Risk management and safety in the use of patient-controlled analgesia pumps: a scoping review / Gestão de risco e segurança no uso de bomba de analgesia controlada pelo paciente: revisão de escopo

ABSTRACT BACKGROUND AND OBJECTIVES: Patient-controlled analgesia (PCA) is effective in controlling pain, but has numerous associated risks, such as: hypotension, respiratory depression, seizures and excessive sedation. The promotion of patient safety aims to reduce the risk of unnecessary health injuries and, therefore, it is important to analyze the failures and risk factors present throughout the process proactively. Therefore, the aim of this study was to map the available evidence on the risks of adverse events associated with the PCA technique and patient safety actions. CONTENTS: This is a scoping review conducted according to the JBI methodology, whose research question was based on the PCC strategy. The source of information is open and the search occurred in three stages. The databases used were: Medline/Pubmed; LILACS; CINAHL/ EBSCOhost; CENTRAL; Portal Capes; SCOPUS; Web of Science; Google academic; Brazilian Digital Library of Theses and Dissertations; Portal NICE; and Portal ISMP. The search strategy was divided into 3 stages: the first occurred in Medline and Cinahl to identify articles and index terms on the topic; the second used all keywords in all included databases; the third consisted of tracking searches in the reference lists of the included studies. The search resulted in 1,164 studies, of which 83 were selected based on the inclusion criteria: addressing the risks associated with the PCA pump or safety measures, hospital context, without restriction as to the type of study, language, and year. The studies are distributed in categories: previous diseases, profile of indications, types of opioids, types of pump and infusion, adverse effects, incidents without harm, stages of risk, and safety measures. CONCLUSION: This study made it possible to identify the risks of adverse events associated with the use of PCA in different stages and safety actions, demonstrating that when performed with appropriate patients, trained staff, safe devices, and correct prescription it provides a statistically significant improvement in pain relief, safely with advantages that conventional analgesia does not have.

RESUMO JUSTIFICATIVA E OBJETIVOS: A analgesia controlada pelo paciente (ACP) é eficaz no controle da dor, porém apresenta inúmeros riscos associados, tais como: hipotensão arterial, depressão respiratória, convulsões e sedação excessiva. A promoção da segurança do paciente visa reduzir o risco de lesões desnecessárias à saúde e, para tanto, é importante analisar as falhas e fatores de risco presentes em todo o processo de forma proativa. Portanto, o objetivo deste estudo foi mapear as evidências disponíveis sobre os riscos de eventos adversos associados à técnica de ACP e a ações de segurança do paciente. CONTEÚDO: Trata-se de uma revisão de escopo realizada segundo a metodologia Joanna Briggs Institute para Scoping Reviews, cuja questão de pesquisa se baseou na estratégia PCC (P: população; C: conceito; C: contexto). As bases de dados utilizadas foram: Medline/Pubmed, LILACS, CINAHL/EBSCOhost, CENTRAL, Portal Capes, SCOPUS, Web of Science, Google acadêmico, Biblioteca Digital Brasileira de Teses e Dissertações, Portal NICE, Portal ISMP. A estratégia de busca foi dividida em 3 etapas: a primeira ocorreu na Medline e Cinahl para identificar artigos e termos de índice sobre o tema; a segunda utilizou todas as palavras-chaves em todas as bases de dados incluídas; a terceira consistiu no rastreamento de pesquisas nas listas de referências dos estudos incluídos. A busca resultou em 1.164 estudos, dos quais 83 foram selecionados com base nos seguintes critérios de inclusão: abordagem dos riscos associados à bomba de ACP ou a medidas de segurança, contexto hospitalar, sem restrição quanto ao tipo de estudo, idioma e ano. Os achados sintetizados estão distribuídos em categorias: doenças prévias, perfil das indicações, tipos de opioides, tipos de bomba e de infusão, efeitos adversos, incidentes sem lesões, estágios de risco e medidas de segurança. CONCLUSÃO: Este estudo possibilitou identificar os riscos de eventos adversos associados ao uso da ACP em diferentes estágios e ações de segurança, demonstrando que quando realizada com pacientes adequados, com equipe treinada, dispositivos seguros e prescrição correta, fornece uma melhora estatisticamente significativa no alívio da dor, de forma segura e com vantagens que a analgesia convencional não possui.

