Self-administration of midazolam for postoperative anxiety: a double blinded study.

Anxiety is almost inevitably present in patients facing surgery. The optimal management of postoperative pain requires the acknowledgement of perioperative anxiety and the inclusion of pharmacological and/or non-pharmacological means of alleviating the fear and worry inherent in the surgical experience. In a double-blind randomized design, 39 patients undergoing total abdominal hysterectomies were given postoperative access to a standard patient-controlled analgesia (PCA) morphine pump for pain and a PCA pump dispensing either low-dose midazolam or saline for anxiety. Measures of anxiety and pain were completed pre-operatively and for 2 days postoperatively. Utilization of morphine and 'anxiolytic agent' were recorded. Analysis of covariance was applied to the data to control for the imbalance of cancer patients between the 2 groups. While both groups of patients chose to utilize their 'anxiety pump' throughout the study, those patients receiving midazolam had significantly lower postoperative Spielberger State Anxiety scores and visual analogue scale anxiety scores. Patient-controlled midazolam in doses used in this study were safe and effective in managing anxiety but did not influence pain scores or the amount of PCA morphine patients used. Pre-operative levels of depression were significantly associated with postoperative pain levels independent of treatment group or cancer diagnosis.

Trigger point injections vs. jet injection in the treatment of myofascial pain.

Trigger point injections using dilute solutions of local anesthetic agents have proved effective for many patients with myofascial pain. The treatment itself, however, can produce severe pain and may occasionally be associated with complications. It was determined in this study that a local anesthetic solution administered by jet injection in the area of myofascial trigger points was capable of providing short-term pain relief equal to conventional trigger point injections using a hypodermic needle and syringe. The jet injector system produced significantly less pain during treatment than conventional trigger point injections and therefore was preferred by most subjects having the opportunity to compare both forms of treatment.

Anesthesia-based pain services improve the quality of postoperative pain management.

Anesthesia-based pain services are facilitating improvements in the quality of care of surgical patients by developing and directing institution-wide perioperative analgesia programs that include interdisciplinary collaborations. However, the impact of anesthesia-based pain services has not been evaluated in a systematic fashion. This prospective multisite study (n = 23 hospitals) utilized a standardized approach to evaluate the quality of pain care provided to patients who were and who were not cared for by an anesthesia-based pain service. A total of 5837 patients were evaluated using a standardized survey that consisted of a medical record review and a patient interview. The data were collected as part of the hospitals' quality improvement activities. Forty-nine percent of the patients were cared for by an anesthesia-based pain service. Patients who received pain service care reported significantly lower pain intensity scores; had lower levels of pain in the postoperative period; had a lower incidence of pruritus, sedation, and nausea; and experienced significantly less pain than expected. In addition, these patients were more likely to receive patient education about postoperative pain management; were more satisfied with their postoperative pain management; and were discharged sooner from the hospital. The findings from this study demonstrate that the care provided by anesthesia-based pain services has a significant impact on patient outcomes.

Spinal opioids in the management of acute and postoperative pain.

The use of spinal opioids in the management of acute pain is now widely accepted. The development of acute pain services has provided standardized approaches to the management of this modality. This article discusses technical considerations, monitoring, and benefits of this approach.

Acute pain services: an academic asset.

Optimal care of surgical patients includes effective control of incisional pain. Attention is beginning to be focused on new in-hospital services created to improve the management of postoperative pain. Additional information regarding the organization and operation of this type of service, especially in the framework of a university hospital, is presented. The specific roles of an academic anesthesiologist involved in acute pain management are: to provide leadership by the development of effective services, to clarify through research optimal treatments, to train future practitioners in the management of acute pain, and to serve as a consultant for improving pain control for the whole medical community.

Acute pain management of the chronic pain patient on opiates: a survey of caregivers at University of Washington Medical Center.

