Patient perspective on herpes zoster and its complications: an observational prospective study in patients aged over 50 years in general practice.

Understanding the effect of herpes zoster and zoster-related pain should inform care to improve health-related quality of life in elderly patients. A 12-month, longitudinal, prospective, multicenter observational study conducted in primary care in France enrolled patients aged ≥ 50 years with acute eruptive herpes zoster. Patient-reported zoster-related pain was assessed by validated questionnaires (Douleur Neuropathique en 4 Questions [DN4], Zoster Brief Pain Inventory [ZBPI], and Neuropathic Pain Symptom Inventory [NPSI]) on days 0 and 15, and at months 1, 3, 6, 9, and 12. Health-related quality of life was assessed by the 12-item short-form health survey (SF-12) and the Hospital Anxiety and Depression scale on day 0 and at months 3, 6, and 12. Of 1358 patients included, 1032 completed follow-up. Mean ± standard deviation age was 67.7 ± 10.7 (range, 50-95) years; 62.2% were women. Most patients (94.1%) were prescribed antiviral drugs. The prevalence of zoster-related pain on day 0 and at months 3, 6, 9, and 12 was 79.6%, 11.6%, 8.5%, 7.4%, and 6.0%, respectively. Patients with persistent pain had lower scores on the physical and mental component summaries of the SF-12 and the ZBPI interference score than those without pain. By logistic regression analysis, main predictive factors on day 0 for postherpetic neuralgia at month 3 were age, male sex, ZBPI interference score, Physical Component Summary score of the SF-12, and neuropathic quality of pain (DN4 score ≥ 4). Despite early diagnosis and treatment with antiviral agents, many patients with herpes zoster experience persistent pain and marked long-term reduction in health-related quality of life.

Impact of systematic evaluation of pain and agitation in an intensive care unit.

OBJECTIVE: To measure the impact of implementation of the systematic evaluation of pain and agitation by nurses using the Behavioral Pain Scale (BPS), the Numerical Rating Scale (NRS) for pain, and the Richmond Agitation Sedation Scale (RASS) associated with medical staff education in analgesia and sedation management in intensive care unit (ICU) patients. DESIGN: Two-phase, prospective, controlled study. SETTING: Twelve-bed medical-surgical ICU in a university hospital. PATIENTS: Consecutive patients staying >24 hrs in ICU. INTERVENTIONS: BPS, NRS, and RASS were measured twice daily, at rest, by independent observers during 21 wks (control group) and after 4 wks of training, by nurses during 29 wks (intervention group). In the intervention group, the treating physician was alerted in case of pain defined by BPS>5 or NRS>3 or in case of agitation defined by RASS>1. MEASUREMENTS AND MAIN RESULTS: A total of 230 patients were included (control group, n=100; intervention group, n=130). Baseline characteristics were not significantly different. The incidence of pain and agitation decreased significantly in the intervention group: 63% vs. 42% (p=.002) and 29% vs. 12% (p=.002), respectively. Rate of severe pain and agitation events defined by NRS>6 and RASS>2, respectively, also decreased significantly. There were significantly more therapeutic changes in the intervention group in the way of an escalation but also in the way of a de-escalation for analgesic and psychoactive drugs. Compared with the control group, there was a marked decrease in the duration of mechanical ventilation (120 [interquartile range 48-312] vs. 65 (24-192) hrs, p=.01) and nosocomial infections rate (17% vs. 8%, p<.05) in the intervention group. There was no significant difference in median length of stay (9 [4, 15] vs. 7 [4, 13] days) and mortality in ICU (12 vs. 15%). CONCLUSIONS: Systematic evaluation of pain and agitation, and analgesics and sedatives need was associated with a decrease in incidence of pain and agitation, duration of mechanical ventilation and nosocomial infections.

Patient-controlled analgesia.

