Delayed epidural catheter removal: the impact of postoperative coagulopathy.

A retrospective analysis of 413 patients who received postoperative epidural analgesia under a standardized protocol found that 84 (20%) had a duration of epidural catheterization of greater than four days. The most common reasons were significant pain (n=64, 15%) and coagulopathy (n=26, 6%). Risk factor analysis for coagulopathy showed an odds ratio of 10.1 (95% confidence interval 4.2-24.5) for prolonged epidural catheterization among patients undergoing hepatectomy. Magnetic resonance imaging, performed in four patients with clinical signs suggestive of epidural haematoma, was negative for a space-occupying lesion in all cases. Eleven patients developed fever and clinical signs suggestive of epidural catheter-related infection, necessitating early catheter removal. Sixteen patients had persistent lower limb weakness at 24 hours after catheter removal. The signs soon resolved in all except two, one of whom had neuropathy related to intraoperative positioning and the other preoperative weakness. Accidental epidural catheter dislodgement occurred in 29 patients (7%) and is potentially hazardous if coagulopathy is unresolved. The risk-benefit ratio and factors complicating catheter removal, especially coagulopathy, should be considered when deciding whether to use epidural techniques.

Functional improvement after physiotherapy with a continuous infusion of local anaesthetics in patients with complex regional pain syndrome.

Three patients were referred to our pain clinic with evidence of complex regional pain syndrome in their extremities. Two presented at the atrophic stage with joint contractures. Multiple analgesics had been prescribed without long-lasting relief. Physiotherapy was required to improve physical activity but was severely limited by pain. We instituted local anaesthetic infusion with the possibility of self-supplementation to facilitate physiotherapy; two via brachial plexus catheters for hand pain and one via epidural catheter for knee pain. Although their resultant pain scores were variable after cessation of local anaesthetic infusion, all the affected joints exhibited marked improvement in range of movement. We propose that this technique is a useful option for patients in all stages of complex regional pain syndrome where the emphasis is now directed toward functional improvement.

Neurolytic celiac plexus block for visceral abdominal malignancy: is prior diagnostic block warranted?

Neurolytic celiac plexus block is a recognised treatment for visceral abdominal pain due to malignancy. The need for a diagnostic celiac plexus block prior to neurolytic blockade is of questionable value, as it may not predict a positive response and may incorrectly predict a lack of response. Our objective is to evaluate the efficacy of diagnostic celiac plexus block. The records of 59 patients treated with celiac plexus block during 1994-2000 were retrospectively reviewed. Diagnostic block was performed on 32 patients prior to the decision for subsequent neurolytic block (Group 1). Another 27 patients were directly treated with a neurolytic celiac plexus block (Group 2). Response of Group 1 to diagnostic and neurolytic blocks was compared. Data from Group 2 was used to project the response of Group 1 should those patients with negative response to diagnostic block proceeded to neurolytic block. A two-by-two table was then constructed. The diagnostic celiac plexus block predicted a positive response with a sensitivity of 93% and a specificity of 37%. The positive predictive value was 85% and the negative predictive value was 58%. The estimated "number needed to test" before a "true" nonrespondent to lytic block to be detected was 16.7. Therefore, a positive response to diagnostic block correlates positively with neurolytic celiac plexus block for abdominal visceral pain due to malignancy. However, diagnostic block is a poor predictor when the response is negative. Hence, its clinical role is questionable and may not be warranted for patients with terminal malignancy.

The impact of postoperative nausea and vomiting on the practice of day surgery for Chinese women with breast diseases.

Background: Day surgery for breast disease is becoming popular but a key limiting factor of success is the development of postoperative nausea and vomiting (PONV). Methods: A prospective study of PONV was conducted on 62 patients undergoing breast surgery under general anaesthesia. Lumpectomy was performed in 40 patients. The other 22 patients underwent major breast operations including modified radical mastectomy and wide local excision and axillary dissection. A total of 10 mg of metoclopramide was injected intravenously on induction of anaesthesia and oral metoclopramide was prescribed as required to treat PONV. Results: PONV occurred in six (15%) and 14 (63.6%) patients undergoing minor and major operations respectively. The onset of PONV occurred earlier following minor than major operations. Eleven patients required antiemetics. Univariate analysis showed that the incidence and the first onset of PONV was significantly associated with major breast operation and duration of operation. Multiple regression analysis demonstrated that duration of operation was the only independent factor that affects the rate of PONV. However, the onset of nausea was associated with major surgery and the onset of vomiting with the duration of the operation. Patients with minor breast surgery were all discharged on the day of surgery. None of the six patients with PONV required readmission. Conclusion: Minor breast surgery can be readily performed as a day case. More effective antiemetic measures against PONV may be required in major breast surgery.

