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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 -
Minerva Anestesiologica Aug 2016
Topics: Analgesia, Epidural; Analgesia, Patient-Controlled; Analgesics, Opioid; Humans; Pain, Postoperative
PubMed: 26883748
DOI: No ID Found -
Anaesthesia Dec 2020The programmed intermittent epidural bolus technique has shown superiority to continuous epidural infusion techniques, with or without patient-controlled epidural... (Comparative Study)
Comparative Study Randomized Controlled Trial
The programmed intermittent epidural bolus technique has shown superiority to continuous epidural infusion techniques, with or without patient-controlled epidural analgesia for pain relief, reduced motor block and patient satisfaction. Many institutions still use patient-controlled epidural analgesia without a background infusion, and a comparative study between programmed intermittent epidural bolus and patient-controlled epidural analgesia without a background infusion has not yet been performed. We performed a randomised, two-centre, double-blind, controlled trial of these two techniques. The primary outcome was the incidence of breakthrough pain requiring a top-up dose by an anaesthetist. Secondary outcomes included: motor block; pain scores; patient satisfaction; local anaesthetic consumption; and obstetric and neonatal outcomes. We recruited 130 nulliparous women who received initial spinal analgesia, and then epidural analgesia was initiated and maintained with either programmed intermittent epidural bolus or patient-controlled epidural analgesia using ropivacaine 0.12% with sufentanil 0.75 µg·ml . The programmed intermittent epidural bolus group had a programmed bolus of 10 ml every hour, with on-demand patient-controlled epidural analgesia boluses of 5 ml with a 20 min lockout, and the patient-controlled epidural analgesia group had a 5 ml bolus with a 12 min lockout interval; the potential maximum volume per hour was the same in both groups. The patients in the programmed intermittent epidural bolus group had less frequent breakthrough pain compared with the patient-controlled epidural analgesia group, 7 (10.9%) vs. 38 (62.3%; p < 0.0001), respectively. There was a significant difference in motor block (modified Bromage score ≤ 4) frequency between groups, programmed intermittent epidural bolus group 1 (1.6%) vs. patient-controlled epidural analgesia group 8 (13.1%); p = 0.015. The programmed intermittent epidural bolus group had greater local anaesthetic consumption with fewer patient-controlled epidural analgesia boluses. Patient satisfaction scores and obstetric or neonatal outcomes were not different between groups. In conclusion, we found that a programmed intermittent epidural bolus technique using 10 ml programmed boluses and 5 ml patient-controlled epidural analgesia boluses was superior to a patient-controlled epidural analgesia technique using 5 ml boluses and no background infusion.
Topics: Adult; Analgesia, Epidural; Analgesia, Obstetrical; Analgesia, Patient-Controlled; Double-Blind Method; Female; Humans; Pregnancy
PubMed: 32530518
DOI: 10.1111/anae.15149 -
Journal of Clinical Anesthesia 1993
Topics: Analgesia; Analgesia, Patient-Controlled; Clinical Trials as Topic; Humans; Injections, Intramuscular; Meta-Analysis as Topic; Research Design; Statistics as Topic
PubMed: 8318236
DOI: 10.1016/0952-8180(93)90012-4 -
Wounds : a Compendium of Clinical... Jan 2019Patient-controlled analgesia (PCA) has become a common practice after surgery, but research has shown that the use of PCA is also a significant risk factor for pressure... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Patient-controlled analgesia (PCA) has become a common practice after surgery, but research has shown that the use of PCA is also a significant risk factor for pressure ulcers. However, no meta-analysis or conclusive review has investigated whether patients using PCA have a significantly higher prevalence of pressure ulcers.
OBJECTIVE
This study explores the association between the use of postoperative PCA and the prevalence of pressure ulcers.
MATERIALS AND METHODS
PubMed, the Cochrane Controlled Register of Trials, Web of Science, China National Knowledge Infrastructure, Wanfang, and Vip databases were searched to identify studies, published up until November 2016, concerning the association between PCA and pressure ulcer prevalence. A manual search of the references of relevant studies also was performed. Odds ratio (OR) and corresponding 95% confidence interval (CI) were used to evaluate the strength of association between the use of PCA after surgery and pressure ulcer prevalence. The methodological quality of included case-control studies and cohort studies was assessed by the Newcastle-Ottawa Scale. The test of heterogeneity, subgroup analysis, meta-regression, Begg's funnel plot, and Egger's test also were used.
