Effect of therapeutic suggestions during general anaesthesia on postoperative pain and opioid use: multicentre randomised controlled trial.

OBJECTIVE: To investigate the effect of therapeutic suggestions played to patients through earphones during surgery on postoperative pain and opioid use. DESIGN: Blinded randomised controlled study. SETTING: Five tertiary care hospitals in Germany. PARTICIPANTS: 385 of 400 patients consecutively recruited from January to December 2018 who were to undergo surgery for 1-3 hours under general anaesthesia. In the per protocol analysis 191 patients were included in the intervention group and 194 patients in the control group. INTERVENTION: The intervention comprised an audiotape of background music and positive suggestions based on hypnotherapeutic principles, which was played repeatedly for 20 minutes followed by 10 minutes of silence to patients through earphones during general anaesthesia. Patients in the control group were assigned to a blank tape. MAIN OUTCOME MEASURES: The main outcome was dose of opioid administered by patient controlled analgesia or nurse controlled analgesia within the first postoperative 24 hours, based on regular evaluation of pain intensity on a numerical rating scale (range 0-10, with higher scores representing more severe pain). RESULTS: Compared with the control group, the intervention group required a significantly (P=0.002) lower opioid dose within 24 hours after surgery, with a median of 4.0 mg (interquartile range 0-8) morphine equivalents versus 5.3 (2-12), and an effect size (Cohen's d) of 0.36 (95% confidence interval 0.16 to 0.56). The number of patients who needed opioids postoperatively was significantly (P=0.001) reduced in the intervention group: 121 of 191 (63%, 95% confidence interval 45% to 70%) patients in the intervention group versus 155 of 194 (80%, 74% to 85%) in the control group. The number needed to treat to avoid postoperative opioids was 6. Pain scores were consistently and significantly lower in the intervention group within 24 hours after surgery, with an average reduction of 25%. No adverse events were reported. CONCLUSIONS: Therapeutic suggestions played through earphones during general anaesthesia could provide a safe, feasible, inexpensive, and non-drug technique to reduce postoperative pain and opioid use, with the potential for more general use. Based on the finding of intraoperative perception by a considerable number of patients, surgeons and anaesthetists should be careful about background noise and conversations during surgery. TRIAL REGISTRATION: German Clinical Trial Register DRKS00013800.

Factors Influencing Satisfaction with Patient-Controlled Analgesia Among Postoperative Patients Using a Generalized Ordinal Logistic Regression Model.

PURPOSE: The purpose of this study was to identify the factors affecting the satisfaction with patient-controlled analgesia (PCA) of patients using a generalized ordinal logistic regression model and to evaluate the difference in results of the ordinal regression from those of binary regression. METHODS: The study design involved secondary analysis of electronic medical records from a single tertiary care hospital in Seoul, Korea. It included 2,409 patients treated with PCA for postoperative pain management after open or laparoscopic abdominal surgery. Binary logistic regression and generalized ordinal logistic regression were used to identify factors affecting satisfaction. RESULTS: Binary logistic regression analysis showed that there was insufficient information for analysis. Generalized ordinal logistic regression revealed that sex, age, pain, PCA usage, and side-effects were common factors affecting PCA satisfaction. However, the effect of some factors affecting PCA satisfaction differed with the level of satisfaction. In open surgery patients, the effect of pain at 6 hours after surgery was significantly greater in the group with lower satisfaction. While, in the laparoscopic surgery patients, the effect of pain at 6-24 hours after surgery was significantly greater in the group with lower satisfaction. CONCLUSION: Generalized logistic regression may be an appropriate statistical method for analyzing ordinal data. Degree of postoperative pain and assessment interval are the most important factors associated with PCA satisfaction. Because the factors affecting PCA satisfaction were different for the two types of abdominal surgeries, customizing PCA to individual patients may potentially improve pain management and consequently increase PCA satisfaction.

Instrumental Control Enhances Placebo Analgesia.