Combined effect of isoflurane and esmolol on sympathetic responses to tracheal intubation.

BACKGROUND: Influences of isoflurane and esmolol on endotracheal intubation induced sympathetic changes could be different. The effect of isoflurane and its combination with esmolol on catecholamine, blood pressure and pulse during endotracheal intubation were investigated. METHODS: Thirty patients were anesthetized with 3.0% isoflurane and tracheal intubation was carried out at the 5th min following the exposure to isoflurane. Half of them received intravenous saline and the other half received esmolol 2 mg/kg at the 4th min. Cardiovascular parameters were recorded and venous blood samples were taken for measurement of catecholamines every min. RESULTS: One min after administration of isoflurane, there was increase of heart rate (P < 0.05), while at the same time the epinephrine level fell (P < 0.05) and norepinephrine level remained unaltered. Both catecholamines raised after intubation (P < 0.05). The sympathetic responses to and the beta-antagonistic effect of esmolol on intubation were not significantly changed in the presence of isoflurane. CONCLUSIONS: Isoflurane increased heart rate while paradoxically decreased epinephrine. Norepinephrine was more specifically related to endotracheal intubation, for its serum level had little change before the event. Based on catecholamine findings, the mechanism of isoflurane effect on the sympathetic system is probably different from that of endotracheal intubation.

Effect of pre-incision skin infiltration on post-hysterectomy pain--a double-blind randomized controlled trial.

In this double-blind placebo-controlled randomized trial, we compared the analgesic effect of preoperative 0.25% bupivacaine (n = 21) skin infiltration with normal saline (n = 19) in patients undergoing abdominal hysterectomy through a lower midline incision. All patients received postoperative patient-controlled analgesia with morphine and were followed for 72 hours. The main outcome measures were morphine consumption and pain score at rest, and the contribution of different components of pain was also assessed prospectively. No statistically significant differences were found. All except one patient (n = 39) could distinguish the different characteristics of somatic and visceral pain. Visceral pain predominated in the first 48 hours. We concluded that local anaesthetic infiltration is not effective in reducing pain after abdominal hysterectomy. Effective postoperative analgesia should aim to eliminate the visceral pain component.

Brachial plexus infusion of ropivacaine with patient-controlled supplementation.

PURPOSE: To report the use of continuous brachial plexus analgesia to facilitate physiotherapy CLINICAL FEATURES: A 34-yr-old man had contractures of the fingers of his dominant hand following a crush injury in 1996. After several operations, he continued to experience severe pain and disability. In order to facilitate painfree active and passive physiotherapy, we performed an axillary brachial plexus block. After insertion of a brachial plexus catheter via the axilla, analgesia was continued for a period of one week using a 3 mlxhr(-1) background infusion of ropivacaine 0.2% with the facility for additional patient-controlled 1 ml boluses. Both active and passive physiotherapy was carried out daily for the entire week. CONCLUSION: This technique was successful with no major complications and resulted in a marked reduction in pain, with improved range of finger movement and general upper limb function.

Preoperative Multidimensional Affect and Pain Survey (MAPS) scores predict postcolectomy analgesia requirement.

