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Anaesthesia Mar 2019
Topics: Analgesia, Obstetrical; Analgesia, Patient-Controlled; Female; Humans; Labor, Obstetric; Meperidine; Pain; Pregnancy; Remifentanil
PubMed: 30549009
DOI: 10.1111/anae.14536 -
British Journal of Anaesthesia Feb 2010To compare the analgesic efficacy of remifentanil with meperidine and fentanyl in a patient-controlled setting (patient-controlled analgesia, PCA). (Comparative Study)
Comparative Study Randomized Controlled Trial
BACKGROUND
To compare the analgesic efficacy of remifentanil with meperidine and fentanyl in a patient-controlled setting (patient-controlled analgesia, PCA).
METHODS
Parturients (n=159) were randomly assigned to receive remifentanil (n=52), meperidine (n=53), or fentanyl (n=54). Pain scores and an observer sedation scores were assessed hourly. Fetal outcome was evaluated with Apgar score, cord blood gas analysis and the Neurologic and Adaptive Capacity Score.
RESULTS
Pain scores decreased in all groups, the decrease varying from mild to moderate, average pain scores remaining above 4.5 cm in all groups. Remifentanil PCA was associated with the greatest decrease in pain scores, but the difference was significant only at 1 h. Pain scores returned towards baseline over time; 3 h after the initiation of treatment, pain scores no longer differed significantly from baseline values in any of the groups. Significantly more parturients receiving meperidine crossed over to epidural analgesia. Overall satisfaction scores were higher with remifentanil, but remifentanil produced more sedation and itching. More periods of desaturation (Sa(o(2)) <95%) were observed during administration of remifentanil and fentanyl. There were no significant differences in fetal outcome between the three groups.
CONCLUSIONS
The efficacy of meperidine, fentanyl, and remifentanil PCA for labour analgesia varied from mild to moderate. Remifentanil PCA provided better analgesia than meperidine and fentanyl PCA, but only during the first hour of treatment. In all groups, pain scores returned to pre-treatment values within 3 h after the initiation of treatment.
Topics: Adult; Analgesia, Obstetrical; Analgesia, Patient-Controlled; Analgesics, Opioid; Consciousness; Double-Blind Method; Female; Fentanyl; Humans; Meperidine; Oxygen; Pain Measurement; Patient Satisfaction; Piperidines; Pregnancy; Pregnancy Outcome; Pruritus; Remifentanil
PubMed: 20008859
DOI: 10.1093/bja/aep359 -
Anaesthesia Feb 2020Postoperative nausea and vomiting is the most common side-effect of opioid-based intravenous patient-controlled analgesia. Apfel's simplified risk score is popular but...
Postoperative nausea and vomiting is the most common side-effect of opioid-based intravenous patient-controlled analgesia. Apfel's simplified risk score is popular but it has some limitations. We developed and validated a dynamic predictive model for nausea or vomiting up to 48 postoperative hours, available as an online web application. Fentanyl was used by 22,144 adult patients for analgesia after non-cardiac surgery under general anaesthesia: we randomly divided them into development (80%) and validation (20%) cohorts, repeated 100 times. We used linear discriminant analysis to select variables for multivariate logistic regression. The incidences of postoperative nausea or vomiting were: 0-48 h, 5691/22,144 (26%); 0-6 h, 2749/22,144 (12%); 6-12 h, 2687/22,144 (12%); 12-18 h, 2624/22,144 (12%); 18-24 h, 1884/22,144 (9%); and 24-48 h, 1082/22,144 (5%). The median (95%CI) area under the receiver operating characteristic curve was 0.72 (0.71-0.73) up to 48 postoperative hours compared with 0.65 (0.64-0.66) for the Apfel model, p < 0.001. The equivalent areas for 0-6 h, 6-12 h, 12-18 h, 18-24 h and 24-48 h were: 0.70 (0.69-0.72); 0.71 (0.69-0.73); 0.69 (0.68-0.71); 0.70 (0.67-0.72); and 0.69 (0.66-0.71), respectively. Our web application allows clinicians to calculate incidences of nausea and vomiting in patients receiving intravenous fentanyl for patient-controlled analgesia.