Nursing actions in the management of pain related to the use of a patient-controlled analgesia pump during the postoperative period of cardiac surgery / Atuação da enfermagem no gerenciamento da dor relacionada ao uso da bomba de analgesia controlada pelo paciente durante o pósoperatório de cirurgia cardíaca

ABSTRACT BACKGROUND AND OBJECTIVES: Acute postoperative pain affects more than 80.0% of patients and approximately 75.0% of cases are described as moderate to severe. Effective pain relief after cardiac surgery has assumed an important role with the introduction of fast track protocols, requiring better monitoring and patient education for its effectiveness. The present study's objective was to verify if nurses have been playing an active role during pain management, so that this brings positive impacts to the patient in pain control. METHODS: A cross-sectional, descriptive study with a quantitative approach, with data extracted and collected from the digital platform Research Electronic Data Capture in March 2020, referring to data entered in the period between October 2018 and October 2019, totaling 326 patients in the postoperative period of cardiac surgery who used the electronic patient-controlled analgesia pump (PCA) model CADD-Legacy PCA. RESULTS: Predominantly male subjects (73.9%), with a mean age of 59.9±14.9 years. Among the characteristics of the PCA pump, intravenous infusion (98.8%) and bolus/PCA mode (98.5%) stood out. There was adequate monitoring of vital signs in compliance in 96.6% of cases, guidance by the nurse at the time of PCA pump installation in 85.9% and pain control after suspension of the PCA pump in 94.2%. With those who had pain controlled after the end of therapy, there was a predominance of pain control in 95% of patients (p=0.11). CONCLUSION: The results show that well-established protocols, adequate monitoring, and the correct orientation of the patient regarding the use of the device, bring positive impacts after suspension of PCA.

RESUMO JUSTIFICATIVA E OBJETIVOS: A dor aguda pós-operatória acomete mais de 80% dos pacientes e, aproximadamente, em 75% dos casos, é descrita como moderada a intensa. O alívio efetivo da dor após cirurgia cardíaca assumiu um papel importante com a introdução de protocolos de via rápida, necessitando de melhor monitoramento e educação do paciente para sua efetividade. O objetivo deste estudo foi verificar se o enfermeiro vem desempenhando um papel ativo durante o gerenciamento da dor, de forma que isso traga impactos positivos ao paciente no controle álgico. MÉTODOS: Trata-se de um estudo transversal, descritivo e de abordagem quantitativa, com dados coletados da plataforma digital Research Electronic Data Capture em março de 2020, referente aos dados inseridos no período entre outubro de 2018 e outubro de 2019, totalizando 326 pacientes em pós-operatório de cirurgia cardíaca que utilizaram bomba de infusão eletrônica modelo CADD-Legacy ACP. RESULTADOS: A média de idade foi de 59,9±14,9 anos (n=326), com um público predominantemente do sexo masculino (73,9%). Dentre as características de bomba de analgesia controlada pelo paciente (ACP), destacaram-se via de infusão endovenosa (98,8%) e modo bolus/ACP (98,5%). Houve monitorização adequada de sinais vitais em conformidade em 96,6% dos casos, orientação feita pelo enfermeiro no momento da instalação da bomba de ACP em 85,9% e controle da dor após suspensão da bomba de ACP em 94,2%. Com aqueles que tiveram dor controlada após término da terapia, observou-se predominância do controle álgico em 95% dos pacientes (p=0,11). CONCLUSÃO: Os resultados mostraram que protocolos bem estabelecidos, monitoramento adequado e orientação correta do paciente quanto ao uso do dispositivo trazem impactos positivos após suspensão da ACP.

Fibrin Clot Mistook as a Worm in the Intravenous Line

There have been several reports of foreign bodies being discovered in the intravenous set. In this case, the patient complained that he found a worm in his intravenous line. It was later confirmed as a long, white fibrin deposit by pathologic examination. This happened even though there was a non-return valve in the intravenous line. Also, since there were few red blood cells in the deposit, it did not look like a blood clot. In cases like this, we suggest that physicians keep this possibility in mind to reassure their patients.