Placebo analgesia is a robust phenomenon readily observed in both experimental and clinical settings. While researchers have begun to unpack its psychobiological mechanisms, important questions remain regarding how we can capitalize on the placebo effect to improve clinical pain outcomes. The current study tested whether providing individuals with instrumental control-that is, control over if and when they administer a treatment-is capable of enhancing placebo analgesia. Using an established electrocutaneous pain design, 87 healthy volunteers either received placebo conditioning with instrumental control over treatment administration, standard passive placebo conditioning without any control over treatment administration, or were allocated to natural history control group with no conditioning and were later tested at equivalent shock intensity with and without placebo applied. Both placebo groups demonstrated initial placebo analgesia. Importantly, however, those provided with instrumental control demonstrated significantly larger and longer lasting placebo analgesia as well as reduced anticipatory autonomic arousal than those receiving standard passive placebo conditioning. This suggests that providing instrumental control over treatment administration can facilitate placebo analgesia by enhancing its magnitude and durability. As such, providing instrumental control over treatment administration may be a cheap and ethical method of using the placebo effect to improve clinical pain outcomes. PERSPECTIVE: Placebo research typically involves passive designs where individuals have no control over treatment administration. We present novel data demonstrating that providing control over treatment administration substantially enhances both the magnitude and duration of placebo analgesia. As such, where possible, providing control may improve clinical pain outcomes via the placebo effect.

Patient-controlled oral analgesia at acute abdominal pain: A before-and-after intervention study of pain management during hospital stay.

AIM: To investigate the patient experience of pain management, when patient-controlled oral analgesia was compared with standard care for patients admitted to hospital with acute abdominal pain. The primary outcome measures were pain intensity and patient perception of care. BACKGROUND: Pain management of patients admitted to hospital with acute abdominal pain can be insufficient. Patient involvement in health care has been seen to have benefits for patients. METHODS: A before-and-after intervention study was conducted in an emergency department observation unit and a surgical department. Data were collected from a questionnaire (APS-POQ-R-D) with the six subscales: pain severity, perception of care, interference with activity, interference with emotions, side effects and patient-related barriers. RESULTS: A total of 156 patients were included. During admission the median score (0-10 scale) for the pain intensity and patient perception of care subscale was 4 (p = 0.96) and 8 (p = 0.92), respectively, in both the control and intervention group. On the activity subscale, the median scores were 6 and 5 (p = 0.17); on the emotion subscale, the scores were 5 and 4 (p = 0.31); and on the side effect subscale, the scores were 3 and 4 (p = 0.18) in the control and intervention group, respectively. Overall, the score was 5-8 at one item about being allowed to participate in decisions about pain treatment as much as wanted. CONCLUSION: Patient-controlled oral analgesia did not improve patient experience of pain management for patients admitted to hospital with acute abdominal pain.

[Remifentanil during labour; has its place in pain relief during labour been decided?] / Remifentanil tijdens de bevalling.

Patient-controlled analgesia using remifentanil (remifentanil PCA) has been used as a new form of pain relief during labour since soon after its release on the market. Reduction in pain scores lasts for 1 to 2 hours, and the analgesia is inferior to that of an epidural. Remifentanil PCA can be an alternative for epidural analgesia in cases where the woman cannot or does not want to receive epidural anaesthesia. In some hospitals in the Netherlands remifentanil PCA is being used on a large scale, possibly because of its less invasive character and for logistical reasons. The Netherlands RAVEL study comparing remifentanil with epidural analgesia showed greater satisfaction with pain relief in the epidural group. There is a high risk of hypoventilation during remifentanil PCA use, leading to desaturation; since desaturation can be a late consequence of hypoventilation, adequate monitoring of the woman is essential. It would be ideal to monitor the frequency and depth of ventilation along with peripheral saturation, and one-on-one care of the woman is advised.

Patient-controlled oral analgesia for acute abdominal pain: A before-and-after intervention study on pain intensity and use of analgesics.

