Cutoff Values for Providing the Ideal Intravenous Patient-Controlled Analgesia According to the Intensity of Postoperative Pain—A Retrospective Observational Study

Background and Objectives: The cutoff values were analyzed for providing the ideal intravenous patient-controlled analgesia (PCA) that could reduce rescue analgesics or antiemetics requirements, based on the grades of postoperative pain intensity (PPI). Materials and Methods: PCA regimens of 4106 patients were retrospectively analyzed, and they were allocated into three groups with low, moderate, and high PPI grades (groups L, M, and H, respectively) based on numeric rating scores obtained 6 h postoperatively. Opioid and non-opioid analgesic doses were converted into fentanyl-equivalent doses (DOSE-FEN-OP and DOSE-FEN-NONOP, respectively). The primary endpoint was the cutoff values of these parameters. Results: With respect to the PCA settings to reduce rescue analgesic and antiemetic requirements, group L required a background infusion rate (BIR) of 1.75–3 mL/h, bolus volume of 0.5–1.25 mL, and lockout interval of ≤12.5 min. Group M required a BIR of 1.75 mL/h, bolus volume of 0.5–1.75 mL, and lockout interval of ≤5 min. Group H required a BIR of 1.75 mL/h, bolus volume of 0.5 mL, and lockout interval of ≤5 min. In assessments of the analgesic doses to reduce rescue analgesic requirement, the DOSE-FEN-OP was at least 950 μg of fentanyl regardless of group, while the DOSE-FEN-NONOP was ≥250 μg, ≥550 μg, and ≥700 μg for the L, M, and H groups, respectively. In assessments of the analgesic doses to reduce rescue antiemetic requirement, DOSE-FEN-OP was ≤950 μg for groups L and M and ≤850 μg for Group H, while DOSE-FEN-NONOP was ≤50 μg, ≤450 μg, and ≤700 μg for groups L, M, and H, respectively. Conclusion: The ideal PCA for reduction in rescue analgesics or antiemetics can be achieved by adjustment of PCA settings and drug dosages carefully with these cutoff values depending on the expected grades of PPI. Especially, the ideal PCA can be provided by adjusting the lockout interval and bolus volume rather than BIR and by applying smaller bolus doses and shorter lockout intervals with an increasing PPI grade.

Effect of Nefopam-Based Patient-Controlled Analgesia with and without Fentanyl on Postoperative Pain Intensity in Patients Following Laparoscopic Cholecystectomy: A Prospective, Randomized, Controlled, Double-Blind Non-Inferiority Trial

Background and Objectives: We investigated the non-inferiority of patient-controlled analgesia (PCA), using either nefopam alone or combined nefopam-fentanyl for postoperative analgesia in patients undergoing laparoscopic cholecystectomy. Materials and Methods: In this prospective, randomized, controlled study, 78 patients were allocated to receive nefopam 240 mg (Group N240) or nefopam 120 mg with fentanyl 600 μg (Group NF), equivalent to fentanyl 1200 μg, with a total PCA volume of 120 mL. Patients were given a loading dose (0.1 mL/kg) from the PCA device along with ramosetron (0.3 mg) and connected to a PCA device with a background infusion rate of 2 mL/h, bolus dose amount set at 2 mL, and lockout interval set at 15 min. Pain scores were obtained using the numeric rating scale (NRS) at 30 min after recovery room (RR) admission, as well as 8 and 24 h postoperatively. The primary outcome was analgesic efficacy evaluated using NRS-rated 8 h postoperatively. Other evaluated outcomes included the incidence rate of bolus demand, rescue analgesic and antiemetic requirements, and postoperative adverse effects. Results: NRS scores were not significantly different between the groups throughout the postoperative period (p = 0.539). NRS scores of group N240 were not inferior to those of group NF at 30 min after RR admission, or at 8 and 24 h postoperatively (mean difference [95% CI], −0.05 [−0.73 to 0.63], 0.10 [−0.29 to 0.50], and 0.28 [−0.06 to 0.62], respectively). Postoperative adverse effects were not significantly different between the two groups (p = 1.000) and other outcomes were also not significantly different between the two groups (p ≥ 0.225). Conclusions: PCA using nefopam alone has a non-inferior and effective analgesic efficacy and produces a lower incidence of postoperative adverse effects compared to a combination of fentanyl and nefopam after laparoscopic cholecystectomy.