Recomendaciones en la analgesia para la artroplastía total de rodilla / Recommendations in analgesia for total knee arthroplasty

Resumen: La artroplastía total de rodilla (ATR) es una intervención muy frecuente, cuyo objetivo es eliminar el dolor y la incapacidad funcional en pacientes con osteoartritis de rodilla. Es una de las intervenciones ortopédicas más exitosas, aunque la mayoría de los pacientes manifiestan dolor agudo postoperatorio (DAP) moderado o intenso. A pesar de los conocimientos médicos actuales, los nuevos analgésicos y técnicas analgésicas, el DAP en la ATR no ha podido ser controlado de forma satisfactoria. La prevalencia de dolor crónico post-ATR varía de 10 a 35% y en ocasiones hasta cuatro meses post-ATR. El objetivo es realizar recomendaciones en México para el manejo de dolor de los pacientes sometidos a artroplastía total de rodilla, tanto en preoperatorio como en transoperatorio y postoperatorio. Se sugiere usar escalas de medición del dolor para estratificarlo y optimizar el tratamiento, la educación del personal sanitario y del paciente; el uso de analgesia multimodal; incluyendo a la pregabalina o gabapentina como adyuvante analgésico preventivo porque reduce el dolor postoperatorio y el requerimiento de opioides. Las técnicas regionales como la combinación del uso de bloqueo del canal del aductor como el IPACK están siendo evaluadas con mejores resultados comparados con el bloqueo femoral. A partir de estas recomendaciones, estimamos fundamental el manejo del dolor postoperatorio de ATR, ya que la satisfacción final del paciente se verá mejorada de gran manera (visitahttp://www.painoutmexico.compara obtener la versión completa del artículo y recomendaciones).

Abstract: Total knee arthroplasty (TKA) is a very frequent intervention, whose objective is to eliminate pain and functional disability in patients with knee osteoarthritis. It is one of the most successful orthopedic interventions although most patients have moderate to severe acute postoperative pain. Despite current medical knowledge, new analgesics and analgesic techniques, the acute postoperative pain in the TKA has not been satisfactorily controlled. The prevalence of chronic pain after TKA varies from 10 to 35%, sometimes it remains up to four months after TKA. The aim is to make recommendations in Mexico for the management of postoperative pain in patients undergoing TKA, both preoperatively, transoperatively and postoperatively. It is suggested: the use of pain measurement scales to stratify and optimize the treatment, health and patient staff education; as well as the use of multimodal analgesia; including pregabalin or gabapentin as preventive analgesia because it reduces postoperative pain and the requirement for opioids. Combination of regional techniques particularly the adductor canal block such as IPACK block are being evaluated with better results compared with femoral block. Based on these recommendations, we consider fundamental the management of postoperative pain of TKA, since the final satisfaction of the patient will be greatly improved (visithttp://www.painoutmexico.comto get the full version of the article and recommendations) .

El ABC de la analgesia controlada por el paciente / The ABCs of patient-controlled analgesia

Resumen La analgesia controlada por el paciente (PCA, por sus siglas en inglés: patient controlled analgesia) es la administración continua y/o intermitente de analgésicos opioides y no opioides a través de un dispositivo con dosis a demanda y control del paciente. Su mecanismo de acción antinociceptivo tiene efecto en la percepción del control del dolor por el propio paciente, en sinergia, con la acción de los medicamentos. Bajo el concepto de concentración mínima efectiva analgésica, las bombas PCA permiten mantener las concentraciones plasmáticas estables de los fármacos, particularmente de los opioides, disminuyendo la carga de atención al personal de enfermería y la administración de medicamentos «por razón necesaria¼. Las bombas de PCA cuentan con un intervalo de seguridad que impide la sobredosificación por intentos repetitivos de activación por el paciente de las dosis en bolos, y se ha demostrado que brindan mejores resultados en la analgesia durante las primeras 24 horas (nivel de evidencia moderada). Las rutas más utilizadas son la vía intravenosa y la vía epidural. En esta revisión se presentan los pasos básicos para el uso de estos dispositivos, preparación y programación de bolos o infusiones analgésicas, así como los pasos seguros que deben considerarse durante su empleo (visite http://www.painoutmexico.com para obtener el artículo completo y videos).

Abstract Patient-controlled analgesia (PCA) is the continuous and/or intermittent administration of opioid and non-opioid analgesics through a device with on-demand doses and patient control. Its mechanism anti-nociceptive has an effect on the perception of pain controlled by the patient himself, in synergy, with the action of the medications. Under the concept of minimum effective analgesic concentration, PCA pumps allow the stable plasma concentrations of the drugs, particularly opioids, to be maintained, reducing the nursing staff attention and the administration of drugs «for necessary reason¼. PCA pumps have a safety interval that prevents overdosing due to repetitive attempts by the patient to activate bolus and has been shown to provide better analgesia during the first 24 hours (moderate level of evidence). The most commonly routes are the intravenous and the epidural. In this review we present the basic steps for the use of these devices, preparation and programming of boluses or analgesic infusions, as well as safety steps during their use (visit http://www.painoutmexico.com to see the full article and videos).

