Clinical analgesic equivalence for morphine and hydromorphone with prolonged PCA.

A morphine to hydromorphone equivalence ratio of 7:1 has become the accepted standard, but evidence supporting it comes from single dose studies performed before the advent of patient controlled analgesia (PCA). We compared morphine and hydromorphone use with PCA in bone marrow transplantation patients who required opioids for the control of severe oral mucositis over several days or weeks. An exploratory analysis of clinical records from 102 patients (981 patient days) who used PCA opioids for varying periods of up to 50 days suggested a morphine to hydromorphone use ratio of 3:1. To clarify this observation, we studied a subset of patients under matched conditions. During a 7 day window in which mean oral mucositis severity did not vary across drug use groups and pain scores did not vary over time, patients in both groups gave equal pain relief satisfaction scores. Thirty-six patients who used morphine and 21 who used hydromorphone contributed data on pain, satisfaction with pain control, and drug consumption. We observed an average morphine/hydromorphone ratio of 3:1. This differs markedly from historical single dose studies used in published dose equivalency recommendations implying that other equivalency ratios in clinical use may be inappropriate.

Review of computer-generated outpatient health behavior interventions: clinical encounters "in absentia".

OBJECTIVE: To evaluate evidence of the effectiveness of computer-generated health behavior interventions-clinical encounters "in absentia"-as extensions of face-to-face patient care in an ambulatory setting. DATA SOURCES: Systematic electronic database and manual searches of multiple sources (1996-1999) plus search for gray literature were conducted to identify clinical trials using computer-generated health behavior interventions to motivate individuals to adopt treatment regimens, focusing on patient-interactive interventions and use of health behavior models. STUDY SELECTION: Eligibility criteria included randomized controlled studies with some evidence of instrument reliability and validity; use of at least one patient-interactive targeted or tailored feedback, reminder, or educational intervention intended to influence or improve a stated health behavior; and an association between one intervention variable and a health behavior. DATA EXTRACTION: Studies were described by delivery device (print, automated telephone, computer, and mobile communication) and intervention type (personalized, targeted, and tailored). We employed qualitative methods to analyze the retrieval set and explore the issue of patient interactive computer-generated behavioral intervention systems. DATA SYNTHESIS: Studies varied widely in methodology, quality, subject number, and characteristics, measurement of effects and health behavior focus. Of 37 eligible trials, 34 (91.9 percent) reported either statistically significant or improved outcomes. Fourteen studies used targeted interventions; 23 used tailored. Of the 14 targeted intervention studies, 13 (92.9 percent) reported improved outcomes. Of the 23 tailored intervention studies, 21 (91.3 percent) reported improved outcomes. CONCLUSIONS: The literature indicates that computer-generated health behavior interventions are effective. While there is evidence that tailored interventions can more positively affect health behavior change than can targeted, personalized or generic interventions, there is little research comparing different tailoring protocols with one another. Only those studies using print and telephone devices reported a theoretic basis for their methodology. Future studies need to identify which models are best suited to which health behavior, whether certain delivery devices are more appropriate for different health behaviors, and how ambulatory care can benefit from patients' use of portable devices.

Use of patient-controlled analgesia for pain control for children receiving bone marrow transplant.

We report 2 years' experience managing 39 preteen (ages 4-12 years) children with patient-controlled analgesia (PCA) for pain associated with bone marrow transplantation (BMT). We prescribed morphine or hydromorphone PCA (starting bolus 20 micrograms/kg morphine or 2 micrograms/kg hydromorphone) with or without continuous infusion (CI), for a period of 6-74 days. The duration of PCA use (median 19 days) depended upon severity of mucositis or other painful conditions. The peak morphine use was on the 11th day after BMT. We prescribed CI opioids in addition to PCA, either at night or around the clock, in 52% of patients. Ninety-five percent of children successfully mastered PCA to control pain associated with BMT. We observed no instances of drug misuse, parental tampering, accidental overdose, or difficulty weaning from opioids. We conclude that opioid PCA, with or without CI, over several days or weeks is safe and effective for preteen children suffering BMT-related pain.

Coagulopathy predicts poor outcome following head injury in children less than 16 years of age.