OBJECTIVE: The provision of acute pain management for the chronic pain patient can pose a challenge. We sought to characterize management issues. SUBJECTS/SETTING: An anonymous survey was distributed to 270 physicians and 212 nurses at University of Washington Medical Center (UWMC) in an attempt to characterize management issues. DESIGN: Caregivers were queried regarding treatment modalities, efficacy of anxiolysis, patient attributes, concern of the quantity of medication, criteria for patient evaluation, and other management issues. RESULTS: Of the respondents, 61.8% were physicians, and 38.2% were nurses. The mean duration in practice was 7.7 years. The responses from the two groups were similar. Seventy-five percent reported using different pain-evaluation techniques for chronic pain patients than those utilized for the "average" patient. Pain scores were used frequently in the average patient, whereas ability to perform activities was used more commonly in the chronic pain patient (p < 0.0001). Half of the respondents expressed concern regarding the amount of medication used and level of sedation. The same proportion found anxiolysis to be a helpful adjunct. The use of a time-contingent "pain cocktail" as an oral medication was a useful strategy for 88% of respondents. The least labor-intensive modality reported was patient-controlled analgesia (PCA) for 84.5% of respondents; intravenous opiate fusion, 5.3%; and epidural analgesia, 11.2%. CONCLUSIONS: The survey describes caregiver concerns regarding this patient population, including medication use, sedation, length of hospital stay, and evaluation techniques.

Patient satisfaction with intravenous PCA or epidural morphine.

In many institutions postoperative patients may receive morphine for analgesia administered into the epidural space, epidural opioid analgesia (EOA), or through intravenous self-administered patient-controlled analgesia pumps (PCA). Although a number of studies have compared the two approaches with regard to efficacy and side effects, there is less known with regard to patient satisfaction and its sources. In this study, 711 patients using PCA morphine and 205 patients receiving epidural morphine following a variety of gynaecological, urological, orthopaedic, and general surgical procedures rated their satisfaction with the method they used on a 0-10 verbal analogue satisfaction scale (0 = very dissatisfied; 10 = very satisfied). A consecutive subset of 100 patients (50 from EOA group and 50 from the PCA group) underwent further evaluation to identify advantages and disadvantages of the technique used which contributed to their satisfaction and/or dissatisfaction. Overall satisfaction (mean +/- SD) in the two large groups was 8.6 +/- 1.8 for PCA and 9.0 +/- 1.5 for EOA (P < 0.01). In the subset of 100 patients, there were differences between the EOA and PCA groups with regard to the advantages and disadvantages selected. Patients in the PCA group identified "personal control" and "method worked quickly" as advantages whereas patients receiving EOA selected "clear mind," "effective relief resting," and "effective relief while moving or coughing." The single disadvantage identified more frequently by PCA patients was "pain immediately after surgery before method became effective." Disadvantages identified more frequently by EOA patients were "side effects" and "poor pain relief." We conclude that overall patient satisfaction was high whether patients received PCA or EOA.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of acute pain.

This review discusses the inadequacies of postoperative pain management in the UK and recommendations to improve its quality. Advanced pain-relieving techniques are available; in this article we discuss the practical considerations of delivering these successfully to patients through the introduction of acute pain teams, and especially through extension of the nurses' role.

Experimental evaluation of local anaesthetic solutions using rat infraorbital nerve block.

The analgesic effectiveness of various local anaesthetic solutions was measured in the distribution of the infraorbital nerve of the rat. Using Sprague-Dawley rats sedated with phenobarbitone 25 mg/kg intraperitoneally and a simple stereotactic technique, 0.2 ml of solution was deposited at the infraorbital notch. The onset and duration of analgesia were ascertained by timing the unilateral absence of aversive response to pinching the upper lip, tested at intervals of five minutes. The experiments were performed with coded solutions, the entire code being preserved intact until completion of the study. Solutions were tested on sets of eight animals weighing 500--600 g. The average duration (minutes +/- S.D.) of analgesia produced by the respective injectates was as follows: Lidocaine 0.5% -42+/-12 Lidocaine 1.0% -47+/-10 Mepivacaine 0.5% -58+/-13 Mepivacaine 1.0% -78+/-23 Procaine 0.5% -0+/-0 Procaine 1.0% -34+/-10 Procaine 1.5% -46+/-13 2-Chloroprocaine 1.5% -38+/-9 Bupivacaine 0.5% -100+/-40 Etidocaine 1.0% -59+/-25 Tetracaine 0.2% -0+/-0 Tetracaine 0.3% -0+/-0 Comparison with other animal models used to evaluate conduction block indicates that this technique affords an improved, standardized and reliable experimental guide to the clinical analgesic properties of local anaesthetic agents.