Working Mode and Effect of Clinical Pharmacists Involved in Postoperative Patient-controlled Analgesia Pump Management / 中国药学杂志

OBJECTIVE: To explore the working mode of clinical pharmacists involved in postoperative patient-controlled analgesia pump management and its effectiveness. METHODS: According to the postoperative analgesia pump workflow and pharmaceutical monitoring route, SPS22.0 software was used to analyze the data of patients undergoing elective surgery in the Department of Spinal Surgery and General Surgery of Nanjing Drum Tower Hospital from January 2014 to December 2018. RESULTS: The patient-controlled analgesia(PCA) usage rate in spine surgery and general surgery increased. The postoperative pain control compliance rate remained above 90%, and the incidence of adverse reactions decreased year by year. CONCLUSION: Since the clinical pharmacists participated in the management of analgesic pumps, the pharmaceutical monitoring of patient-controlled analgesia pumps has improved the quality of postoperative pain management, enabling patients to receive reasonable, economical and safe drug treatment.

Patient Satisfaction And Cost Analysis Of Analgesia Management For Post-Operative Procedures In Htaa: Pca Vs. Conventional Method

@#Acute pain service (APS) offer several techniques to the post-operative patient in controlling and relieving the pain such as intravenous infusion, patient-controlled analgesia, epidural infusion, subcutaneous or intramuscular injection and intrathecal administration. The effectiveness of and satisfaction towards APS is not clearly defined. Therefore, the aim of this study is to conduct the cost analysis and comparison between these techniques and patient satisfaction. The study design for cost analysis was retrospective study. The means of the data were calculated based on Integration Store of Hospital Tengku Ampuan Afzan records. In addition, the evaluation of patient’s satisfaction was conducted by using a cross-sectional study design. The mean of the data was calculated and analysed by using Chi-square test. The total cost required to prepare PCA for post-operative patient was the highest with RM 8810.98. Meanwhile, the cost for subcutaneous morphine injection, epidural infusion and peripheral block injection were RM 2.11, RM 5323.95 and RM 4.95 respectively. However, when taking into the aspect of patient’s satisfaction, PCA has the highest level of excellent performance with 54.6% compare to EDA (33%) and BLOCK (12.4%) with the p-value is less than 0.05. In conclusion, every drug has its own side effects. As the healthcare provider, it is a need to ensure drugs that were given to the patients are at the very minimum risk of having the side effects. Based on the findings of this study, it could be said that both drugs have lower percentage of people experienced the side effect after treated with the drugs. Therefore, the future study should be more focusing on the side effect of the drugs used. In terms of cost spent for the methods, the PCA regimen is more likely expensive compared to the conventional methods. However, based on survey among the patients, PCA-treated patients expressed higher satisfaction compared to the conventional regimen of pain management.

Effects on postoperative nausea and vomiting of nefopam versus fentanyl following bimaxillary orthognathic surgery: a prospective double-blind randomized controlled trial

BACKGROUND: Postoperative nausea and vomiting (PONV) frequently occurs following bimaxillary orthognathic surgeries. Compared to opioids, Nefopam is associated with lower incidences of PONV, and does not induce gastrointestinal tract injury, coagulopathy, nephrotoxicity, or fracture healing dysfunction, which are common side effects of Nonsteroidal anti-inflammatory drugs. We compared nefopam- and fentanyl-induced incidence of PONV in patients with access to patient-controlled analgesia (PCA) following bimaxillary orthognathic surgeries. METHODS: Patients undergoing bimaxillary orthognathic surgeries were randomly divided into nefopam and fentanyl groups. Nefopam 120 mg or fentanyl 700 µg was mixed with normal saline to a final volume of 120 mL. Patients were given access to nefopam or fentanyl via PCA. Postoperative pain intensity and PONV were measured at 30 minutes and 1 hour after surgery in the recovery room and at 8, 24, 48, and 72 hours after surgery in the ward. The frequency of bolus delivery was compared at each time point. RESULTS: Eighty-nine patients were enrolled in this study, with 48 in the nefopam (N) group and 41 in the fentanyl (F) group. PONV occurred in 13 patients (27.7%) in the N group and 7 patients (17.1%) in the F group at 8 hours post-surgery (P = 0.568), and there were no significant differences between the two groups at any of the time points. VAS scores were 4.4 ± 2.0 and 3.7 ± 1.9 in the N and F groups, respectively, at 8 hours after surgery (P = 0.122), and cumulative bolus delivery was 10.7 ± 13.7 and 8.6 ± 8.5, respectively (P = 0.408). There were no significant differences in pain or bolus delivery at any of the remaining time points. CONCLUSION: Patients who underwent bimaxillary orthognathic surgery and were given nefopam via PCA did not experience a lower rate of PONV compared to those that received fentanyl via PCA. Furthermore, nefopam and fentanyl did not provide significantly different postoperative pain control.