The authors examined the relationship between fibrin degradation products (FDP) and outcome in children with isolated head injury by reviewing the records of 69 children who met the following criteria: (1) less than 16 years of age; (2) diagnosis of isolated head injury and (3) FDP levels. Outcome was evaluated using the following Glasgow Outcome Scale (GOS): 1 = death; 2 = vegetative state; 3 = functionally impaired; 4 = minimal dysfunction; 5 = premorbid level of functioning. Poor outcome was defined as GOS 1-3. Twenty-nine of 33 patients with FDP > 1000 (g/mL had GOS scores < 4 compared to 4/36 patients (11%) with FDP < 1000 microg/mL (Fisher's Exact Probability Test P < .0001). When stratified by GCS, no other prognosticator of outcome was needed when GCS was < 7 and > 12. In patients with GCS 7-12, however, 4/6 with FDP >1000 microg/mL had a poor outcome and all 12 patients with FDP < 1000 microg/mL had a good outcome (P = .004). The authors conclude that FDP > 1000 microg/mL predicts poor outcome in children with isolated head injury. Fibrin degradation products are a strong independent prognosticator of outcome in children when GCS is between 7 and 12.

Exercise induced chronic compartment syndrome of the first dorsal interosseous compartment of the hand: a case report.

Exercise-induced chronic compartment syndrome in the first dorsal compartment is an uncommon entity and relatively rare condition which is not very well understood. It is a usually activity-related condition and is associated with decreased function of muscle with intracompartmental swelling. We present a case with proven exercise-induced raised compartment pressure that responded well to surgical fasciotomy.

Measurement in pain therapy: is pain relief really the endpoint?

Pain is not an isolated symptom. Severe pain creates fatigue, impairs concentration, compromises mood, degrades sleep and diminishes overall activity level. The goal of intervention for chronic pain must include alleviating the functional impairment that pain produces as well as its discomfort. Evaluating treatment outcome requires: (1) quantification of both pain intensity and pain-related impairment; and (2) review of how the relationship between these variables changes as a function of treatment. Simply tracking pain intensity level as an indicator of pain relief is insufficient and can lead to misinterpretation of the effects of an intervention.

Craniotomy procedures are associated with less analgesic requirements than other surgical procedures.

UNLABELLED: The conventional wisdom that neurosurgical patients experience minimal postoperative pain and require little analgesia has been challenged. To address this, we reviewed our anesthesia and postanesthesia care unit (PACU) records for 1995 and compared pain management in patients undergoing major intracranial and selected extracranial procedures. We recorded patient weight, operative time, time in the PACU, intraoperative and postoperative opioid use, PACU pain scores, and level of consciousness in patients who had undergone open fixation of mandible or maxilla (Group E), clipping of aneurysms or excision of tumors (Group I), or lumbar laminectomy (Group L). Group I (n = 78) patients received less fentanyl in the operating room (0.016 microg x kg(-1) x min(-1) versus 0.023 microg x kg(-1) x min(-1) for Group E [n = 134] and 0.023 microg x kg(-1) x min(-1) for Group L [n = 21]; P < 0.05), received less morphine in the PACU (0.0004 vs 0.0013 vs 0.0015 mg kg(-1) x min(-1); P < 0.005), reported lower pain scores (0.76 vs 2.5 vs 2.4; P < 0.05), and spent less time in the PACU (89.5 vs 109 vs 105 min; P < 0.05) than Group E or L patients. Our results were similar when only patients with Glasgow Coma Scale scores > or = 14 were used in a subset analysis. We conclude that patients suffer less pain and use fewer opioids in the PACU after intracranial surgery than after facial reconstruction or lumbar laminectomy. Our results confirm that the average craniotomy patient has less postoperative pain than patients who undergo other surgical procedures, although patients who undergo frontal craniotomy may require more aggressive pain management. IMPLICATIONS: This study compares the pain report and analgesic use in patients after intracranial versus extracranial surgery. The results confirm the commonly held but recently challenged belief that neurosurgery patients suffer less pain postoperatively than other patients. In this study, we found that most patients report minimal pain after intracranial surgery but that a small subset of patients, many of whom have undergone frontal craniotomies, require aggressive treatment of postoperative pain.