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Hong Kong Medical Journal = Xianggang... Oct 2020Pain relief is an important component of modern obstetric care and can be produced by neuraxial, systemic, or inhalational analgesia or various physical techniques. We... (Review)
Review
Pain relief is an important component of modern obstetric care and can be produced by neuraxial, systemic, or inhalational analgesia or various physical techniques. We review the most recent evidence on the efficacy and safety of these techniques. Over the past decade, the availability of safer local anaesthetics, ultra-short acting opioids, combined spinal-epidural needles, patient-controlled analgesic devices, and ultrasound have revolutionised obstetric regional analgesia. Recent meta-analyses have supported epidural analgesia as the most efficacious technique, as it leads to higher maternal satisfaction and good maternal and fetal safety profiles. We examine the controversies and myths concerning the initiation, maintenance, and discontinuation of epidural analgesia. Recent evidence will also be reviewed to address concerns about the effects of epidural analgesia on the rates of instrumental and operative delivery, lower back pain, and breastfeeding. New developments in labour analgesia are also discussed.
Topics: Analgesia, Epidural; Analgesia, Obstetrical; Analgesia, Patient-Controlled; Female; Humans; Labor Pain; Pain Management; Pregnancy
PubMed: 32943586
DOI: 10.12809/hkmj208632 -
BMJ (Clinical Research Ed.) Sep 2015
Topics: Acute Pain; Analgesia, Patient-Controlled; Effect Modifier, Epidemiologic; Emergency Service, Hospital; Humans; Pain Management; Randomized Controlled Trials as Topic; Wounds and Injuries
PubMed: 26341898
DOI: 10.1136/bmj.h4672 -
BMC Anesthesiology Feb 2022Postpartum depression (PPD) is a common complication of cesarean section. S-ketamine given intravenously during surgery can help prevent PPD. However, whether S-ketamine... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Postpartum depression (PPD) is a common complication of cesarean section. S-ketamine given intravenously during surgery can help prevent PPD. However, whether S-ketamine in patient-controlled intravenous analgesia (PCIA) can reduce the incidence of PPD is unknown. This study assessed the effect of S-ketamine as an adjuvant in PCIA for preventing PPD in women undergoing cesarean delivery.
METHODS
A total of 375 parturients scheduled to undergo cesarean section and then receive PCIA were recruited from a single center and were randomly assigned to control (C) group (sufentanil 2 μg/kg + tropisetron 10 mg) or S-ketamine (S) group (S-ketamine 0.5 mg/kg + sufentanil 2 μg/kg + tropisetron 10 mg). The primary outcome was the incidence of PPD measured by the Edinburgh postnatal depression scale (EPDS) after surgery. The secondary outcomes were EPDS scores, visual analog scale (VAS) scores, Ramsay sedation scale (RSS) scores, and the rate of adverse events, including headache, nausea, dizziness, drowsiness, and vomit.
RESULTS
A total of 275 puerperal women were included in the study. The rate of depression in parturient on postoperative days 3, 14, 28 in the C group and S group were 17.6 and 8.2% (p < 0.05), 24.2 and 9.8% (p < 0.05), and 19.0 and 17.2% (p = 0.76) respectively. EPDS scores in the C group and S group on postoperative days 3,14, and 28 were 7.65 ± 3.14 and 6.00 ± 2.47 (p < 0.05), 7.62 ± 3.14 and 6.38 ± 2.67 (p < 0.05), and 7.35 ± 3.17 and 6.90 ± 2.78 (p = 0.15), respectively. The rate of adverse events in the C group and S group were headache 3.3 and 4.1% (p = 0.755), nausea 5.9 and 8.2% (p = 0.481), dizziness 9.2 and 12.3% (p = 0.434), drowsiness 6.5 and 10.7%(p = 0.274), and vomit 5.9 and 5.7% (p = 0.585).
CONCLUSIONS
S-ketamine (0.01 mg/kg/h) as an adjuvant in PCIA significantly reduces the incidence of PPD within 14 days and relieves pain within 48 h after cesarean delivery, without increasing the rate of adverse reactions.
TRIAL REGISTRATION
Registered in the Chinese Clinical Trial Registry ( ChiCTR2100050263 ) on August 24, 2021.