Perioperative Factors Associated with Severe Pain in Post-Anesthesia Care Unit after Thoracolumbar Spine Surgery: A Retrospective Case-Control Study

STUDY DESIGN: A retrospective case-control study. PURPOSE: To evaluate the effect of nitrous oxide and anesthetic and operative factors associated with severe pain in the early postoperative period after thoracolumbar spine surgery. OVERVIEW OF LITERATURE: Thoracolumbar spine surgery is the most common procedure in spine surgery, and up to 50% of the patients suffer from moderate to severe pain. Nitrous oxide has analgesic, anxiolytic, and anesthetic effects; nevertheless, its benefits for early postoperative pain control and opioid consumption remain to be established. METHODS: The medical records of eligible participants who underwent thoracolumbar spine surgery between July 2016 and February 2017 were reviewed. Enrolment was performed consecutively until reaching 90 patients for the case (severe pain) group (patients with a pain score of >7 out of 10 at least once during the post-anesthesia care unit [PACU] admission), and 90 patients for the control (mild-to-moderate pain) group (patients with a pain score of <7 in every PACU assessment). The data collected comprised patient factors, anesthetic factors, surgical factors, PACU pain score, and PACU pain management. RESULTS: A total of 197 patients underwent thoracolumbar spine surgery with an incidence of early postoperative severe pain of 53.3%. The case-control study revealed no differences in the factors related to pain intensity. A subgroup analysis was performed for failed back surgery syndrome (FBSS), spinal stenosis, and spondylolisthesis. After multivariate analyses, only the age group of 19–65 years and the baseline Oswestry Disability Index (ODI) were found to be significant risk factors for early postoperative severe pain in the PACU (odds ratio [OR], 2.86; 95% confidence interval [CI], 1.32–6.25; OR, 1.03; 95% CI, 1.01–1.05, respectively). CONCLUSIONS: Nitrous oxide, anesthetic agents, and surgical techniques did not affect the early postoperative pain severity. Age under 66 years and the baseline ODI were the significant risk factors for pain intensity during the early postoperative period of the FBSS, spinal stenosis, and spondylolisthesis subgroups.

The efficacy of different modes of analgesia in postoperative pain management and early mobilization in postoperative cardiac surgical patients: A systematic review

Cardiac surgery induces severe postoperative pain and impairment of pulmonary function, increases the length of stay (LOS) in hospital, and increases mortality and morbidity; therefore, evaluation of the evidence is needed to assess the comparative benefits of different techniques of pain management, to guide clinical practice, and to identify areas of further research. A systematic search of the Cochrane Central Register of Controlled Trials, DARE database, Joanna Briggs Institute, Google scholar, PUBMED, MEDLINE, EMBASE, Academic OneFile, SCOPUS, and Academic search premier was conducted retrieving 1875 articles. This was for pain management postcardiac surgery in intensive care. Four hundred and seventy-one article titles and 266 abstracts screened, 52 full text articles retrieved for critical appraisal, and ten studies were included including 511 patients. Postoperative pain (patient reported), complications, and LOS in intensive care and the hospital were evaluated. Anesthetic infiltrations and intercostal or parasternal blocks are recommended the immediate postoperative period (4–6 h), and patient-controlled analgesia (PCA) and local subcutaneous anesthetic infusions are recommended immediate postoperative and 24–72 h postcardiac surgery. However, the use of mixed techniques, that is, PCA with opioids and local anesthetic subcutaneous infusions might be the way to go in pain management postcardiac surgery to avoid oversedation and severe nausea and vomiting from the narcotics. Adequate studies in the use of ketamine for pain management postcardiac surgery need to be done and it should be used cautiously.