RESULTS
Four cohort studies and 1 case-control study were included. In these 5 studies, 265 participants were identified. In pooled analysis, heterogeneity was 0 among the studies. In a fixed effects model, postoperative pressure ulcer was associated with PCA (pooled OR, 3.525; 95% CI, 1.655-7.509). Subgroup analysis of these 5 studies yielded an OR of 3.29 (95% CI, 1.47-7.40) for cesarean section, 5.10 (95% CI, 0.24-107.55) for general surgery, and 5.10 (95% CI, 0.24-107.55) for orthopedic surgery. There was no heterogeneity among the 5 studies. Additional meta-regression of year and incidence did not find significant outcomes.
CONCLUSIONS
This meta-analysis shows PCA may be associated with an increased risk of postoperative pressure ulcer, especially after caesarean section. More evidence-based studies on this research field are needed to draw a firmer conclusion.
Topics: Analgesia, Obstetrical; Analgesia, Patient-Controlled; Cesarean Section; Female; Humans; Observational Studies as Topic; Pain Measurement; Postoperative Complications; Pregnancy; Pressure Ulcer
PubMed: 30372416
DOI: No ID Found -
Anaesthesia Aug 2017
Topics: Acute Pain; Analgesia, Patient-Controlled; Cost-Benefit Analysis; Emergency Service, Hospital; Humans
PubMed: 28555748
DOI: 10.1111/anae.13893 -
Anaesthesia May 1997
Topics: Analgesia, Patient-Controlled; Humans; Nurse-Patient Relations; Pain, Postoperative; Patient Satisfaction
PubMed: 9165955
DOI: 10.1111/j.1365-2044.1997.126-az0120.x -
BMC Anesthesiology Jan 2021To investigate the relationship between intrapartum maternal fever and the duration and dosage of patient-controlled epidural analgesia (PCEA). (Observational Study)
Observational Study
BACKGROUND
To investigate the relationship between intrapartum maternal fever and the duration and dosage of patient-controlled epidural analgesia (PCEA).
METHODS
This observational study included 159 pregnant women who voluntarily accepted PCEA. During labor, patients with body temperature ≥ 38 °C were classified into the Fever group, (n = 42), and those with body temperature < 38 °C were classified into the No-fever group (n = 117). The outcome measures included the duration of PCEA, number of PCEA, and total PCEA amount. Body temperature and parturient variables, including interpartum fever status and the duration of any fever were monitored.
RESULTS
The total PCEA duration and total PCEA amount in the Fever group were significantly higher than the corresponding values in the No-fever group (both, p < 0.05). The duration of fever was weakly correlated with the duration of PCEA (R = 0.08) and the total PCEA amount (R = 0.05) (both, p < 0.05). The total and effective PCEA were higher in the Fever group than in the No-fever group (both, p < 0.05). The total PCEA duration and total PCEA amount were positively correlated with the incidence of fever (both, p < 0.05). The diagnostic cutoff value for fever was 383 min, with a sensitivity of 78.6% and specificity of 57.3%. The mean temperature-time curves showed that parturients who developed fever had a steeper rise in temperature.
CONCLUSIONS
This study showed that there were weak time- and dose-dependent correlations between PCEA and maternal fever during delivery. A total PCEA duration exceeding 6.3 h was associated with an increase in the duration of maternal intrapartum fever.
Topics: Adult; Analgesia, Epidural; Analgesia, Obstetrical; Analgesia, Patient-Controlled; Dose-Response Relationship, Drug; Drug Administration Schedule; Female; Fever; Humans; Labor, Obstetric; Pregnancy; Time Factors
PubMed: 33514322
DOI: 10.1186/s12871-021-01249-1 -
The Journal of Surgical Research Jul 2022The initial settings on an intravenous patient-controlled analgesia (IV-PCA) pump can represent a significant source of postoperative opioid exposure. The primary aim of...