AIM: To compare the use of patient-controlled oral analgesia with nurse-controlled analgesia for patients admitted to hospital with acute abdominal pain. The primary outcome measure was pain intensity. The secondary outcome measures were the use of analgesics and antiemetics. BACKGROUND: Inadequate pain management of patients with acute abdominal pain can occur during hospital admission. Unrelieved acute pain can result in chronic pain, stroke, bleeding and myocardial ischemia. METHODS: A before-and-after intervention study was conducted in an emergency department and a surgical department with three subunits. Data were collected from medical charts and analyzed using chi-squared and Kruskal-Wallis tests. RESULTS: A total of 170 patients were included. The median pain intensity score, using the numeric ranking scale, was 2.5 and 2 on Day 2 (p = 0.10), 2 and 2 on Day 3 (p = 0,40), 2.5 and 0 on Day 4 (p = 0.10), 2 and 0 on Day 5 (p = 0.045) in the control and intervention group, respectively. The percentage of patients receiving analgesics was 93 and 86 on Day 2 (p = 0.20), 91 and 75 on Day 3 (p = 0.02), 89 and 67 on Day 4 (p = 0.009) and 80 and 63 on Day 5 (p = 0.39). The use of antiemetics was similar in the two groups. CONCLUSION: Patient-controlled oral analgesia significantly reduced the numerical ranking pain scale score on Day 5 and the consumption of analgesics on Days 3 and 4 after hospital admission. Patient-controlled oral analgesia is feasible as pain management for patients, but only with minor impact on experienced pain intensity and use of analgesics.

Effects of anaesthesia and analgesia on long-term outcome after total knee replacement: A prospective, observational, multicentre study.

BACKGROUND: Perioperative regional anaesthesia may protect from persistent postsurgical pain (PPSP) and improve outcome after total knee arthroplasty (TKA). OBJECTIVES: Aim of this study was to evaluate the impact of regional anaesthesia on PPSP and long-term functional outcome after TKA. DESIGN: A web-based prospective observational registry. SETTING: Five Italian Private and University Hospitals from 2012 to 2015. PATIENTS: Undergoing primary unilateral TKA, aged more than 18 years, informed consent, American Society of Anesthesiologists (ASA) physical status classes 1 to 3, no previous knee surgery. INTERVENTION(S): Personal data (age, sex, BMI and ASA class), preoperative pain assessed by numerical rating scale (NRS) score, and risk factors for PPSP were registered preoperatively. Data on anaesthetic and analgesic techniques were collected. Postoperative pain (NRS), analgesic consumption, major complications and patient satisfaction were registered up to the time of discharge. PPSP was assessed by a blinded investigator during a phone call after 1, 3 and 6 months, together with patient satisfaction, quality of life (QOL) and walking ability. MAIN OUTCOME MEASURES: Experience of PPSP according to the type of peri-operative analgesia. RESULTS: Five hundred sixty-three patients completed the follow-up. At 6 months, 21.6% of patients experienced PPSP, whereas autonomy was improved only in 56.3%; QOL was worsened or unchanged in 30.7% of patients and improved in 69.3%. Patients receiving continuous regional anaesthesia (epidural or peripheral nerve block) showed a lower NRS through the whole peri-operative period up to 1 month compared with both single shot peripheral nerve block and those who did not receive any type of regional anaesthesia. No difference was found between these latter two groups. Differences in PPSP at 3 or 6 months were not significantly affected by the type of anaesthesia or postoperative analgesia. A higher NRS score at 1 month, younger age, history of anxiety or depression, pro-inflammatory status, higher BMI and a lower ASA physical status were associated with a higher incidence of PPSP and worsened QOL at 6 months. CONCLUSION: Continuous regional anaesthesia provides analgesic benefit for up to 1 month after surgery, but did not influence PPSP at 6 months. Better pain control at 1 month was associated with reduced PPSP. Patients with higher expectations from surgery, enhanced basal inflammation and a pessimistic outlook are more prone to develop PPSP. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02147730.

[Effect of pre-surgical stress on recovery of patients undergoing hip replacement procedures]. / Stres przed zabiegiem operacyjnym a przebieg okresu pooperacyjnego u pacjentów po wszczepieniu endoprotezy stawu biodrowego.

The aim of this study was to assess the effect of emotional stress experienced by patients prior to surgery on the process of post-surgical recovery. The study covered 50 hospitalised patients (31 women and 19 men) who underwent hip replacement procedures. The research relied on STAI-X1 anxiety questionnaire, as well as a specially prepared survey and the analysis of medical documentation. The results of the study suggest that fears most frequently listed by patients include fear of pain and anaesthesia, as well as anxieties related to the possibility of medical complications and the need to rely on a stranger. A positive statistical correlation was found between the level of emotional stress and the occurrence of psychological and care problems in the first three days following the surgery (unfounded anxieties, self-removal of drainage, ports or dressing). In addition, a statistically significant relation was found between the emotional stress level before the surgery and the number of times the patient's blood pressure exceeded 140/90 mmHg (p = 0.0408), as well as his or her consumption of analgesics (p = 0.0033), sedatives (p = 0.0340) and soporific drugs (p = 0.0273) in postoperative period.