Clinical Effect of Small-Dose Dexmedetomidine Combined with Oxycodone for Patient-Controlled Analgesia After Colon Cancer Surgery

This study aimed to elucidate the efficacy and safety of oxycodone combined with dexmedetomidine for patientcontrolled analgesia after colon cancer. Sixty patients were randomly divided into the experimental and control groups (n = 30 each). The control group received 0.5 mg/kg oxycodone. The experimental group received 0.5 mg/kg oxycodone and 2 μg/kg dexmedetomidine. Both groups were administered normal saline (NS) up to 100 mL (via background infusion at 2 mL/h with a 0.5-mL bolus dose and 15-min lockout interval). Both groups received oxycodone 0.1 mg/kg and tropisetron 5 mg, 20 min before the end of surgery. The MAP and HR of T1, T2, T3, and T4 were recorded in three groups. After the operation, a blinded observer assessed pain using the visual analogue scale (VAS) score, level of sedation (Ramsay score), and postoperative nausea and vomiting score at 2, 6, 24, 48 h. Side effects included dizziness, shivering, headache, and pruritus. The results showed that, in the experimental group, the T2∼T5 activity pain and T2∼T4 visceral pain VAS scores of patients were obviously lower than those in the control group (activity pain P T2∼T5 = 0.000, visceral pain P T2 = 0.018, P T3 = 0.001, P T4 = 0.010). The dosage of analgesic pump and number of rescue analgesia occurrences in the experimental group were far lower than those in the control group (P = 0.000 and P = 0.029, respectively). The time of first anus exhaust of the patients in the experimental group was obviously earlier than that of the control group (P = 0.030), and the number of vomiting occurrences of the patients in the experiment group was obviously lower than that in the control group (P = 0.023). No significant differences in the incidence of other adverse reactions were observed between the two groups within 48 h post-operation (P >0.05). In summary, oxycodone combined with dexmedetomidine can be safely and effectively used for analgesia after laparoscopic radical resection of colon cancer.

Perbandingan Efektivitas Patient-Controlled Analgesia (PCA) Fentanil, PCA Morfin dan Tramadol Intravena sebagai Analgetik Pasca Operasi Modified Radical Mastectomy

