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The first anaesthesia-based acute pain service in Singapore is described. The benefits, risks and resource implications of such a service during its first two years are reviewed. One thousand two hundred and sixty-eight (1,268) post-operative patients were treated with either patient-controlled analgesia (310 patients) or epidural opioid analgesia (958 patients). Retrospective analysis of the data revealed good patient satisfaction with a low incidence of potentially life threatening side-effects: more than 79% of patients reported satisfaction with pain control while only 0.2% of patients receiving epidural opioid analgesia experienced clinically significant respiratory depression. There were no reports of respiratory depression in the patient-controlled analgesia group. The authors conclude that the provision of an acute pain service in the local context was safe and resulted in excellent post-operative patient satisfaction.
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PMID:A two-year experience of an acute pain service in Singapore. 925 1

A prospective survey of one thousand and sixty-two patients receiving epidural analgesia in surgical wards was undertaken over a two-year period. The duration of infusion ranged from one to fourteen days, with a mode of three days. There were 1131 episodes where a local anaesthetic and opioid mixture was used and 160 where opioids were used alone. Local anaesthetic was not used without opioids. 23% of catheters were removed prematurely because of catheter related problems including accidental dislodgement (13%) and skin site inflammation (5.3%). No epidural abscess or haematoma was identified. In 14% of the total number of episodes there was either no demonstrable block or complications occurred requiring a change of solution: 30% of this group were salvaged following intervention by the Acute Pain Service (APS). The incidence of respiratory depression was 0.24%. There was no case of delayed respiratory depression. Epidural analgesia can be used safely in surgical wards provided that regular review of the patients is undertaken. It must be anticipated however, that up to 20% of patients will not receive adequate analgesia for the first 48 hours postoperatively. The failure rate could be halved if accidental dislodgement of epidural catheters could be eliminated.
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PMID:Epidural analgesia: prospective audit of 1062 patients. 980 29

Inadequate training of physicians contributes to the undertreatment of cancer pain. To address these concerns, the University of Kentucky has introduced a 4-week course for final-year medical students that teaches the principles of clinical pharmacology and pain management. The purposes of this study are to assess the knowledge deficits of final-year medical students about the use of morphine for cancer pain and to assess the efficacy of a short course on cancer pain management. Eighty-six final-year medical students completed a 22-item questionnaire assessing their knowledge and attitudes toward the use of morphine for cancer pain. Students indicated their agreement with each statement on a four-point scale (one, strongly disagree; four, strongly agree). All students then completed a compulsory short course on pain management. The course content included a 1-hr lecture on chronic nonmalignant pain, a 1-hr lecture on acute pain management, and a 1-hr lecture on cancer pain management. In addition, students completed small-group, problem-based learning modules on several aspects of pain management. After the course, all students completed the same 22-item survey. The alpha reliability score of the pretest instrument was 0.55, and the posttest reliability was 0.86. Upon course completion, students agreed most strongly (mean +/- SEM) that morphine should be given on a regular schedule for cancer pain (3.41 +/- 0.08), that cancer pain management frequently requires co-analgesics (3.36 +/- 0.06), and that patients with good pain relief function better than those with continuing pain (3.39 +/- 0.08). A comparison of pretest and posttest means on specific items suggested that the greatest amount of learning took place in the following content areas: morphine is a good oral analgesic; increases in cancer pain should be treated by increasing the morphine dose; respiratory depression is not a concern for cancer pain patients; and morphine can be used over a wide range of doses. The regular use of morphine was recognized as the treatment drug of choice for cancer pain. The students showed improved knowledge scores on ten of the 22 items on the posttest survey. A significant increase in learning occurred on six knowledge and attitude items. On only one item (nausea as a side effect of morphine) did the knowledge scores decrease on the posttest. A significant minority (40%) of senior medical students had deficits in knowledge about the use of morphine for cancer pain. The risk of addiction, respiratory depression, and tolerance were misunderstood by a significant minority (25%) of students.
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PMID:Medical student knowledge of morphine for the management of cancer pain. 967 Jun 36

Postoperative pain therapy in modern clinical practice still has significant deficits. Establishing acute pain services is reported to be a method of improving pain therapy. In this prospective study, 104 orthopaedic patients were treated with a postoperative epidural infusion of a combination of bupivacaine and sufentanil. Pain intensity and side effects were recorded daily by pain management personnel, and the pain therapy was adjusted according to the patients' need. The results showed that pain control was insufficient in 29 patients, and that side effects developed in 45 patients, included one patient with late respiratory depression. We conclude that acute pain service is essential in order to improve postoperative analgesia.
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PMID:[Acute pain service. Organization and results]. 980 May 10