OBJECTIVES: One aim of this study was to evaluate the relation of scores on the Multidimensional Affect and Pain Survey (MAPS) that was administered before surgery to postoperative morphine consumption and patient-controlled analgesia. A second aim of the study was to compare the ability of MAPS administered postsurgery with the commonly used Numerical Pain Rating Scale to predict patient-controlled analgesia behavior. DESIGN: The MAPS questionnaire measures pain, suffering, and well-being. It was administered to patients 1 day before and 1 day after left hemicolectomy for colon cancer. The relations of the two scores to postoperative pain control were determined. PATIENTS: Thirty-four patients in the surgical ward of a general hospital admitted for colorectal cancer surgery participated in this study. RESULTS: High preoperative MAPS scores on sensory and emotional words predicted postoperative morphine dosage, dose presses, and lockout presses. Greater morphine consumption was correlated positively with high presurgery MAPS scores in four of the eight "Suffering" subclusters (Depressed Mood, Anger, Anxiety, and Fear). High presurgery MAPS scores in 13 of the 17 "Sensory Qualities" subclusters (e.g., Bothersome, Intense Pain, Pain Extent, Incisive Pressure, Traction/Abrasion) were correlated positively with lockout presses. Neither the postsurgery MAPS nor the postsurgery Numerical Pain Rating Scale predicted patient-controlled analgesia behavior. CONCLUSION: The emotional states and attitudes of the patients toward pain before surgery are important factors in determining patient-controlled analgesia pressing behavior and postoperative demand for analgesics.

Prevention of postoperative nausea and vomiting in gynaecological laparotomies: a comparison of tropisetron and ondansetron.

In a randomized, double-blind study, the antiemetic efficacy of a single bolus of tropisetron 5 mg (group T, 37 patients), ondansetron 4 mg (group O, 39 patients) or saline (group C, 45 patients) given at induction was compared in a homogeneous group of 121 patients undergoing gynaecological laparotomy and receiving postoperative patient-controlled intravenous morphine for 24 to 48 hours. Fewer group T and group O patients developed severe nausea compared to group C (P < 0.01, log rank test in Kaplan-Meier analysis). Group T patients also had lower nausea scores than group O at 8 to 16h (P < 0.05). The overall incidences of severe nausea in groups T, O, and C were 5.4%, 17.9%, and 44.4% respectively (P < 0.001, group T vs group C; P < 0.05 group O vs group C). In conclusion, the 5-hydroxytryptamine 3 receptor antagonists tropisetron and ondansetron were superior to placebo in preventing PONV.

Increased nausea and dizziness when using tramadol for post-operative patient-controlled analgesia (PCA) compared with morphine after intraoperative loading with morphine.

Thirty-eight ASA I-III patients undergoing lower abdominal operations were randomly allocated to receive either morphine (group M, patient-controlled analgesia bolus = 1 mg of morphine) or tramadol (group T, patient-controlled analgesia bolus = 10 mg of tramadol) for post-operative patient-controlled analgesia (PCA) after receiving morphine intraoperatively. There were no between-group differences in the pain, sedation or vomit scores. The nausea scores were significantly higher in group T in the initial 20 h and between 32 and 36 h (P < 0.01, 0-4 and 8-12 h; P < 0.05, 4-8, 12-16, 16-20 and 32-36 h). The incidence of dizziness was also significantly higher in group T (68.4% vs. 31.6%, group T vs. group M, P < 0.05). There was no difference in the overall satisfaction. We conclude that the use of tramadol, compared with morphine, for post-operative PCA after intraoperative loading with morphine is associated with more nausea and dizziness, but with similar sedation, quality of analgesia and patient satisfaction.

An audit of the safety of an acute pain service.

We audited and analysed the adverse effects and safety of postoperative pain management on 2509 consecutive patients under care of the Acute Pain Service at a tertiary referral teaching hospital over a 32-month period. Our standard respiratory monitoring consisted of continuous pulse oximetry, hourly respiratory rate counting, sedation scoring and intermittent arterial blood gas sampling. This protocol was reliable and detected six episodes of bradypnoea, 13 of hypercapnia and 23 of oxygen desaturation occurring in 39 patients (1.8% of all spontaneously breathing patients). Two patients required naloxone injection and none had long-term sequelae. Hypotension due to epidural bupivacaine 0.0625% and fentanyl 3.3 micrograms.ml-1 infusion occurred in four patients (1.2%), all with a sensory block higher than T5. They readily responded to fluid infusion and ephedrine (two patients). Postoperative nausea or vomiting occurred in 723 (28.8%) and 380 (15.1%) patients, respectively. Odds ratio analysis showed that the risk factors for postoperative nausea and vomiting were: female gender, gynaecological operations, nongeriatric patients and systemic analgesia. Postoperative nausea and vomiting decreased analgesic efficacy by discouraging the use of patient-controlled analgesia and was regarded as equally distressing as pain. Other side-effects included: pruritus in 182 patients; dizziness in 333 and lower limb weakness in 73 (21.2% of patients receiving epidural local anaesthetics). It is concluded that a standard monitoring and management protocol, an experienced nursing team and reliable Acute Pain Service coverage is mandatory for the safe use of modern analgesic techniques.