Topics: Analgesia, Patient-Controlled; Analgesics, Opioid; Anesthetics, Intravenous; Comorbidity; Female; Fentanyl; Humans; Male; Middle Aged; Motion Sickness; Postoperative Nausea and Vomiting; Risk Factors; Sex Factors; Smoking; Surveys and Questionnaires
PubMed: 31531854
DOI: 10.1111/anae.14849 -
The Cochrane Database of Systematic... Mar 2013There are two common techniques for postoperative pain control after intra-abdominal surgery: patient-controlled analgesia (PCA) with intravenous opioids and continuous... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
There are two common techniques for postoperative pain control after intra-abdominal surgery: patient-controlled analgesia (PCA) with intravenous opioids and continuous epidural analgesia (CEA). It is uncertain which method has better pain control and fewer adverse effects.
OBJECTIVES
The objective of this review was to compare PCA opioid therapy with CEA for pain control after intra-abdominal surgery in terms of analgesic efficacy, side effects, patient satisfaction and surgical outcome by meta-analysis of the relevant trials.
SEARCH METHODS
We searched CENTRAL (The Cochrane Library Issue 4, 2002), MEDLINE (January 1966 to October 2002), EMBASE (January 1988 to October 2002), and reference lists of articles. We also contacted researchers in the field.
SELECTION CRITERIA
Randomized controlled trials of adult patients after intra-abdominal surgery comparing the effect of two pain control regimens in terms of analgesic efficacy and side effects. In the patient-controlled analgesia (PCA) group the patient should be able to operate the device himself. In the continuous epidural analgesia group there was no PCA device.
DATA COLLECTION AND ANALYSIS
Two authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. Adverse effects information was collected from the trials.
MAIN RESULTS
Nine studies involving 711 participants were included. The PCA group had a higher pain visual analogue scale than the CEA group during 6, 24 and 72 hour periods. The weighted mean difference and 95% confidence interval of resting pain was 1.74 (95% CI 1.30 to 2.19), 0.99 (95% CI 0.65 to 1.33), and 0.63 (95% CI 0.24 to 1.01), respectively. The length of hospital stay and other adverse effects were not statistically different except that the incidence of pruritus was lower in the PCA group, odds ratio of 0.27 (95% CI 0.11 to 0.64).
AUTHORS' CONCLUSIONS
CEA is superior to opioid PCA in relieving postoperative pain for up to 72 hours in patients undergoing intra-abdominal surgery, but it is associated with a higher incidence of pruritus. There is insufficient evidence to draw comparisons about the other advantages and disadvantages of these two methods of pain relief.
Topics: Abdomen; Analgesia, Epidural; Analgesia, Patient-Controlled; Analgesics, Opioid; Humans; Injections, Intravenous; Pain, Postoperative; Randomized Controlled Trials as Topic
PubMed: 23543529
DOI: 10.1002/14651858.CD004088.pub3 -
Journal of Pain and Symptom Management Oct 1997Between December 1989 and March 1996, more than 6000 patients were treated with patient-controlled analgesia (PCA) at Auckland Hospital. The overall incidence of... (Clinical Trial)
Clinical Trial Randomized Controlled Trial
Between December 1989 and March 1996, more than 6000 patients were treated with patient-controlled analgesia (PCA) at Auckland Hospital. The overall incidence of potentially life-threatening complications was low (0.28%). A small number (276) received PCA with a background opioid infusion. This technique was associated with a higher incidence of such complications (1.08%, P < 0.05). To further characterize the safety and utilization of PCA, a subgroup of 300 patients was analyzed. The average duration of PCA was 76.4 +/- 39.2 hr. The peak morphine consumption was highest on the day of operation (45.4 +/- 37.0 mg) and rapidly declined over the next 3 postoperative days (40.6 +/- 39.0, 33.3 +/- 26.2, and 27.8 +/- 36.6 mg, respectively). The ratio of drug demands to deliveries decreased from 1.76 on the morning of the first postoperative day to 1.17 on the evening of the third. The percentage of patients with inadequate analgesia (pain score > or = 3/10) and an inability to comply with physiotherapy (Bruggemann comfort score < or = 2/10) was high on the first postoperative day (42% and 18%, respectively). Men used significantly more morphine than women (141.7 +/- 123.6 versus 102.7 +/- 111.2 mg, P < 0.0001) and general surgical patients used more morphine than urology and orthopedic patients (152.6 +/- 136.9 versus 96.0 +/- 84.2 and 83.7 +/- 97.9 mg, P < 0.0001). There was no association between morphine consumption and age (r = -0.216). Of the 6% of patients who experienced hypoxemia and 2% who experienced respiratory depression, virtually all had one of three risk factors: bolus dose greater than 1 mg morphine, age greater than 65 years, or intra-abdominal surgery. The most common side effects were nausea and sedation. The incidence of nausea was highest on day 1 (28%) and decreased over the next 2 days (14.3% and 4.7%, respectively). A similar pattern was observed with sedation (incidence over the first 3 days: 28%, 9.3%, and 3.3%, respectively). Overall patient satisfaction scores were high (8.3/10 +/- 1.9). We conclude that the risk of serious complications with PCA is very low, but worrying degrees of hypoxemia and bradypnea do occur. We suggest prescribing regimens that may reduce complications and identify patients at high risk.