We report organisation principles and three year experience of Acute Pain Service in general surgery clinic. 481 patients were treated after abdominal and vascular interventions, hemorrhoidal varices and mammectomies. Continuous epidural, combined spinal-epidural, intrapleural anaesthesia and continuous brachial plexus block were used for pain control. Time of analgesia varied from 1 to 4 days. The level of analgesia was assessed as good (VAS 3) in 94.8% of cases. Complications were mainly technical due to catheter or antibacterial filter failure. In 2% of cases cardiovascular complications were observed. Respiratory depression occurred in 1 patient. The work of APS team was assessed as very good by both surgeons and patients.
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PMID:[Organization of services for treatment of postoperative pain--3-year experience]. 985 8

A 3-year study investigated the experience and management of postoperative pain following elective surgery in an adolescent sample, using a variety of valid, reliable instruments and semi-structured interviews. In addition to the adolescent subjects, the views of one parent of each adolescent were sought and a sample of health professionals comprising surgeons, anaesthetists and nurses were interviewed about acute pain in adolescent patients. This paper presents some of the main findings pertaining to pain assessment and management. Pain, experienced by most adolescents on the 1st and 3rd postoperative days, was influenced by the presence of anxiety and depression, in addition to the maturational stage; differences between in-patients and day cases are highlighted. Recommendations for practice include the need for more effective pain management and raising awareness of the importance of both psychological state and adjustment to adolescence in this age-group.
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PMID:Postoperative pain assessment and management in adolescents. 1006 66

Nonsteroidal anti-inflammatory drugs are often used in the management of those with acute pain secondary to sickle cell disease due to potent analgesic effects along with a lack of addictive potential, respiratory depression, and central nervous system effects, as may occur with narcotics. Caution should be observed in the use of nonsteroidal anti-inflammatory drugs in patients with compromised renal function. We present a case of a 17-year-old sickle cell disease patient with an acute painful episode and normal renal function indices who subsequently developed irreversible renal failure and a perirenal hematoma following the administration of ketorolac, despite adequate hydration. Due to its inhibitory effect on prostaglandin-mediated vasodilation, we advise caution in the use of ketorolac for the pain management of sickle cell painful episodes. We recommend following the administration guidelines for ketorolac for renal-compromised patients in those with painful episodes of sickle cell disease, and if used in this patient population, renal function must be very closely monitored.
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PMID:Ketorolac-induced irreversible renal failure in sickle cell disease: a case report. 1010 Feb 93

The discovery of opioid receptors and the subsequent development of the technique of epidural and intrathecal opioid administration are undoubtedly two of the most significant advances in pain management in recent decades. The use of spinal opioids is widespread and increasing. The technique is used widely to treat intraoperative, postoperative, traumatic, obstetric, chronic, and cancer pain. Newer developments include the increasing use of combined local anesthetics and opioids or nonopioids and also PCEA, particularly in the obstetric population. Meta-analysis of controlled trials has demonstrated improved pulmonary outcome in patients receiving epidural postoperative analgesia. Although rare, respiratory depression continues to be a major problem of the technique. None of the currently available opioids is completely safe; however, extensive international experience has shown that patients receiving spinal opioids for postoperative analgesia can be safely nursed on regular wards, provided that trained personnel and appropriate guidelines are available. The importance of a good acute pain service to provide the safe and effective use of spinal opioids cannot be overemphasized.
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PMID:Epidural and spinal agents for postoperative analgesia. 1035 57

We examined the antinociceptive effect of intrathecally administered magnesium sulphate (MgSO4) in rats, using acute pain models including mechanical pressure, heat and subcutaneous formalin injection. According to the locomotion test 10 microliters of 6.2% MgSO4 did not produce motor paralysis. At the same dose, responses to pressure and heat were intact, compared with controls given saline. MgSO4 produced depression of pain responses only after the first 10 min in the formalin test. Our studies indicated that MgSO4 did not show remarkable antinociceptive effects in acute pain models.
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PMID:The effect of intrathecal magnesium sulphate on nociception in rat acute pain models. 1036 59

Tension-type headaches, the most prevalent form of headache, are differentiated as being either episodic or chronic. The episodic form is a physiologic response to stress, anxiety, depression, emotional conflicts, fatigue, or repressed hostility. Treatment focuses on the use of over-the-counter or prescribed simple analgesics for pain relief. Successful treatment of the chronic form depends on recognition of depression or persistent anxiety states. Primary care physicians can effectively manage most of these patients with nonhabituating anxiolytic or antidepressant medications; however, referrals for psychotherapy may be required in some cases. When tension-type headaches occur in children and adolescents, the physician must explore the patient's family and social relationships as well as school performance. In addition to nonhabituating drug therapies, family counseling and biofeedback may be helpful. In coexisting migraine and tension-type headaches, nonhabituating analgesics may be used for the relief of acute pain; the use of ergotamine and triptans should be restricted to relief of the hard or sick headache. Tricyclic antidepressants or monoamine oxidase inhibitors are the gold standards for prophylaxis, although the selective serotonin reuptake inhibitors may be indicated in less severe cases. Several forms of biofeedback have also proved effective. Nonetheless, some patients with this form of headache may require psychiatric treatment for severe depression.
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PMID:Tension-type headache. 1068 86


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