Effects of Dexmedetomidine in Combination with Sufentanil - based Intravenous Patient - controlled Analgesia after Video - assisted Thoracoscopic Surgery / 现代医院

Objective To investigate the effects of dexmedetomidine in combination with sufentanil-based intravenous patient-controlled analgesia. Methods 60 ASA Ⅰ～Ⅱ patients undergoing video-assisted thoracoscopic surgery were divided into two groups (30 patients in each group). In group A, only sufentanil was included in the reagent of patient-controlled analgesia. In group B, dexmedetomidine and sufentanil were included. Results Compared to Group A, consumption of sufentanil in group B at 8h, 24h and 48h after surgery and the incidence of nausea were significantly lower (P＜0.05). The side effects incidences such as vomiting, deep sedation, urine retention and pruritus were comparable between two groups. Conclusion Dexmedetomidine-sufentanil combination for postoperative analgesia in video-assisted thoracoscopic surgery patients resulted in significant sufentanil sparing and lower incidence of nausea.

Efficacy of High-dose Morphine with Different Continuous Administration Routes:a Prospective Study in Pa-tients with Advanced Cancer Pain / 中国药师

Objective:To compare the efficacy of morphine with intravenous injection and subcutaneous injection in the treatment of advanced cancer,and explore the indications of different drug delivery methods for high-dose morphine. Methods: A prospective study was performed,and 46 cases of patients with advanced cancer pain were collected and divided into intravenous group and subcutaneous group according to the administration route. Pain was assessed during the administration,and the analgesic efficiency and the incidence of adverse reactions were observed to compare the efficacy and safety of two different ways to give high-dose morphine. Results:No statisti-cally significant differences were found in the number of outbreaks needed to be rescued,the frequency of morphine-induced drug deliver-y,the efficiency of analgesia after opioid transfer,and the incidence of opioid-related side effects between the groups (P>0.05). The dose of morphine in the subcutaneous group was higher than that of the intravenous group(P<0.05). Conclusion:The continuous ad-ministration of morphine with intravenous injection and subcutaneous injection can quickly,safely and effectively relieve pain. With the same analgesic efficacy,patients can choose appropriate administration route according to the dose of morphine, the influence degree of primary diseases and the individual will.

Low concentration continuous femoral nerve block improves analgesia and functional outcomes after total knee arthroplasty in spinal anesthesia

BACKGROUND: Total knee arthroplasty (TKA) is associated with severe pain postoperatively. Femoral nerve block is commonly used for pain control after TKA. This study investigated whether continuous femoral nerve block (CFNB) can improve postoperative analgesia and functional outcome as compared to intravenous patient controlled analgesia (PCA) in patients with TKA. METHODS: We reviewed the electronic medical records of patients who underwent TKA with spinal anesthesia between March 2014 and February 2015. In Group IV, postoperative pain was managed by IV-PCA. Group CFNB received CFNB-PCA via a device. Thirty patients were enrolled per group. Patient outcomes were assessed by analgesia, functional outcomes, and health-related quality of life factors. RESULTS: Additional analgesics and additional nerve block for adequate pain control were significantly more frequent in the IV than CFNB group (P = 0.015 and P = 0.012, respectively). Range of motion up to 105 degrees was prolonged in the IV group than CFNB group (P = 0.013). EuroQol five dimensions score was improved in the CFNB group than IV group postoperative 3 weeks (P = 0.003). The incidence of transfusion due to postoperative bleeding was significantly frequent in the IV group than CFNB group (P = 0.042). CONCLUSIONS: Postoperative low concentration continuous femoral nerve block for analgesia after TKA improves analgesia, functional outcomes, and incidence of transfusion without falling risk.

Comparison of Ramosetron Dose in Patients with Postoperative Nausea and Vomiting Who Received Oxycodone-Based Intravenous Patient-Controlled Analgesia after Undergoing Gynecological Laparoscopic Surgery