Increasing patient knowledge on the proper usage of a PCA machine with the use of a post-operative instructional card.

OBJECTIVES: The purpose of this study was to see if an instructional card, attached to the PCA machine following total hip arthroplasty describing proper use of the device, would positively affect subjects' understanding of device usage, pain scores, pain medication consumption and satisfaction. METHODS: Eighty adults undergoing total hip replacements who had been prescribed PCA were randomized into two study groups. Forty participants received the standard post-operative instruction on PCA device usage at our institution. The other 40 participants received the standard of care in addition to being given a typed instructional card immediately post-operatively, describing proper PCA device use. This card was attached to the PCA device during their recovery period. On post-operative day one, each patient completed a questionnaire on PCA usage, pain scores and satisfaction scores. RESULTS: The pain scores in the Instructional Card group were significantly lower than the Control group (p = 0.024). Subjects' understanding of PCA usage was also improved in the Instructional Card group for six of the seven questions asked. CONCLUSION: The findings from this study strongly support that postoperative patient information on proper PCA use by means of an instructional card improves pain control and hence the overall recovery for patients undergoing surgery. In addition, through improved understanding it adds an important safety feature in that patients and potentially their family members and/or friends may refrain from PCA-by-proxy. This article demonstrates that the simple intervention of adding an instructional card to a PCA machine is an effective method to improve patients' knowledge as well as pain control and potentially increase the safety of the device use.

Effects of parecoxib on analgesia benefit and blood loss following open prostatectomy: a multicentre randomized trial.

BACKGROUND: This multi-centre, prospective, randomized, double-blind, placebo-controlled study was designed to test the hypotheses that parecoxib improves patients' postoperative analgesia without increasing surgical blood loss following radical open prostatectomy. METHODS: 105 patients (64 ± 7 years old) were randomized to receive either parecoxib or placebo with concurrent morphine patient controlled analgesia. Cumulative opioid consumption (primary objective) and the overall benefit of analgesia score (OBAS), the modified brief pain inventory short form (m-BPI-sf), the opioid-related symptom distress scale (OR-SDS), and perioperative blood loss (secondary objectives) were assessed. RESULTS: In each group 48 patients received the study medication for 48 hours postoperatively. Parecoxib significantly reduced cumulative opioid consumption by 24% (43 ± 24.1 mg versus 57 ± 28 mg, mean ± SD, p=0.02), translating into improved benefit of analgesia (OBAS: 2(0/4) versus 3(1/5.25), p=0.01), pain severity (m-BPI-sf: 1(1/2) versus 2(2/3), p < 0.01) and pain interference (m-BPI-sf: 1(0/1) versus 1(1/3), p=0.001), as well as reduced opioid-related side effects (OR-SDS score: 0.3(0.075/0.51) versus 0.4(0.2/0.83), p=0.03). Blood loss was significantly higher at 24 hours following surgery in the parecoxib group (4.3 g⋅dL(-1) (3.6/4.9) versus (3.2 g⋅dL(-1) (2.4/4.95), p=0.02). CONCLUSIONS: Following major abdominal surgery, parecoxib significantly improves patients' perceived analgesia. Parecoxib may however increase perioperative blood loss. Further trials are needed to evaluate the effects of selective cyclooxygenase-2 inhibitors on blood loss. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00346268.

The role of maternal attachment in the experience of labor pain: a prospective study.