Background : Modified Radical Mastectomy often accompanied by moderate to severe post-operative pain. Some patients who received intermitten analgesic combination of tramadol and ketorolac still complaining of pain. PCA is a new method of analgesic administration. The use of PCA fentanyl and PCA morphine is expected to be more effective in the management of MRM post-operative pain. The aim of study : This study aims to determine the effectivity, side effects and patient satisfaction level between intravenous PCA fentanyl, PCA morphine and tramadol as an analgesic for post-operative MRM. Methods : Double-blind clinical trial of 36 patients who were scheduled to undergo MRMfulfilled this study criteria. After general anesthesia, the patients were divided into 3 groups of post-operative analgesic treatment: 1) PCA fentanyl group with fentanyl loading dose 50 mcg, demand dose 20 mcg, 10 min interval lockout, 70 mcg/hour dose limit, infusion background 30 mcg/hour; 2) PCA group morphine with morphine loading dose 4 mg, demand dose 1 mg, 10 minute interval lockout, 6 mg/hour limit dose, no background infusion; 3) tramadol group who received intravenous tramadol 100 mg/8 hours. Periodic assessment of NRS score, RASS score, vital signs, side effects and patient satisfaction levels during first 24 hours post-operative. Data analyzed with Shapiro-Wilk followed by Kruskal-Wallis or One Way ANOVA, were considered significant if p<0.05. Result : PCA fentanyl is the most effective, followed by PCA morphine then tramadol. PCA fentanyl and PCA morphineRASS score are lower than tramadol(p=0,000). Drugs side effects are nausea,vomiting and dizziness which not statistically significant. PCA fentanyl provides the highest patient satisfaction level, while there is no significant differences between PCA morphine and tramadol(p=0,009). Blood pressure, respiratory rate and pulse rate PCA fentanyl and PCA morphine is significantly lower than tramadol group. Conclusion :PCA fentanyl and PCA morphine are more effective than tramadol. PCA fentanyl providesthe highest patient satisfaction level. Drugs side effects are nausea, vomiting and dizziness which not statistically significant. Keyword : MRM,PCA fentanil, PCA morfin, tramadol, effectivity, side effects, patient satisfaction level Latar Belakang : Operasi Modified Radical Mastectomy menimbulkan nyeri derajat sedang hingga berat pasca operasi. Sebagian pasien yang mendapat kombinasi anagetik tramadol dan ketorolak secara berkala, masih mengeluh nyeri. PCA merupakan metode baru pemberian analgetik. Penggunaan PCA fentanil dan PCA morfin diharapkan dapat lebih efektif dalam mengatasi nyeri pasca operasi MRM. Tujuan : Penelitian ini bertujuan untuk mengetahui perbandingan efektivitas, efek samping dan tingkat kepuasan pasien antara penggunaan PCA fentanil, PCA morfin dan tramadol intravena sebagai analgetik pasca operasi MRM. Metode :Dilakukan uji klinis tersamar ganda terhadap 36 pasien rencana operasi MRM yang memenuhi kriteria penelitian. Setelah dilakukan anestesi umum, pasien dibagi dalam 3 kelompok perlakuan pemberian analgetik pasca operasi: 1) kelompok PCA fentanil dengan fentanilloading dose 50 mcg, demand dose 20 mcg, lockout interval 10 menit, limit dose70 mcg/jam, background infusion 30 mcg/jam; 2) kelompok PCA morfin denganmorfin loading dose 4 mg, demand dose 1 mg, lockout interval 10 menit, limit dose6 mg/jam, tanpa background infusion; 3)kelompok tramadol yang mendapat tramadol intravena 100 mg/8jam. Dilakukan penilaian berkala skor NRS, RASS, tanda vital, efek samping dan tingkat kepuasan pasien selama 24 jam pasca operasi. Data dianalisa dengan Shapiro-Wilk dilanjutkan Kruskal-Wallis atau One wayANOVA, dianggap bermakna bila p< 0,05. Hasil :Efektivitas terbaik pada PCA fentanil, diikuti PCA morfin lalu tramadol. Skor RASS PCA fentanil dan PCA morfin lebih rendah dari tramadol (p=0,000). Terdapat efek samping mual, muntah dan dizziness yang secara statistik tidak berbeda bermakna. Tingkat kepuasan pasien tertinggi pada kelompok PCA fentanil, sedangkan antara kelompok PCA morfin dan tramadol tidak berbeda bermakna(p=0,009). Tekanan darah, laju napas dan laju nadi kelompok PCA fentanil dan PCA morfin lebih rendah daripada tramadol. Simpulan:PCA fentanil dan PCA morfin lebih efektif dibandingkan tramadol. PCA fentanil memberikan tingkat kepuasan pasien yang lebih tinggi dibanding PCA morfin dan tramadol. Terdapat efek samping mual, muntah dan dizziness namun secara statistik tidak berbeda bermakna Kata Kunci : MRM, PCA fentanil, PCA morfin, tramadol, efektivitas, efek samping, tingkat kepuasan pasien

Adding dexmedetomidine to morphine-based analgesia reduces early postoperative nausea in patients undergoing gynecological laparoscopic surgery: A randomized controlled trial

Purpose: Few studies have investigated the effect of dexmedetomidine on postoperative nausea and vomiting (PONV) in patients following gynecological laparoscopic surgery. We investigated if adding dexmedetomidine to a morphine-based patient-controlled analgesia (PCA) could reduce the incidence of PONV in this patient population. Methods: In this double-blind randomized-controlled trial,122 patients undergoing gynaecological laparoscopic surgery were randomly allocated to receive either a mixture of dexmedetomidine 1μg ml-1 and morphine 0.5mg ml-1 (Group Dex) or morphine 0.5mg ml-1 alone (Group Ctrl) for postoperative i.v. PCA. PCA pump was programmed as followed: bolus dose 2ml, lockout interval 8 minutes and background infusion at a rate of 1ml h-1. The primary outcome was the incidence of nausea and vomiting within 24 hours after operation. Results: The incidence of nausea and total PONV during the first 2h period was significantly lower in the Group Dex than in the Group Ctrl (10% vs 25%, P=0.031 and 0.031, respectively). There were no significant differences in regard to the total incidence of PONV (41% vs 52%, P=0.204), PONV score, time to first onset of PONV, or the need for rescue antiemetics in the first 24 hr following surgery between the two groups. Conclusions: For female patients undergoing gynecological laparoscopic surgery, adding dexmedetomidine to morphine-based PCA reduced the incidence of early postoperative nausea but not total PONV within 24h after surgery.