OBJECTIVE: Pain that occurs following gynecological laparoscopic surgery is a main cause for prolonged hospitalization. As a solution, various intravenous patient-controlled analgesia (IV PCA) systems have been used to control postoperative pain. This study explored the relationship between the dose of the ramosetron used to control postoperative nausea and vomiting (PONV) and its effect when oxycodone was used as the IV PCA. METHODS: Ninety-two patients (age, 18–70 years) undergoing gynecological laparoscopic surgery received oxycodone as IV PCA and were divided into the RB and RM group. Towards the end of surgery, the RB group patients were given 0.3 mg ramosetron as an IV bolus, and those in the RM group were given 0.3 mg ramosetron plus and additional 0.6 mg as IV PCA. The degree of PONV, postoperative pain, and pain felt during coughing were observed for 0.5, 2, 4, 8, 24, and 48 hours postoperatively. Patient satisfaction and comfort were assessed at 24 and 48 hours. RESULTS: No differences in operation time, anesthesia period, or amounts of propofol and remifentanil used were observed between the groups. IV PCA demand, severity of PONV, postoperative pain, and coughing pain were also similar between the groups. Patient comfort was similar between the groups at 24 and 48 hours postoperatively. CONCLUSION: No difference in the incidence of PONV was detected between patients who used only 0.3 mg ramosetron as an intravenous bolus and those who received an additional 0.6 mg ramosetron mixed in IV PCA when oxycodone was offered as the IV PCA after undergoing gynecological laparoscopic surgery.

Postoperative infusion of a low dose of dexmedetomidine reduces intravenous consumption of sufentanil in patient-controlled analgesia / 대한마취과학회지

BACKGROUND: Combining adjunctive medications with patient-controlled analgesia (PCA) has been used to minimize opioid related side-effects. The aim of this study was to evaluate whether postoperative infusion of a sub-sedative dose of dexmedetomidine can reduce opioid consumption and opioid related side-effects. METHODS: We selected 60 patients from 18 to 60 years old with an American Society of Anesthesiologists physical status of 1–2 who were scheduled for elective surgery. The types of surgery were limited to thoracoscopic wedge resection of the lung and pulmonary wedge resection under a mini-thoracotomy. Patients received PCA with sufentanil upon arrival in the recovery room, along with a separate continuous infusion of dexmedetomidine that was not mixed in the PCA but started at the same time. Patients were randomly allocated to two groups: dexmedetomidine 0.15 μg/kg/h was administered to patients in group D and normal saline was administered to patients in group C. The visual analogue scale (VAS) pain score, blood pressure, pulse rate, and respiratory rate were measured at each assessment. PCA related side-effects were evaluated. RESULTS: The VAS pain score was significantly lower in the dexmedetomidine group. Patients in the dexmedetomidine group required significantly less PCA at postoperative 1–4, 4–8, and 8–24 h time intervals. The incidence of nausea was significantly less in the dexmedetomidine group, and levels of sedation and hemodynamic variables except for blood pressure at postoperative 8 h were similar between the groups. CONCLUSIONS: In conclusion, a postoperatively administered sub-sedative dose of dexmedetomidine reduces PCA sufentanil consumption and decreases nausea.

Optimal Concentration of Sufentanil for Patient Controlled Epidural Analgesia in Gastrectomy / 계명의대학술지

Patient controlled epidural anlagesia is a commonly used method for postoperative pain management. The purpose of this study is to determine the optimal concentration of sufentanil for patient controlled epidural analgesia. Twenty eight patients who underwent elective gastrectomy were enrolled in this study. Patients were randomly assigned to one of two groups of 0.5 µg/mL (group S1) and 0.7 µg/mL (group S2). At 2 hours, 1 day, 2 days and 3 days after surgery, the patient's pain degree was checked by numerical rating scale (NRS) and the presence of side effects was assessed. In both groups, the NRS decreased linearly with time. The NRS of the two groups differed but the trend of decrease did not show significant difference. The overall incidence of side effects was 45.5% (group S1) and 58.8% (group S2), respectively. Patient controlled epidural analgesia using sufentanil was effective in controlling postoperative pain, which was found to decrease with time. When comparing the two concentrations used in this study, 0.5 µg/mL had a lower incidence of side effects than the concentration of 0.7 µg/mL, and the pain relief trends of the two concentrations were similar.