INTRODUCTION
The initial settings on an intravenous patient-controlled analgesia (IV-PCA) pump can represent a significant source of postoperative opioid exposure. The primary aim of this study was to evaluate the impact of first day IV-PCA use on total inpatient opioid use after open pancreatectomy, before and after standardization of initial dosing.
METHODS
Inpatient oral morphine equivalents (OMEs) were reviewed for pancreatectomy patients treated with IV-PCA at a single institution before and after (3/2016-8/2017 versus 3/2019-11/2020) implementation of a standardized initial IV-PCA dosing regimen (initial limit 0.1 mg hydromorphone, or 1 mg OME, every 10 min as needed). IV-PCA OME in the first 24 h and the total inpatient OME were compared between cohorts.
RESULTS
Of 220 total patients, 132 were in the prestandardization (PRE) historical cohort. A first-24-h IV-PCA use was different (PRE median 95 mg versus poststandardization [POST] 15 mg, P < 0.001). The median total inpatient OME was different (P < 0.001) between PRE (525 mg, interquartile range [IQR] 239-951 mg) and POST patients (129 mg, IQR 65-204 mg) with 77% (median 373 mg) of total inpatient OMEs contributed by IV-PCA in the PRE and 56% (median 64 mg) in the POST cohorts. There were similar patient-reported pain scores between groups.
CONCLUSIONS
Standardizing initial IV-PCA settings was associated with a reduced first-24-h opioid exposure, proportional and absolute total IV-PCA use, and total inpatient OMEs. Because of the contribution of an IV-PCA to the total inpatient opioid exposure, purposeful reduction or omission of an IV-PCA is critical to perioperative opioid reduction strategies.
Topics: Analgesia, Patient-Controlled; Analgesics, Opioid; Humans; Inpatients; Morphine; Opioid-Related Disorders; Pain, Postoperative; Pancreatectomy
PubMed: 35306260
DOI: 10.1016/j.jss.2022.02.031 -
BMC Pregnancy and Childbirth Mar 2020Intravenous remifentanil patient-controlled analgesia (RPCA) is an alternative for epidural analgesia (EA) in labor pain relief. However, it remains unknown whether RPCA... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Intravenous remifentanil patient-controlled analgesia (RPCA) is an alternative for epidural analgesia (EA) in labor pain relief. However, it remains unknown whether RPCA is superior to EA in decreasing the risk of intrapartum maternal fever during labor.
METHODS
According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review and meta-analysis was performed by searching PubMed, EMBASE and the Cochrane Central Register of Controlled Trials from inception to April 2019. All randomized controlled trials (RCTs) investigating the risk of intrapartum maternal fever with RPCA compared with EA alone or EA in combination with spinal analgesia during labor were included.
RESULTS
A total of 825 studies were screened, and 6 RCTs including 3341 patients were identified. Compared with EA, RPCA was associated with a significantly lower incidence of intrapartum maternal fever (risk ratio [RR] 0.48, P = 0.02, I = 49%) during labor analgesia. After excluding 2 trials via the heterogeneity analysis, there was no difference in the incidence of intrapartum fever between patients receiving RPCA and those receiving EA. Satisfaction with pain relief during labor was lower in the RPCA group than that in the EA group (- 10.6 [13.87, - 7.44], P < 0.00001, I = 0%). The incidence of respiratory depression was significantly greater in the RPCA group than that in the EA group (risk ratio 2.86 [1.65, 4.96], P = 0.0002, I = 58%). The incidence of Apgar scores < 7 at 5 min in the RPCA group was equivalent to that in the EA group.
CONCLUSION
There is no solid evidence to illustrate that the incidence of intrapartum maternal fever is lower in patients receiving intravenous RPCA than in patients receiving EA.
Topics: Analgesia, Epidural; Analgesia, Obstetrical; Analgesia, Patient-Controlled; Analgesics, Opioid; Apgar Score; Female; Fever; Humans; Infant, Newborn; Labor Pain; Labor, Obstetric; Obstetric Labor Complications; Pain Management; Pain Measurement; Patient Satisfaction; Pregnancy; Remifentanil
PubMed: 32164593
DOI: 10.1186/s12884-020-2800-y