Perbandingan Efektivitas Patient-Controlled Analgesia (PCA) Fentanil, PCA Morfin dan Tramadol Intravena Sebagai Analgetik Pasca Operasi Modified Radical Mastectomy (MRM)

Latar Belakang: Operasi Modified Radical Mastectomy menimbulkan nyeri derajat sedang hingga berat pasca operasi. Sebagian pasien yang mendapat kombinasi anagetik tramadol dan ketorolak secara berkala, masih mengeluh nyeri. PCA merupakan metode baru pemberian analgetik. Penggunaan PCA fentanil dan PCA morfin diharapkan dapat lebih efektif dalam mengatasi nyeri pasca operasi MRM.Tujuan: Penelitian ini bertujuan untuk mengetahui perbandingan efektivitas, efek samping dan tingkat kepuasan pasien antara penggunaan PCA fentanil, PCA morfin dan tramadol intravena sebagai analgetik pasca operasi MRM.Metode:Dilakukan uji klinis tersamar ganda terhadap 36 pasien rencana operasi MRM yang memenuhi kriteria penelitian. Setelah dilakukan anestesi umum, pasien dibagi dalam 3 kelompok perlakuan pemberian analgetik pasca operasi: (1) kelompok PCA fentanil dengan fentanil loading dose 50 mcg, demand dose 20 mcg, lockout interval 10 menit, limitdose 70 mcg/jam, background infusion 30 mcg/jam; (2) kelompok PCA morfin dengan morfin loading dose 4 mg, demand dose 1 mg, lockout interval 10 menit, limit dose 6 mg/jam, tanpa background infusion; (3)kelompok tramadol yang mendapat tramadol intravena 100 mg/8jam. Dilakukan penilaian berkala skor NRS, RASS, tanda vital, efek samping dan tingkat kepuasan pasien selama 24 jam pasca operasi. Data dianalisa dengan Shapiro-Wilk dilanjutkan Kruskal-Wallis atau One way ANOVA, dianggap bermakna bila p< 0,05.Hasil:Efektivitas terbaik pada PCA fentanil, diikuti PCA morfin lalu tramadol. Skor RASS PCA fentanil dan PCA morfin lebih rendah dari tramadol (p=0,000). Terdapat efek samping mual, muntah dan dizziness yang secara statistik tidak berbeda bermakna. Tingkat kepuasan pasien tertinggi pada kelompok PCA fentanil, sedangkan antara kelompok PCA morfin dan tramadol tidak berbeda bermakna(p=0,009).Simpulan: PCA fentanil dan PCA morfin lebih efektif dibandingkan tramadol. PCA fentanil memberikan tingkat kepuasan pasien yang lebih tinggi dibanding PCA morfin dan tramadol. Terdapat efek samping mual, muntah dan dizziness namun secara statistik tidak berbeda bermakna.

Patient controlled analgesia: The impact of an 8 versus 10 minute lockout interval in postoperative patients

The purpose of this study was to compare the level of pain control achieved with 8 versus 10 minute lockout intervals in adult patients who received patient controlled analgesia (PCA) within 24 hours of surgery. There was no difference in pain in the first 72 hours between the 8 minute and 10 minutes group. Additionally, there was no difference in time to first PCA regimen change or a composite outcome of adverse events.

Edema caused by continuous epidural hydromorphone infusion: A case report and review of the literature