Topics: Adult; Analgesia, Patient-Controlled; Antidepressive Agents; Cesarean Section; Depression, Postpartum; Female; Humans; Ketamine; Young Adult
PubMed: 35172727
DOI: 10.1186/s12871-022-01588-7 -
JAMA Surgery Jul 2020Morbidity is still high in pancreatic surgery, driven mainly by gastrointestinal complications such as pancreatic fistula. Perioperative thoracic epidural analgesia... (Comparative Study)
Comparative Study Randomized Controlled Trial
IMPORTANCE
Morbidity is still high in pancreatic surgery, driven mainly by gastrointestinal complications such as pancreatic fistula. Perioperative thoracic epidural analgesia (EDA) and patient-controlled intravenous analgesia (PCIA) are frequently used for pain control after pancreatic surgery. Evidence from a post hoc analysis suggests that PCIA is associated with fewer gastrointestinal complications.
OBJECTIVE
To determine whether postoperative PCIA decreases the occurrence of gastrointestinal complications after pancreatic surgery compared with EDA.
DESIGN, SETTING, AND PARTICIPANTS
In this adaptive, pragmatic, international, multicenter, superiority randomized clinical trial conducted from June 30, 2015, to October 1, 2017, 371 patients at 9 European pancreatic surgery centers who were scheduled for elective pancreatoduodenectomy were randomized to receive PCIA (n = 185) or EDA (n = 186); 248 patients (124 in each group) were analyzed. Data were analyzed from February 22 to April 25, 2019, using modified intention to treat and per protocol.
INTERVENTIONS
Patients in the PCIA group received general anesthesia and postoperative PCIA with intravenous opioids with the help of a patient-controlled analgesia device. In the EDA group, patients received general anesthesia and intraoperative and postoperative EDA.
MAIN OUTCOMES AND MEASURES
The primary end point was a composite of pancreatic fistula, bile leakage, delayed gastric emptying, gastrointestinal bleeding, or postoperative ileus within 30 days after surgery. Secondary end points included 30-day mortality, other complications, postoperative pain levels, intraoperative or postoperative use of vasopressor therapy, and fluid substitution.
RESULTS
Among the 248 patients analyzed (147 men; mean [SD] age, 64.9 [10.7] years), the primary composite end point did not differ between the PCIA group (61 [49.2%]) and EDA group (57 [46.0%]) (odds ratio, 1.17; 95% CI, 0.71-1.95 P = .54). Neither individual components of the primary end point nor 30-day mortality, postoperative pain levels, or intraoperative and postoperative substitution of fluids differed significantly between groups. Patients receiving EDA gained more weight by postoperative day 4 than patients receiving PCIA (mean [SD], 4.6 [3.8] vs 3.4 [3.6] kg; P = .03) and received more vasopressors (46 [37.1%] vs 31 [25.0%]; P = .04). Failure of EDA occurred in 23 patients (18.5%).
CONCLUSIONS AND RELEVANCE
This study found that the choice between PCIA and EDA for pain control after pancreatic surgery should not be based on concerns regarding gastrointestinal complications because the 2 procedures are comparable with regard to effectiveness and safety. However, EDA was associated with several shortcomings.
TRIAL REGISTRATION
German Clinical Trials Register: DRKS00007784.
Topics: Aged; Analgesia, Epidural; Analgesia, Patient-Controlled; Female; Gastrointestinal Diseases; Humans; Male; Middle Aged; Pain, Postoperative; Pancreaticoduodenectomy; Postoperative Complications
PubMed: 32459322
DOI: 10.1001/jamasurg.2020.0794 -
British Journal of Anaesthesia Sep 2022Laparoscopic hepatectomy is associated with trauma and severe pain. We examined whether bilateral, ultrasound-guided, single-injection erector spinae plane block (ESPB)... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Laparoscopic hepatectomy is associated with trauma and severe pain. We examined whether bilateral, ultrasound-guided, single-injection erector spinae plane block (ESPB) could improve on postoperative analgesia compared with patient-controlled intravenous analgesia in patients undergoing laparoscopic hepatectomy.