OBJECTIVE: To examine the influence of attachment dimensions and sociodemographic and physical predictors in the experience of labor pain. METHODS: Eighty-one pregnant women were assessed during their third trimester of pregnancy and during labor. The perceived intensity of pain in the early stages of labor (3 cm of cervical dilatation) and before the administration of patient-controlled epidural analgesia was measured using a visual analog scale. Pain was also assessed indirectly based on anesthetic doses. Attachment was assessed using the Adult Attachment Scale-Revised. RESULTS: Attachment anxiety and avoidance were positively and significantly correlated with labor pain and anesthetic consumption. In the multivariate models, attachment anxiety was a significant predictor of higher pain at 3 cm of cervical dilatation (ß = 0.36, p = .042) and before the administration of patient-controlled epidural analgesia (ß = 0.51, p = .002). Older age (ß = 0.31, p = .005), a shorter duration of labor (ß= -0.41, p = .001), and attachment avoidance (ß = 0.41, p = .004) were significant predictors of higher anesthetic use. CONCLUSIONS: The study findings suggest that perceived labor pain and anesthetic use are strongly associated with attachment, rather than demographic and physical factors. These data support the importance of understanding the experience of labor pain within an attachment theoretical framework.

Low-dose ketamine via intravenous patient-controlled analgesia device after various transthoracic procedures improves analgesia and patient and family satisfaction.

Ketamine was recently shown to attenuate postoperative pain when used in combination with morphine in patients who had undergone general and orthopedic surgery. We assessed its effects in 46 patients undergoing minimally invasive direct coronary artery bypass, off-pump coronary artery bypass, or thoracotomy and correlated them with patient and family satisfaction. Patient-controlled analgesia (PCA) was available for 72 hours. One group received 2mg/bolus morphine randomly and double-blindly (group MO), and another group received 1mg morphine plus 5mg ketamine/bolus (group MK), both using IV-PCA. The patients' pain and satisfaction rates were assessed three times daily during hospitalization using a visual analog scale. Their families' satisfaction was assessed as well. Although the 3-day mean amount of morphine used by the MK patients was approximately 60% of that used by the MO patients, their levels of pain and satisfaction were better than those of the MO group. There was an inverted and statistically significant correlation between the patients' level of satisfaction on the second postoperative day (POD) and the satisfaction of their families on POD 2, 3, and 7 and the POD 3 patients' pain assessment in the MK group but not in the MO group. There were no differences in hemodynamic, respiratory, side effects, or complication rates between the groups. The conclusion is that the effects of adding a small ketamine dose to half of the standard morphine dose via IV-PCA after thoracotomy was superior to the standard morphine dose in terms of the patients' self-reported pain score and satisfaction, as well as the family satisfaction rate.

Supplementing relaxation and music for pain after surgery.

BACKGROUND: Most postoperative patients have unrelieved pain despite the use of patient-controlled analgesia. Nurses need additional effective modalities. Relaxation and music (RM), in addition to analgesics, have been shown to reduce pain more than do analgesics alone. OBJECTIVES: The objectives of the study were to test an intervention of patient teaching for pain management (PT) and compare it with RM for immediate and general effects on postoperative pain. METHODS: Patients having abdominal surgery and receiving patient-controlled analgesia aged 18-75 years (n = 517) were randomized to four groups: PT, RM, a combination (PTRM), and a control. A 2 x 2 factorial design was used to assess PT-Effects and RM-Effects. Immediate effects on pain were measured on visual analogue sensation and distress scales before and after five 20-min tests in the first 2 days. Because participants also listened independently, general nonimmediate effects were examined at eight other times. RESULTS: Using multivariate analysis of covariance with contrasts and pretest control, immediate RM-Effects on pain were found at Day 1 a.m. (p < .001), Day 1 p.m. (p = .04), and Day 2 a.m. (p = .04). No PT-Effects or nonimmediate RM-Effects were found. DISCUSSION: Patient teaching did not result in less pain and did not support the theoretical proposition that PT reduces pain. However, the immediate RM-Effects supported the proposition that nonpharmacological adjuvants to analgesics can ease pain without adding side effects.