Epidural infusion of bupivacaine 0.0625% plus fentanyl 3.3 micrograms/ml provides better postoperative analgesia than patient-controlled analgesia with intravenous morphine after gynaecological laparotomy.

One hundred and twenty women undergoing gynaecological abdominal operations were randomized to receive either epidural bupivacaine 0.0625% + fentanyl 3.3 micrograms/ml infusion (Group EPI, n = 57), or patient-controlled intravenous morphine analgesia (Group PCA, n = 54) for postoperative pain relief. The groups were comparable in demographic data, types and duration of operation. Group EPI achieved significantly lower verbal rating scale of pain (VRS) at rest at 0, 4, 12, 16, 20, 28 and 40th postoperative hours. The VRS during cough were also significantly lower in Group EPI at 0, 4, 8, 12, 28 and 36th postoperative hours. None of the patients had respiratory depression or hypotension. Nausea/vomiting occurred in 52.6%/33.3% of patients in Group EPI and 52.7%/37.0% in Group PCA. Most patients (84.2% in Group EPI and 72.2% in Group PCA) rated their pain management as "good". We conclude that epidural infusion of bupivacaine 0.0625% and fentanyl 3.3 micrograms/ml provide better analgesia than patient-controlled intravenous morphine after gynaecological laparotomy.

Comparison of tramadol and tramadol/droperidol mixture for patient-controlled analgesia.

PURPOSE: To compare the analgesic efficacy and side effects of tramadol vs tramadol and droperidol for post-operative patient-controlled analgesia (PCA). METHODS: Randomised, double-blind study. Thirty-four patients undergoing elective colorectal or head and neck surgery were allocated to Group 1 (n = 18, PCA bolus 10 mg tramadol) or Group 2 (n = 16, PCA bolus 10 mg tramadol + 0.1 mg droperidol). Anaesthesia was induced with fentanyl and thiopentone and maintained with O2, N2O plus enflurane or isoflurane with iv morphine at doses decided by the attending anaesthetists. Muscle relaxation was achieved with atracurium or vecuronium. Patients were observed four-hourly for pain using an 11-point verbal rating scale (VRS). Nausea and vomiting, and sedation were assessed using four-point scales post-operatively. Vital signs, request for rescue anti-emetic and analgesic, and overall satisfaction were recorded. RESULTS: The mean nausea scores were lower in Group 2 (1.00 +/- 1.33 vs 0.06 +/- 0.25 at 0-8 hr, 1.22 +/- 1.93 vs 0.06 +/- 0.25 at 8-16 hr, P < 0.01; 0.81 +/- 1.68 vs 0 at 32-40 hr, P < 0.05; Group 1 vs Group 2). The vomiting scores were also lower (0.50 +/- 1.04 vs 0 at 0-8 hr, 0.67 +/- 1.50 vs 0, at 8-16 hr, P < 0.05; Group 1 vs Group 2). Seven (39%) patients in Group 1, but none in Group 2 requested rescue anti-emetic (P < 0.01). There were no differences in VRS, sedation score, overall satisfaction or vital signs. CONCLUSION: Tramadol and droperidol combination is superior to tramadol alone for post-operative PCA. It provides a similar quality of analgesia with less nausea and vomiting and without an increase in sedation.

Postoperative analgesia reduces mortality and morbidity after esophagectomy.

BACKGROUND: To study the influence of postoperative analgesia on morbidity and mortality after esophagectomy. METHODS: The outcomes of 578 patients who underwent one-stage resection between 1986 and 1995 were analyzed. Patients who received either epidural morphine, patient-controlled analgesia, or continuous intravenous morphine infusion supervised by an anesthesiology-based acute pain service (group APS, n = 299) were compared with those for whom conventional intramuscular meperidine injections were used (group CON, n = 279). RESULTS: For patients who underwent transthoracic esophagectomy, group APS (n = 226) had a lower incidence of pulmonary complications (13% versus 25%, P = 0.002), cardiovascular complications (21% versus 43%, P < 0.001), and hospital mortality (8% versus 14%, P = 0.038) when compared with group CON (n = 189). No similar difference was demonstrated in patients who underwent esophagectomy without thoracotomy. The hospital stay (days) was shorter in group APS than in group CON for both transthoracic esophagectomy (22 +/- 20 versus 30 +/- 37, P = 0.005) and nontransthoracic esophagectomy patients (19 +/- 13 versus 25 +/- 21, P = 0.029). CONCLUSION: Adequate postoperative analgesia is associated with lower cardiopulmonary complications, lower mortality and reduced cost in patients undergoing transthoracic esophagectomy.