Drug choices for intravenous and spinal analgesia.

Opioids remain at the center of most postoperative pain control therapies. The choice between full agonist opioids should be determined by the time for a given dose to produce its maximum effect (i.e., latency to peak effect), and the duration of action. There is little to choose between different opioids administered by patient-controlled analgesia. Parenterally-administered NSAIDs (e.g., ketorolac) contribute significantly to analgesia and reduce opioid requirements. Morphine may be the opioid of choice for epidural administration. The combination of epidural opioids and local anesthetics provides synergistic analgesia and appears to provide superior analgesia with activity. Several nonopioid receptor agonists are under investigation as neuraxial analgesics.

Epidural block for treatment of renal colic during pregnancy.

This report documents for the first time the application of continuous segmental epidural block (T11 to L2) to treat renal colic complicating pregnancy. The block was maintained for 16 hours and the pain did not recur. Advantages for the mother, and possibly for the foetus, are considered. The published experience of others using this technique in nonpregnant patients is reviewed.

Epidural morphine after anterior cruciate ligament repair: a comparison with patient-controlled intravenous morphine.

To compare the management of postoperative pain using morphine administered by epidural catheter with intravenous patient-controlled analgesia (PCA), we prospectively studied 47 consecutive cases involving repair of the anterior cruciate ligament of the knee. Both the quality of analgesia and the incidence of side effects were documented. Compared with patients receiving PCA morphine, patients given epidural morphine reported significantly lower pain scores both at rest (0.7 +/- 1.1 versus 3.4 +/- 2.1, P less than 0.01) and with mobilization (3.2 +/- 2.1 versus 6.1 +/- 2.1, P less than 0.01). Although patients receiving epidural morphine had a greater incidence of urinary retention, there were no significant differences in the incidence of nausea or pruritus. There was no respiratory depression in either group. We conclude that epidural morphine provides superior analgesia with a clinically inconsequential increase in side effects. Further, epidural morphine may have special advantages when early mobilization is indicated.

Age predicts effective epidural morphine dose after abdominal hysterectomy.

To determine whether there is a relation between patient age and the effective dose of epidural morphine for relief of incisional pain after abdominal hysterectomy, experience treating 66 patients between the ages of 22 and 84 years was retrospectively examined. Linear regressions were plotted for age vs effective 24-hr morphine dose, age vs pain at rest, and age vs pain during coughing. To evaluate the frequency of side effects, the population was classified into three age groups (less than 40, 40-60, greater than 60 yr) and examined by Fisher's exact test for possible differences. Although there was wide interpatient variability, there was a correlation between patient age and effective 24-hr morphine dose (r = -0.40, P less than 0.01). The relation is described by the following equation: 24-hr morphine dose (mg) = 18-age(0.15). The quality of analgesia did not diminish with the smaller doses administered to the older patients. The frequency of side effects did not differ significantly in the three age groups. These observations may be related to higher CSF morphine concentrations or to a greater analgesic effect from morphine absorbed systemically from the epidural space in older patients.

Postoperative pain management in gynecology oncology patients utilizing epidural opiate analgesia and patient-controlled analgesia.

