Patient-controlled analgesia and oral mucositis pain in hematological malignancies.

Oral mucositis (OM) pain is an anticipated complication of immunosuppressive therapies for hematological malignancies. Opioids are effective for OM-associated pain and dysfunction that is refractory to simple measures. At the study institution, parenteral opioids are preferentially prescribed for the treatment of complicated OM. This audit explores the efficacy of opioids for the management of OM pain using morphine, oxycodone, and fentanyl patient-controlled analgesia (PCA). Pain scores, opioid consumption, resumption of oral intake, and the duration of admission were retrospectively analyzed from patient records over an 18-month period. Two-thirds of included patients had ceased PCA therapy by day 6, by which time there was a meaningful 35.4 percent reduction in pain scores, with very few side effects reported. Interagent comparison demonstrated no significant differences in mean daily pain scores; however, a larger sample size would facilitate an investigation of clinically significant nuances in treatment differences, if they exist.

Management of postsurgical pain in the community.

Following surgery there is often a need for ongoing pain management after the patient is discharged from hospital. This can be made easier if the patient has an appropriate discussion before leaving hospital about what pain they can expect, and they are given a management plan Paracetamol and non-steroidal anti-inflammatory drugs are suitable for most patients. Drugs with a short half-life, such as ibuprofen, may need to be taken regularly Short-acting opioids can have a short-term role, providing guidelines are followed. There is a predictable period of time after surgery when the benefit of an opioid is expected to be maximised before harmful adverse effects will dominate Gabapentinoids are useful for neuropathic pain, but have a limited role in nociceptive pain. Like opioids, they have a risk of misuse The surgeon should be consulted if the patient develops new pain or the postoperative pain becomes more severe Most postsurgical pain will resolve within three months. If not, it is deemed persistent pain that may warrant specialist assessment

Effective strategy to guide pathology test ordering in surgical patients.

BACKGROUND: Ordering of pathology testing by junior medical staff is often a haphazard process with little regard to the appropriateness of test ordering. The aim of the present study was to reduce ordering of inappropriate pathology tests in surgical patients attending the pre-admission clinic (PAC) through the introduction of a protocol-based test ordering system and to create an environment where such improvement can be sustained. METHODS: This is a prospective study with a retrospective control group. Three cohorts of patients attending the PAC were included. Group I (n = 700) attended prior to the introduction of the test protocols (April-June 2002) and acted as a control group. Group II (n = 720) attended after the protocol introduction (April-June 2003), and group III (n = 763) attended during the subsequent 3-month period from July to August 2003. The study examined the numbers of patients in each group who were ordered any of eight standard pathology tests. The average number of tests per patient, and cost of tests per patient were also ascertained. RESULTS: Following the introduction of pathology test protocols, the ordering of all but one of the eight tests was statistically significantly reduced. In particular, ordering of coagulation studies was reduced from 22.5% to 13.8% and electrolytes, urea and creatinine from 65.2% to 48.25% of patients (both P < 0.0001). Average number of tests performed per patient declined from 2.48 to 1.88, representing a savings of 10.33 dollars per patient (a decrease from 42.22 dollars to 31.89 dollars) and a projected annualized cost saving in excess of 26,000 dollars. CONCLUSIONS: Provided that certain preliminary guidelines are followed, these protocols can reduce pathology test ordering in any pre-admission Service.

New directions in pain management.

Pain medicine is one of the most rapidly developing medical specialties of today. While there are many modalities that can be used in managing the patient in pain, drug treatment remains, for the most part, the cornerstone of treatment. Opioids retain their position as the foundation of most analgesic strategies, although they tend to be used nowadays in combination with adjuvant analgesics such as paracetamol and nonsteroidal antiinflammatory drugs. The range of available opioids has also been expanded with drugs such as hydromorphone and oxycodone, originally developed almost a century ago. This expanded choice has resulted in the concept of opioid rotation in chronic pain states, an approach that is aimed at maintaining pain control while minimizing adverse effects. Nonsteroidal antiinflammatory drugs continue to play an important role, especially as adjuvants, and the development of drugs such as celecoxib and refecoxib, highly specific for the inhibition of cyclooxygenase 2 pathway has been a further advance. The treatment of neuropathic pain continues to be a challenge to the clinician. While this has traditionally been treated with drugs from the anticonvulsant, antiarrhythmic and anti-depressant groups, results from these treatments have often been less than satisfactory. This has led to the development of completely new drug classes that modulate neuronal transmission in pain pathways, some of which are derived from exotic animal sources, such as the conotoxins from the marine snail family and epibatidine from a species of frog. The role of cannabinoids remains controversial.