Background: Intraspinal drug delivery (IDD) therapy has been increasingly employed in patients with intractable, nonmalignant pain. Before implantation of permanent intraspinal pump, an intraspinal opioid screening trial is conducted to demonstrate the efficacy. The patient-controlled continuous epidural opioid infusion trail, performed in an outpatient setting, is widely accepted by many interventional pain specialists.Objective: To report a case of severe edema observed during the continuous epidural hydromorphone infusion trial.Case Report: An otherwise healthy 68-year-old lady with a 5-year history of severe low back pain and bilateral leg pain because of failed back surgery syndrome was referred to our clinic for IDD therapy.A tunneled lumbar epidural catheter was placed at L2- L3 with catheter tip advanced to L1 under fluoroscopic guidance. Satisfactory catheter placement was confirmed by epidurogram. The catheter was then tunneled subcutaneously and connected to a Microject™ patient-controlled epidural analgesia (PCEA) pump (Codman, Raynham, MA). The pump was programmed to deliver hydromorphone (0.1 mg/ml) at basal rate of 0.3 ml/h. The bolus dose was 0.1 ml with a 60-minute lockout interval. The patient was instructed how to operate the infusion pump. During the following infusion trial, she reported satisfactory analgesia (>70 percent pain reduction) and was able to wean off her other systemic opioids. However, she developed diffuse edema and gained over 16 pounds during the 5-day infusion trial. Her edema finally resolved 3-4 days after termination of the epidural infusion.Conclusion: Edema may occur and persist during epidural hydromorphone infusion. This report represents the first case report, to the best of our knowledge, describing severe edema in a patient on continuous epidural hydromorphone administration during an outpatient epidural infusion trial.

Perbandingan Efek Pemberian Ketamin 0,15 Mg/Kgbb Iv Prainsisi dan Ketamin 0,15 Mg/Kgbb Iv Pascabedah terhadap Kebutuhan Analgesik Morfin Pascabedah pada Pasien Operasi Ortopedi Ekstremitas Bawah

Latar Belakang : Ketamin telah digunakan sebagai analgesia perioperatif sejak lama. Namun cara pemberian yang efektif masih belum jelas.Tujuan : membandingkan efek pemberian ketamin prainsisi, selama operasi dan 24 jam pascabedah dengan pemberian ketamin selama 24 jam pascabedah terhadap kebutuhan morfin pascabedah.Metode : Penelitian ini merupakan uji tersamar acak ganda. Total sampel 50 dibagi dalam 2 kelompok pasien dengan operasi ortopedi ekstremitas bawah dengan anestesi spinal. Kelompok pertama, mendapatkan ketamin 0,15 mg/kgBB IV prainsisi + 0,1 mg/kg/jam selama operasi dan 24 jam pascabedah. Kelompok kedua mendapatkan ketamin 0,15 mg/kgBB IV pascabedah + 0,1 mg/kg/jam selama 24 jam pascabedah. Kedua kelompok mendapatkan analgesia pascabedah morfin via patient-controlled analgesia dengan loading dose 2 mg, bolus dose 1 mg dan lockout interval 7 menit. Jangka waktu pemberian morfin pertama pascabedah dihitung dari akhir operasi hingga saat pemberian morfin loading dose atas permintaan pasien; konsumsi morfin pascabedah dihitung dalam 24 jam.Hasil : Tidak ada perbedaan yang bermakna di antara kedua kelompok baik dalam waktu pemberian analgesik pertama (p=0,055) maupun konsumsi morfin dalam 24 jam (p=0,351).Simpulan : Ketamin tidak memiliki efek analgesia preventif pada pasien yang menjalani anestesi spinal.

DISCRIMINATION OF PAIN INTENSITY LEVEL AND SIDE EFFECTS OF POSTOPERATIVE PAIN USING PARAMETERS EXTRACTED FROM THE EVOKED PAIN PATTERN

The value of evoked potentials (EPs) in the clinical assessment of physiological function has been recognized for some time by those with specialized neurophysiological interests. Based on this concept, we have applied this novel technique for discrimination of pain intensity level and side effects using time-domain parameters extracted from the evoked pain pattern (EPP) in postoperative pain via patient-controlled analgesia (PCA). In conventional PCA systems, each delivery is similar to evoked pain stimulation, and we then count the following demands in a lockout interval. Therefore, the EPP is calculated and averaged from several lockout intervals in a period of time. From this calculation, the evoked parameters of area, latency, and amplitude of each period of time can be easily extracted. A total of 741 cases from 1519 patients at a medical center have been screened and compared with these three parameters using different visual analog scales (VAS) and side effects (SE). The results indicate that the area parameter is a good indicator for higher VAS patients and the variance of latency parameter is a better outcome for interpreting the patients with SE. However, the amplitude parameter shows no significant differences in both VAS and SE groups. Using massive information from clinical trials and a novel technique of evoked pain stimulation algorithm, we demonstrate that evoked parameters (i.e. area and latency) can serve as indicators to assess various clinical evidences, such as VAS and SE associated with postoperative pain.