The efficacy, applicability and side-effects of postoperative intravenous patient-controlled morphine analgesia: an audit of 1233 Chinese patients.

We analyzed data from 1233 Chinese patients of a wide age range who received patient-controlled analgesia (PCA) intravenous morphine for postoperative pain relief, during the period of January 1992 to May 1995. The analgesic regimen was standardized as follows: PCA bolus 1 to 1.5 mg; lock-out interval 5 minutes; one-hour maximum dose 0.075 to 0.1 mg.kg-1 and background infusion 0 or 0.5 mg.h-1. Most patients underwent major surgery that was broadly subclassified according to the anatomical area involved. The median verbal numerical rating scales of pain (0 to 10) at rest and while coughing for the first, second and third 24 hours were 3.0/5.0, 1.5/4.0 and 0/3.0 respectively and the corresponding demand to delivery ratios were 2.8 +/- 2.9, 2.6 +/- 2.4 and 2.4 +/- 2.6. The overall morphine consumptions in 1004 of these Chinese patients were 27.5 +/- 16.8, 17.8 +/- 16.1 and 18.1 +/- 21.0 micrograms.kg-1.h-1 during the first 16, 17 to 41 and 42 to 66 postoperative hours respectively. These figures were the same as for Caucasian patients managed in the same institution. Morphine consumption was significant higher following thoracic, upper abdominal and spinal surgery. Also it was higher in patients younger than 65 years, males, cigarette smokers and those with ASA physical status I or II. The commonest side-effects were nausea (34.5%) and vomiting (18.2%). Bradypnoea and oxygen desaturation occurred in 0.5% and 1.6% respectively. All cases were promptly detected and managed with no adverse outcomes. Most patients were satisfied (76.7% ranked "good") with their postoperative analgesia. The commonest reasons for dissatisfaction were inadequate pain relief, nausea and reluctance to self-control analgesic administration. It is concluded that PCA with intravenous morphine is effective and safe as a routine postoperative technique for Chinese surgical patients.

A clinical audit for postoperative pain control on 1443 surgical patients.

BACKGROUND: Moderate to severe pain occurs in 75 to 100% of patients after major operations. Pain control techniques, for examples the patient controlled analgesia (PCA) and epidural analgesia, are effective in relieving postoperative pain. Routine delivery of these pain control techniques to patients undergoing operations can be provided by an anaesthesiologists-based acute pain service (APS). METHODS: This manuscript audited postoperative pain management service to 1369 ethnic Chinese patients and 74 patients of other races, over a 30 mon period in a teaching hospital in Hong Kong. The APS was prioritized to elderly patient (36.1%, aged 65 or higher), patients of poor physical condition (27.0% ASA III or IV) and those undertaken major operations. Most patients (1348, 93.4%) received either one of the four standardized analgesic regimens including PCA or epidural analgesia. RESULTS: The median verbal quantitative scale of pain (VQS) at rest/movement were 2.0/4.3 on operative day and 0/0.6 on 4th postoperative day. The morphine consumption in 665 Chinese patients (PCA intravenous morphine) was 26.1 +/- 14.3 mg/kg/h (mean +/- SD) during the first 20 postoperative hours. This decreased to 18.1 +/- 15.1 at 21th to 44th and 18.5 +/- 14.9 at 45th to 68th hours postoperatively. There was no difference in morphine consumption between Chinese patients and other races. The incidence for nausea and vomiting were 26.5% and 13.3%, respectively. Respiratory derangement occurred in 23 patients (1.9%) and almost always accompanied by somnolence. Most patients (1176, 81.5%) rated their postoperative analgesia on discharge from the care of APS. CONCLUSIONS: Effective and safe postoperative analgesia in Chinese patients can be achieved with currently available pain control techniques such as epidural and PCA. APS is a practicable approach to deliver these techniques to postoperative patients on a routine basis.