METHODS
Fifty adults were randomly allocated to receive patient-controlled intravenous analgesia alone or combined with bilateral single-injection ESPB (ropivacaine 0.5%, 15 ml on each side). Primary outcome was resting pain scores at 3 h postoperatively assessed with visual analogue scale (VAS). Secondary outcomes included VAS scores at rest and during movement at 6, 12, 16, 20, 24, 48, and 72 h postoperatively; use of intraoperative opioids; postoperative rescue analgesia; sleep quality; time of first ambulation; ESPB-related complications; and ropivacaine concentration in plasma.
RESULTS
The ESPB group showed lower resting VAS scores at 3 h postoperatively (mean [standard deviation]), 2.0 (0.5) vs 4.3 (0.7), P<0.001, and significantly lower scores at rest and during movement at 6-24 h postoperatively. The ESPB group showed lower intraoperative opioid use, lower consumption of rescue analgesia within 72 h postoperatively, and better sleep quality. ESPB subjects began to ambulate 10 h earlier than control subjects. None of the ESPB subjects showed ESPB-related complications, and analysis of a subset of subjects showed that ropivacaine concentrations in plasma decreased gradually over time.
CONCLUSIONS
Compared with patient-controlled intravenous analgesia only, preoperative ultrasound-guided erector spinae plane block can improve postoperative analgesia, reduce opioid demand, and accelerate recovery in patients undergoing laparoscopic hepatectomy.
CLINICAL TRIAL REGISTRATION
Chinese Clinical Trial Registry ChiCTR1900020961.
Topics: Adult; Analgesia, Patient-Controlled; Analgesics, Opioid; Hepatectomy; Humans; Laparoscopy; Nerve Block; Pain, Postoperative; Ropivacaine; Ultrasonography, Interventional
PubMed: 35803754
DOI: 10.1016/j.bja.2022.05.013 -
Medicine Oct 2018Total hip replacement (THR) and, particularly, total knee replacement (TKR), are painful surgical procedures. Effective postoperative pain management leads to a better... (Observational Study)
Observational Study
Total hip replacement (THR) and, particularly, total knee replacement (TKR), are painful surgical procedures. Effective postoperative pain management leads to a better and earlier functional recovery and prevents chronic pain. Studies on the control of pain during the postoperative rehabilitation period are not common. The aim of this study is to present results of a perioperative anesthetic protocol, and a pain treatment protocol in use in the Orthopaedic and the Rehabilitation intensive units of our Hospital. 100 patients (50 THR and 50 TKR) were retrospectively included in this observational study. Numeric Rating Scale (NRS) for pain at rest registered in the clinical sheet was retrieved for all patients and analyzed with respect to the spinal anaesthesia given for the surgery, local analgesia, analgesia protocol adopted during the postoperative days in the Orthopaedic Unit, the antalgic treatment given during the stay within the Rehabilitation Unit, the postoperative consumption of rescue pain medication, and any collateral effect due to the analgesic therapy. Patients reached standard functional abilities (walking at least 50 meters and climbing/descending stairs) at a mean length of 8 days without medication-related complications. Mean NRS during the time of stay was 1.3 ± 0.3 for THR and 1.3 ± 0.2 for TKR) and maximum mean NRS was 1.8 ± 0.5 for TKR and 1.8 ± 0.6 for THR. The use of rescue therapy in the rehabilitation guard was correlated with the mean NRS pain and the maximum NRS pain. A very good control of pain with the perioperative anesthetic protocol and pain treatment protocol in use was obtained.
Topics: Aged; Analgesia, Patient-Controlled; Analgesics; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Female; Humans; Male; Middle Aged; Pain Management; Pain Measurement; Pain, Postoperative; Recovery of Function; Retrospective Studies; Treatment Outcome
PubMed: 30290604
DOI: 10.1097/MD.0000000000012484 -
BMJ (Clinical Research Ed.) Dec 2020To investigate the effect of therapeutic suggestions played to patients through earphones during surgery on postoperative pain and opioid use. (Randomized Controlled Trial)
Randomized 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.