Aspectos psicológicos no uso da bomba de analgesia controlada pelo paciente / Psychological aspects of the use of patient-controlled analgesia pump

JUSTIFICATIVA E OBJETIVOS: A observação dos profissionais da Equipe de Controle da Dor da Disciplina de Anestesiologia da Faculdade de Medicina da Universidade de São Paulo sugere que os pacientes em uso de bomba de analgesia controlada pelo paciente (ACP) desenvolvem o que parece ser uma relação afetiva positiva com o equipamento e reagem melhor ao tratamento da dor do que aqueles que recebem os analgésicos administrados pelos métodos tradicionais. O objetivo deste estudo foi verificar se há na literatura pesquisas que tenham investigado as hipóteses por nós consideradas de que essa relação afetiva positiva com a bomba de ACP ocorreria porque a mesma funcionaria como um "representante materno", investido de qualidades hedônicas positivas; ou como objeto transicional de afeto numa situação vivida como estado de desamparo e desmoronamento; ou que acionar a bomba de ACP teria efeito de autoinvestimento de poder. CONTEÚDO: Um levantamento nos bancos de dados PUBMED e BVS usando as palavras: Pain (dor) and helplessness (desamparo), Pain and PCA pump (bomba de ACP), Pain and helplessness and PCA pump, Coping (enfrentamento) and pain and PCA pump, Analgesia controlada pelo paciente e Analgesia controlada pelo paciente e psicologia, identificou 4693 resultados, sendo selecionados 20 abstracts do PUBMED, dos quais, em posterior exame, foram selecionados 6 relativos à dor e desamparo e 10 relativos à dor e a bomba de ACP.CONCLUSÃO: A literatura ainda carece de estudos clínicos sistematizados sobre os aspectos subjetivos da adaptação dos pacientes ao uso da bomba ACP, e os estudos que examinam a satisfação do paciente devem ser incrementados visando a melhor utilização desse recurso terapêutico que melhora o manuseio e controle farmacológico da dor. Este estudo levanta algumas hipóteses, sugere alguns conceitos-chave e faz algumas considerações nessa direção.

BACKGROUND AND OBJECTIVES: Professionals of the Pain Control Team of the Anesthesiology Discipline, School of Medicine, University of São Paulo observed that patients under patient-controlled analgesia (PCA) pump develop what seems to be a positive affective relationship with the equipment and better react to pain treatment as compared to those receiving analgesics via traditional methods. This study aimed at verifying whether there are in the literature studies investigating our hypothesis that such positive affective relationship with PCA pump would happen because it function as a "maternal representative", invested of positive hedonistic qualities; or as a transitional object of affection in a situation lived as a state of helplessness and collapse; or that activating the PCA pump would have an effect of self-empowerment.CONTENTS: A survey on PUBMED and BVS databases using the words: Pain and helplessness, Pain and PCA pump, Pain and helplessness and PCA pump, Coping and Pain and PCA pump, Patient-controlled analgesia and Patient-controlled analgesia and psychology has found 4693 results, of which 20 PUBMED abstracts were selected, from which, in a further analysis, 6 were selected with regard to pain and helplessness and 10 with regard to pain and patient-controlled analgesia pump.CONCLUSION: Literature still lacks systematized clinical studies on the subjective aspects of patients? adaptation to the use of PCA pump and studies analyzing patients? satisfaction should be incremented aiming at a better use of such therapeutic tool which improves pain management and pharmacological control. This study raises some hypotheses, suggests some key-concepts and makes some considerations in this direction.

Development and validation of a new instrument to evaluate the ease of use of patient-controlled analgesic modalities for postoperative patients.