Topics: Adult; Analgesia, Patient-Controlled; Female; Humans; Male; Middle Aged; Postoperative Care
PubMed: 9379067
DOI: 10.1016/s0885-3924(97)00182-6 -
British Journal of Anaesthesia Apr 1992
Topics: Analgesia, Patient-Controlled; History, 20th Century; Humans; Safety; United Kingdom; United States
PubMed: 1642907
DOI: 10.1093/bja/68.4.331 -
Journal of Pain and Symptom Management May 2005Patient-controlled analgesia (PCA) has become the gold standard for acute pain management since it was first introduced 20 years ago, and its merits have been discussed... (Comparative Study)
Comparative Study Review
Patient-controlled analgesia (PCA) has become the gold standard for acute pain management since it was first introduced 20 years ago, and its merits have been discussed in quite a large number of publications. This review summarizes the more recent developments, such as new application devices and strategies, including intranasal, spinal, and regional PCA; patient-controlled sedation; experience with children and elderly people; and some data from chronic pain situations. Analyzing PCA literature from 2001 onwards confirms the author's long belief that the PCA principle ("WYNIWYG": what you need is what you get) was the most important aspect of a patient-controlled strategy, more or less independent of the type of drug or machine. Discovering this principle has changed the understanding of pain and suffering.
Topics: Analgesia, Patient-Controlled; Cost-Benefit Analysis; Humans; Neoplasms; Pain; Treatment Outcome
PubMed: 15907649
DOI: 10.1016/j.jpainsymman.2005.01.005 -
Interactive Cardiovascular and Thoracic... Feb 2012A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'is the addition of ketamine to morphine... (Review)
Review
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'is the addition of ketamine to morphine patient-controlled analgesia (PCA) following thoracic surgery superior to morphine alone'. Altogether 201 papers were found using the reported search, of which nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. This consisted of one systematic review of PCA morphine with ketamine (PCA-MK) trials, one meta-analysis of PCA-MK trials, four randomized controlled trials of PCA-MK, one meta-analysis of trials using a variety of peri-operative ketamine regimes and two cohort studies of PCA-MK. Main outcomes measured included pain score rated on visual analogue scale, morphine consumption and incidence of psychotomimetic side effects/hallucination. Two papers reported the measurements of respiratory function. This evidence shows that adding ketamine to morphine PCA is safe, with a reported incidence of hallucination requiring intervention of 2.9%, and a meta-analysis finding an incidence of all central nervous system side effects of 18% compared with 15% with morphine alone, P = 0.31, RR 1.27 with 95% CI (0.8-2.01). All randomized controlled trials of its use following thoracic surgery found no hallucination or psychological side effect. All five studies in thoracic surgery (n = 243) found reduced morphine requirements with PCA-MK. Pain scores were significantly lower in PCA-MK patients in thoracic surgery papers, with one paper additionally reporting increased patient satisfaction. However, no significant improvement was found in a meta-analysis of five papers studying PCA-MK in a variety of surgical settings. Both papers reporting respiratory outcomes found improved oxygen saturations and PaCO(2) levels in PCA-MK patients following thoracic surgery. We conclude that adding low-dose ketamine to morphine PCA is safe and post-thoracotomy may provide better pain control than PCA with morphine alone (PCA-MO), with reduced morphine consumption and possible improvement in respiratory function. These studies thus support the routine use of PCA-MK instead of PCA-MO to improve post-thoracotomy pain control.
Topics: Analgesia, Patient-Controlled; Analgesics; Analgesics, Opioid; Benchmarking; Evidence-Based Medicine; Humans; Ketamine; Morphine; Pain Measurement; Pain, Postoperative; Thoracotomy; Treatment Outcome
PubMed: 22159259
DOI: 10.1093/icvts/ivr081 -
BMC Medical Informatics and Decision... Nov 2012Appropriate postoperative pain management contributes to earlier mobilization, shorter hospitalization, and reduced cost. The under treatment of pain may impede... (Comparative Study)
Comparative Study
BACKGROUND
Appropriate postoperative pain management contributes to earlier mobilization, shorter hospitalization, and reduced cost. The under treatment of pain may impede short-term recovery and have a detrimental long-term effect on health. This study focuses on Patient Controlled Analgesia (PCA), which is a delivery system for pain medication. This study proposes and demonstrates how to use machine learning and data mining techniques to predict analgesic requirements and PCA readjustment.