Topics: Adolescent; Adult; Aged; Analgesia, Patient-Controlled; Analgesics, Opioid; Anesthesia, General; Female; Germany; Humans; Intraoperative Period; Male; Middle Aged; Music Therapy; Pain Management; Pain Measurement; Pain, Postoperative; Single-Blind Method; Suggestion; Treatment Outcome; Young Adult
PubMed: 33303476
DOI: 10.1136/bmj.m4284 -
Minerva Anestesiologica Aug 2016
Topics: Analgesia, Epidural; Analgesia, Patient-Controlled; Analgesics, Opioid; Humans; Pain, Postoperative
PubMed: 26883748
DOI: No ID Found -
The Cochrane Database of Systematic... Jun 2015This is an updated version of the original Cochrane review published in Issue 4, 2006. Patients may control postoperative pain by self administration of intravenous... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
This is an updated version of the original Cochrane review published in Issue 4, 2006. Patients may control postoperative pain by self administration of intravenous opioids using devices designed for this purpose (patient controlled analgesia or PCA). A 1992 meta-analysis by Ballantyne et al found a strong patient preference for PCA over non-patient controlled analgesia, but disclosed no differences in analgesic consumption or length of postoperative hospital stay. Although Ballantyne's meta-analysis found that PCA did have a small but statistically significant benefit upon pain intensity, a 2001 review by Walder et al did not find statistically significant differences in pain intensity or pain relief between PCA and groups treated with non-patient controlled analgesia.
OBJECTIVES
To evaluate the efficacy and safety of patient controlled intravenous opioid analgesia (termed PCA in this review) versus non-patient controlled opioid analgesia of as-needed opioid analgesia for postoperative pain relief.
SEARCH METHODS
We ran the search for the previous review in November 2004. For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 12), MEDLINE (1966 to 28 January 2015), and EMBASE (1980 to 28 January 2015) for randomized controlled trials (RCTs) in any language, and reference lists of reviews and retrieved articles.
SELECTION CRITERIA
We selected RCTs that assessed pain intensity as a primary or secondary outcome. These studies compared PCA without a continuous background infusion with non-patient controlled opioid analgesic regimens. We excluded studies that explicitly stated they involved patients with chronic pain.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted data, which included demographic variables, type of surgery, interventions, efficacy, and adverse events. We graded each included study for methodological quality by assessing risk of bias and employed the GRADE approach to assess the overall quality of the evidence. We performed meta-analysis of outcomes that included pain intensity assessed by a 0 to 100 visual analog scale (VAS), opioid consumption, patient satisfaction, length of stay, and adverse events.
MAIN RESULTS
Forty-nine studies with 1725 participants receiving PCA and 1687 participants assigned to a control group met the inclusion criteria. The original review included 55 studies with 2023 patients receiving PCA and 1838 patients assigned to a control group. There were fewer included studies in our updated review due to the revised exclusion criteria. For the primary outcome, participants receiving PCA had lower VAS pain intensity scores versus non-patient controlled analgesia over most time intervals, e.g., scores over 0 to 24 hours were nine points lower (95% confidence interval (CI) -13 to -5, moderate quality evidence) and over 0 to 48 hours were 10 points lower (95% CI -12 to -7, low quality evidence). Among the secondary outcomes, participants were more satisfied with PCA (81% versus 61%, P value = 0.002) and consumed higher amounts of opioids than controls (0 to 24 hours, 7 mg more of intravenous morphine equivalents, 95% CI 1 mg to 13 mg). Those receiving PCA had a higher incidence of pruritus (15% versus 8%, P value = 0.01) but had a similar incidence of other adverse events. There was no difference in the length of hospital stay.
AUTHORS' CONCLUSIONS
Since the last version of this review, we have found new studies providing additional information. We reanalyzed the data but the results did not substantially alter any of our previously published conclusions. This review provides moderate to low quality evidence that PCA is an efficacious alternative to non-patient controlled systemic analgesia for postoperative pain control.
Topics: Analgesia, Patient-Controlled; Analgesics, Opioid; Humans; Pain, Postoperative; Patient Satisfaction; Randomized Controlled Trials as Topic
PubMed: 26035341
DOI: 10.1002/14651858.CD003348.pub3 -
Anaesthesia Aug 2017
Topics: Acute Pain; Analgesia, Patient-Controlled; Cost-Benefit Analysis; Emergency Service, Hospital; Humans
PubMed: 28555748
DOI: 10.1111/anae.13893