Comparison of oxycodone and fentanyl for postoperative patient-controlled analgesia after orthopedic surgery

BACKGROUND: Oxycodone is widely used as bolus or patient-controlled analgesia (PCA) for control of postoperative pain. The aim of this study was to assess the efficacy and side effects of oxycodone for somatic pain by comparing oxycodone and fentanyl intravenous PCA after orthopedic surgery. METHODS: Seventy-three patients undergoing orthopedic surgery were randomly assigned to receive fentanyl or oxycodone using intravenous PCA (potency ratio 1:60). Pain severity at rest and with movement and adverse effects were assessed at 1, 6, 24, and 48 hours after surgery. The PCA dose and patient satisfaction scores were measured at 48 hours after surgery. RESULTS: The resting visual analogue scale (VAS) and moving VAS scores of the oxycodone group were significantly higher than those of the fentanyl group at 6 hours (P = 0.001, P = 0.021), but at 48 hours, the resting and moving VAS of the oxycodone group were significantly lower than those of the fentanyl group (P = 0.014, P = 0.037). There were no significant differences in adverse effects, satisfaction scores, dose of patient-controlled mode, or total cumulative PCA dose. CONCLUSIONS: With a 1:60 ratio of oxycodone to fentanyl when using PCA for pain control after orthopedic surgery, the use of larger doses of oxycodone for 6 hours is effective in controlling early postoperative pain.

Modern techniques to optimize neuraxial labor analgesia

Neuraxial analgesia is the gold standard method for pain relief in labor. Several techniques can optimize both the initiation and maintenance of neuraxial labor analgesia. Initiation techniques such as combined spinal-epidural or dural puncture epidural may offer some advantages over standard epidural insertion. The use of ultrasound to assist with landmarking and optimizing block placement improves neuraxial success, and is particularly useful in certain patient populations. Maintaining labor analgesia with a regimen that includes background programmed intermittent boluses with a patient-controlled epidural analgesia component affords the best combination of pain relief and avoidance of undesired effects. These techniques are most effective when dilute local anesthetics with lipophilic opioids are utilized.

Comparison of Propacetamol plus Fentanyl and Fentanyl alone with Patient Controlled Analgesia after Total Knee Arthroplasty

OBJECTIVE: Opioid analgesics, for postoperative pain management, are an indispensable group of medication; however, they also have a variety of adverse drug reactions (ADR). Multimodal methods, combining non-opioid analgesics with opioid analgesics, have been investigated to increase the effects of analgesics and reduce ADR with opioid-sparing effects. The purpose of this study was to compare the effects of patient-controlled analgesia (PCA) with fentanyl alone, and PCA with fentanyl and intravenous (i.v.) propacetamol to determine the effects of pain control, cumulative opioid usage, and opioid ADR. METHODS: The subjects were patients who underwent total knee arthroplasty at the Seoul Veterans hospital from January 1, 2015 to December 31, 2016. The study period was from postoperative day 0 (POD0) to day 3 (POD3), and the retrospective study was conducted using electronic medical records. RESULTS: Pain severity was significantly low at POD1 (p = 0.017), POD2 (p = 0.003), and POD3 (p = 0.002) in the multimodal group. The fentanyl only group frequently reported both moderate and severe pain at a statistically significant level. This was consistent with the analysis of the pro re nata (PRN) intramuscular analgesia usage at the time of numerical rating scale (NRS) 4 and above. The opioid-sparing effect confirmed that the average opioid dose equivalent to i.v. morphine dose was 9.4 mg more than that used for the multimodal group in the fentanyl only group. The ADRs and length of stay between the two groups were not statistically different. CONCLUSION: The results of this study suggest that the combination therapy of fentanyl and i.v. propacetamol is superior to fentanyl monotherapy.

Knowledge and Practice of Patient-controlled Analgesia Use and Management among Nurses / 한국간호교육학회지

PURPOSE: The purpose of this study was to investigate the knowledge and practice of patient-controlled analgesia use and management (PCA-UM) among nurses. METHODS: Data were collected from 182 nurses employed by four general hospitals having more than 300 beds in Daejeon. The data were collected using self-report questionnaires from November 4 to November 20, 2015. Collected data were analyzed using descriptive statistics, t-test, and ANOVA. RESULTS: The average nurses' knowledge about PCA-UM was 14.8 points out of 20. PCA-UM knowledge was significantly higher for nurses with experience in PCA education (t=3.55, p < .001). Most participants (91.2%) wanted to get PCA training, 86.8% of them provided PCA education to patients after surgery. Approximately 62% of participants regularly evaluated the level of consciousness of patients with PCA. CONCLUSION: Findings indicate that the knowledge and practice of PCA-UM among nurses were insufficient to provide safe and effective pain management to postoperative patients with PCA. Therefore, it is concluded that it is necessary to develop standardized PCA education programs for nurses to provide safe and effective pain management to postoperative patients with PCA.