OBJECTIVE: To describe the development and psychometric evaluation of a questionnaire assessing the ease of use that patients associate with patient-controlled analgesia (PCA) modalities. METHODS: Qualitative interviews were conducted with patients who had experience with intravenous (IV) PCA for postoperative pain management to generate items relevant to the ease of using PCA modalities. The content validity of the resulting questionnaire was examined through follow-up patient interviews, and an expert panel reviewed the questionnaire. Cognitive debriefing interviews were conducted with patients to determine the clarity and content of the instructions, items, and response scales, and the ease of completing the instrument. Psychometric evaluation was performed with patients who had undergone surgery and received IV PCA for postoperative pain management. Item and scale quality and the internal consistency reliability of the questionnaire were assessed. Construct validity was evaluated by examining the relationship between subscales of the questionnaire with patient-reported outcome measures. Known-groups validity was determined by assessing the instrument's ability to differentiate between patients with versus without an IV PCA problem. A potential limitation of this study was the exclusive sampling of patients who had experience with IV PCA. RESULTS: The Patient Ease-of-Care (EOC) Questionnaire included 23 items in the following subscales: Confidence with Device, Comfort with Device, Movement, Dosing Confidence, Pain Control, Knowledge/Understanding, and Satisfaction. Coefficient alpha reliability estimates were ≥ 0.66 for Overall EOC (includes all subscales except Satisfaction) and all EOC subscales. Construct validity was supported by the moderate relationship between the Pain Control subscale and measures of pain severity and pain interference; additional evidence of construct validity was provided by correlations of the Confidence with Device subscale, the Satisfaction subscale, and Overall EOC with measures of pain severity, pain interference, and satisfaction. Significant mean score differences were reported between participants with and without IV PCA problems for Overall EOC and for the Comfort with Device, Confidence with Device, Movement, Pain Control, and Satisfaction subscales indicating known-groups validity. CONCLUSIONS: Results provide evidence for the reliability and validity of the Patient EOC Questionnaire as a measure of the ease of use that patients associate with PCA systems and may be useful for evaluating emerging PCA modalities.

Patients' assessment of the convenience of fentanyl HCl iontophoretic transdermal system (ITS) versus morphine intravenous patient-controlled analgesia (IV PCA) in the management of postoperative pain after major surgery.

The patient-controlled fentanyl HCl iontophoretic transdermal system (ITS) is a compact, self-contained, needle-free system that has been approved for acute postoperative pain management in hospitalized adults. The objective of the present analysis was to evaluate patients' assessment of fentanyl ITS and morphine intravenous patient-controlled analgesia (IV PCA) convenience on 7 different subscales, using a validated patient ease of care (EOC) questionnaire in 2 prospective, open-label, randomized, phase IIIb clinical trials. Patients received fentanyl ITS or morphine IV PCA (N = 1,305) for up to 72 h after total hip replacement surgery (THR study) or abdominal or pelvic surgery (APS study). For the majority of items on the patient EOC questionnaire, trends suggest that greater percentages of patients reported the most positive response for fentanyl ITS than they did for morphine IV PCA in both studies; differences were particularly noteworthy for items on the Movement subscale. In the THR study, more patients in the fentanyl ITS group were responders compared with those in the morphine IV PCA group for the subscales Confidence with Device, Pain Control, Knowledge/Understanding, and Satisfaction. In the APS study, responder rates for these subscales did not differ between treatment groups. These findings indicate that patients assessed the EOC associated with fentanyl ITS higher compared with morphine IV PCA for the management of acute postoperative pain and suggest that fentanyl ITS has the potential to improve acute postoperative pain care for patients and nurses.

Incidence of urinary retention in patients with thoracic patient-controlled epidural analgesia (TPCEA) undergoing thoracotomy.

Up to 100% of patients treated with epidural analgesia can experience urinary retention, which may be related to dermatomal level of the epidural block, epidural medication, and surgical procedure. This study was designed to identify the incidence of urinary retention in patients who receive thoracic patient-controlled epidural analgesia (TPCEA) after thoracotomy. Forty-nine patients were enrolled and received epidural infusion of ropivacaine 0.2% or mixture of bupivacaine 0.1% with hydromorphone 0.015 mg/mL. Epidural catheter placement level was verified by chest X-rays. Indwelling urinary catheters were removed between 12 and 48 h after surgery when no longer required for fluid monitoring. Four hours later, patients were assessed for urinary retention using bladder ultrasound. Residual bladder volume was recorded, and urinary retention was defined as an inability to void or a bladder volume of greater than 600 mL at 4 h. Twenty-four hours after the catheter removal, patients completed a questionnaire to assess their perception of the indwelling catheter before and after its removal. Five participants (approximately 10%) with epidural catheters between T3 and T5 with bupivacaine/hydromorphone epidural solution were recatheterized. No association was established between catheter level, drug type, infusion rate, and urinary retention. Although 76% of patients did not report any physical discomfort with the indwelling urinary catheter, 66% felt relief after its removal and 18% did not ambulate with the inserted urinary catheter. The incidence of postoperative urine retention was low (10%), indicating that unless required for other purposes, indwelling urinary catheters may be removed between 12 and 48 h after surgery while receiving TPCEA.