects by trained medical and nursing staff, monitoring of respiration and vigilance is not necessary for the PCA regimen we used.
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PMID:[Evaluation of postoperative pain therapy with patient-controlled analgesia from the viewpoint of the patient and nursing staff]. 1009


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