Intraoperative analgesia is the purview of anesthesiologists whereas postoperative pain is traditionally managed by surgeons. This series reports 19 months experience of anesthesiologists using epidural opiate analgesia (EOA) or patient-controlled analgesia (PCA) to treat postoperative pain in 302 patients following surgery for pelvic malignancy. For the 244 (81%) patients who received EOA, a lumbar epidural catheter was placed just prior to surgery, injected with local anesthetic for intraoperative analgesia, and injected with preservative-free morphine at appropriate intervals postoperatively to relieve pain. Fifty-eight patients (19%) used PCA which consisted of small self-administered boluses of intravenous narcotics. All patients were seen daily to ensure adequate analgesia and to treat side effects. Utilizing a 0-10 verbal rating scale (0 = no pain; 10 = worst pain imaginable), mean pain with EOA was 0.75 at rest and 2.6 with coughing. Mean pain ratings with PCA were 2.8 at rest and 5.0 during coughing. Side effects with EOA included nausea or vomiting (28%) and pruritus (20%). The only side effect of significance with PCA was nausea or vomiting (21%). All patients improved with treatment of side effects. Acceptance of these techniques is indicated by a steady increase in the number of gynecologic oncology surgical patients utilizing these modalities (50% at the outset to 87% currently).

Electrical nerve location: numerical and electrophoretic comparison of insulated vs uninsulated needles.

We compared the electrical characteristics of insulated and uninsulated needles in two models that simulate use of a stimulator for nerve localization. With a digital computer, we solved for and graphed the contours of constant electric field strength, defining regions of simulated tissue in which a nerve would become depolarized for a particular stimulation current. We found that with an uninsulated needle, these regions extend proximally along the needle shaft with their widest dimension located slightly shallow to the tip, but with insulated needles, the regions are almost circular and are centered slightly deep to the needle tip. We confirmed these findings by electrophoresis of bromphenol blue dye in polyacrylamide gel. We also found that the necessary stimulator current is much more dependent on the depth of needle insertion with uninsulated needles than with insulated needles. We conclude that the electrical characteristics of insulated needles are more favorable for successful nerve block.

Bilateral traumatic renal artery thrombosis.

A case of bilateral traumatic renal artery thrombosis involving three renal arteries is presented. Four other cases of this entity are summarized for comparison. The recommended course of investigation is outlined, and the urgency of immediate surgical intervention is emphasized.

Prophylactic transdermal scopolamine patches reduce nausea in postoperative patients receiving epidural morphine.

To evaluate the efficacy of prophylactic transdermal scopolamine in reducing nausea associated with postoperative epidural analgesia, we studied 32 healthy adult women undergoing major gynecologic surgery. The patients were randomized in a double blind fashion to receive either a cutaneous scopolamine patch or a visually identical cutaneous placebo patch. Postoperative analgesia was provided solely with epidural morphine. Nausea was treated with metoclopramide and droperidol. At 24 hours postoperatively, the mean nausea score was significantly lower with scopolamine than with placebo (1 +/- 2 vs 51 +/- 42, respectively, P less than 0.05). The number of patients reporting "zero nausea" was significantly greater with scopolamine patches than with placebo patches (13 vs 1, P less than 0.01). The mean number of times antiemetic drugs were administered per patient was lower with scopolamine than with placebo patches (0.2 +/- 0.4 vs 2.8 +/- 2.6, P less than 0.05). It is concluded that prophylactic transdermal scopolamine patches reduce nausea in postoperative patients receiving epidural morphine.

Postoperative epidural morphine is safe on surgical wards.

The use of epidural morphine for postoperative analgesia outside of intensive care units remains controversial. In this report our anesthesiology-based acute pain service documents experience with 1,106 consecutive postoperative patients treated with epidural morphine on regular surgical wards. This experience involved 4,343 total patient days of care and 11,089 individual epidural morphine injections. On a 0-10 verbal analog scale, patient-reported median pain scores at rest and with coughing or ambulation were 1 (inter-quartile range 3) and 4 (interquartile range 4), respectively. The incidence of side effects requiring medication were as follows: pruritus 24%, nausea 29%, and respiratory depression 0.2%. There were no deaths, neurologic injuries, or infections associated with the technique. Migration of epidural catheters into the subarachnoid space and into epidural veins each occurred twice. Overall, 1,051 of the 1,106 patients (95%) experienced none of the following problems: catheter obstruction, premature dislodgement, painful injections, catheter migration, infection, or respiratory depression. We conclude that postoperative pain can be safely and effectively treated with epidural morphine on surgical wards.