METHODS
The sample in this study included 1099 patients. Every patient was described by 280 attributes, including the class attribute. In addition to commonly studied demographic and physiological factors, this study emphasizes attributes related to PCA. We used decision tree-based learning algorithms to predict analgesic consumption and PCA control readjustment based on the first few hours of PCA medications. We also developed a nearest neighbor-based data cleaning method to alleviate the class-imbalance problem in PCA setting readjustment prediction.
RESULTS
The prediction accuracies of total analgesic consumption (continuous dose and PCA dose) and PCA analgesic requirement (PCA dose only) by an ensemble of decision trees were 80.9% and 73.1%, respectively. Decision tree-based learning outperformed Artificial Neural Network, Support Vector Machine, Random Forest, Rotation Forest, and Naïve Bayesian classifiers in analgesic consumption prediction. The proposed data cleaning method improved the performance of every learning method in this study of PCA setting readjustment prediction. Comparative analysis identified the informative attributes from the data mining models and compared them with the correlates of analgesic requirement reported in previous works.
CONCLUSION
This study presents a real-world application of data mining to anesthesiology. Unlike previous research, this study considers a wider variety of predictive factors, including PCA demands over time. We analyzed PCA patient data and conducted several experiments to evaluate the potential of applying machine-learning algorithms to assist anesthesiologists in PCA administration. Results demonstrate the feasibility of the proposed ensemble approach to postoperative pain management.
Topics: Age Factors; Algorithms; Analgesia, Patient-Controlled; Analysis of Variance; Artificial Intelligence; Blood Pressure; Chicago; Decision Trees; Drug Administration Schedule; Female; Heart Rate; Humans; Male; Neural Networks, Computer; Outcome and Process Assessment, Health Care; Pain Management; Pain, Postoperative; Predictive Value of Tests; Retrospective Studies; Risk Factors; Socioeconomic Factors
PubMed: 23148492
DOI: 10.1186/1472-6947-12-131 -
Anesthesiology Dec 1998Many studies have shown the efficacy of patient-controlled analgesia (PCA). However, it is not clear whether PCA has clinical or economic benefits in addition to... (Clinical Trial)
Clinical Trial Comparative Study Randomized Controlled Trial
BACKGROUND
Many studies have shown the efficacy of patient-controlled analgesia (PCA). However, it is not clear whether PCA has clinical or economic benefits in addition to efficient analgesia. The current study was designed to evaluate these issues by comparing PCA with regularly administered intramuscular injections of opioids after hysterectomy.
METHODS
This prospective study included 126 patients who underwent abdominal hysterectomy and were randomly assigned to receive PCA or regularly timed intramuscular injections of morphine during a period of 48 h. Doses were adjusted to provide satisfactory analgesia in both treatment groups. Pain at rest and with movement, functional recovery, drug side effects, and patient satisfaction were measured using rating scales and questionnaires. The costs of PCA and intramuscular therapy were calculated based on personnel time and drug and material requirements.
RESULTS
Comparable analgesia was observed with the two treatment methods, with no significant differences in the incidence of side effects or patient satisfaction. The medication dosage had to be adjusted significantly more frequently in the intramuscular group than in the PCA patients. The PCA did not favor a faster recuperation time compared with intramuscular therapy in terms of times to ambulation, resumption of liquid and solid diet, passage of bowel gas, or hospital discharge. The results of the economic evaluation, which used a cost-minimization model and sensitivity analyses, showed that PCA was more costly than regular intramuscular injections despite the fact that no costs for the pump were included in the analyses. Cost differences in nursing time favoring PCA were offset by drug and material costs associated with this type of treatment.
CONCLUSIONS
Compared with regularly scheduled intramuscular dosing, PCA is more costly and does not have clinical advantages for pain management after hysterectomy. Because of the comparable outcomes, the general use of PCA in similar patients should be questioned.
Topics: Analgesia; Analgesia, Patient-Controlled; Analgesics, Opioid; Costs and Cost Analysis; Drug Costs; Female; Humans; Hysterectomy; Injections, Intramuscular; Middle Aged; Pain Measurement; Pain, Postoperative; Prospective Studies
PubMed: 9856712
DOI: 10.1097/00000542-199812000-00015