Using a portable infusion pump, intravenous opioid patient-controlled analgesia (PCA) permits a patient to self-deliver a small bolus of opioid to achieve prompt relief without over sedation. Use of PCA for pain management is increasing in hospitals, largely because it can provide equivalent or better analgesia than conventional nurse-administered opioid analgesia, and patients are more satisfied with its use. There is no decisive pharmacological or clinical argument for the choice of one opioid rather than another. Thus, morphine remains the most frequently used opioid in PCA. The adjunction of non-opioid drugs to morphine in the PCA reservoir is still very controversial. A new investigational PCA transdermal system using iontophoresis to deliver fentanyl seems to provide an adequate pain control with the advantages of needle-free, preprogrammed, self-contained device. Whatever drug or device used, the overall success of the PCA technique relies mainly on the expert supervision of nurses or anesthesiologists in an Acute Pain Service. Indeed, PCA is effective and significant only on the condition that there is careful preoperative patient education and strict postoperative monitoring. In addition, preoperative patient selection allows to exclude patients with evidence of cognitive dysfunction or physical disabilities, making the use of the patient-controlled device impossible. Caution is required among patients with respiratory or renal insufficiency. In the future, the indispensable improvement in the management of postoperative pain should lead to a greater expansion of PCA. However, more pharmaco-economic evaluations will be needed on the cost-effectiveness issue.

Posterior perineal block with ropivacaine 0.75% for pain control during and after hemorrhoidectomy.

BACKGROUND AND OBJECTIVES: As perioperative pain management is a difficult challenge during hemorrhoidectomy, we tested the hypothesis that posterior perineal block (PPB) with local anesthetics alone is able to provide adequate pain control during and after surgery. METHODS: In a prospective, blinded, randomized study, we studied analgesic conditions and side effects of PPB in American Society of Anesthesiologists (ASA) I-II patients undergoing hemorrhoidectomy. Patients received general anesthesia (GA) either with PPB (0.75% ropivacaine, 40 mL (PPB group) or without PPB (control group). All patients received intravenous morphine patient-controlled analgesia (PCA) for postoperative pain control (morphine, 1.5 mg-boluses, 8-minute lockout interval). Intra- and postoperative opioids consumption was recorded, and pain assessments were performed at 1, 2, 4, 8, 12, and 24 hours using a visual analog scale (VAS). RESULTS: VAS scores were significantly lower during the first 8 postoperative hours in the PPB group as compared with the control group (P <.001). The PPB group required significantly less opioids during anesthesia (P <.001) and during the first postoperative day (P <.001) as compared with the control group. Time to first defecation and duration of hospitalization were identical in both groups. CONCLUSIONS: The present study shows that PPB with 40 mL 0.75% ropivacaine (300 mg) was a simple, effective, and safe method to provide better postoperative analgesia than PCA alone following surgical hemorrhoidectomy. In addition, PPB was shown to significantly reduce opioid consumption intraoperatively and during the first postoperative day.

Postoperative patient-controlled analgesia in the elderly: risks and benefits of epidural versus intravenous administration.

Postoperative patient-controlled analgesia provided by the intravenous route using morphine (PCA) or by the epidural route using an opioid in combination with a local anaesthetic (patient-controlled epidural analgesia; PCEA) is not yet routinely used in the elderly. However, this modality theoretically provides adequate control of postoperative pain in such patients. Firstly, an assessment of the level of pain is particularly difficult in the elderly, and patient-controlled techniques that enable the self-administration of analgesic could resolve this problem. Secondly, these techniques provide a fine and controlled titration of analgesic doses. Since analgesic-induced adverse effects increase with age, the risk of overdose is therefore reduced. Thirdly, effective postoperative patient-controlled analgesia may attenuate detrimental physiologic responses, and contribute to improvement in patient outcomes. In the elderly, PCEA provides better pain relief, particularly for dynamic pain, and improves postoperative recovery with a low incidence of adverse effects compared with PCA. PCA and PCEA techniques have a good safety profile in the elderly only when there is careful preoperative patient selection and strict postoperative monitoring. Standard observation of vital signs, sedation and pain scores and assessment of mental status are required. Patient selection is necessary to identify those patients who may be incapable of using the device (e.g. patients with evidence of cognitive dysfunction or physical disabilities). In addition, caution is required among patients with respiratory, renal or hepatic insufficiency. PCA and PCEA are particularly useful for elderly patients undergoing major thoraco-abdominal surgery. However, there is a need for further research in elderly patients. In the future, improvements in the management of postoperative pain in the elderly will lead to a greater expansion of self-controlled techniques.