Showing papers on "Pain medicine published in 1994"

The prevention of postoperative pain

Abstract: Patients want safe and effective analgesia Our goal is to prevent postoperative pain in an efficient and cost effective manner For most patients, the pain can be managed using simple, non-invasive and inexpensive analgesic techniques Given the current economic climate, cost will become increasingly important There will be financial pressure to expand the scope of ambulatory surgery There will be pressure to discharge patients as soon as they are able to take oral medications Outpatient analgesia is the oldest and most widespread form of patient-controlled analgesia--We already have the knowledge and the analgesics necessary to prevent postoperative pain What we need now is logical, rational, and universal application of this information

Difficult laryngoscopy: obtaining the best view

Abstract: The anaesthesia community is now well aware that respiratory-related events are the most common cause of brain death and whole body death due to anaesthesia and that difficulty/failure to establish the airway is the most common cause of these respiratory-related events. This issue of the Canadian Journal of Anaesthesia contains an excellent description of the experience of one major teaching hospital with establishing the airway; this experience likely "reflects the reality of the actual practice setting" for many anaesthesia caregivers.2 The paper by Drs. Rose and Cohen greatly strengthens several understandings that were suggested by previous studies and are summarized in several recent reviews. 3-5 First, the incidence of "troublesome" or "awkward" intubation requiting "less than or equal to two laryngoscopies" is relatively common and is approximately 1-18% (the authors found 2.5%). Second, the incidence of "difficult" intubation requiring "more than two laryngoscopies" is approximately 1-4% (the authors found 1.8%). Third, the incidence of "abandoned/failed intubation" is approximately 0.05-0.35% (the authors found 0.30%). Fourth, the incidence of "cannot ventilate by mask, cannot intubate" is somewhere around 0.0001-0.02% (the authors had a near miss incidence of 0.01%). The wide range of incidences cited above for all degrees of difficulty generally reflect the difference between the obstetrical and general surgical population of patients. Fifth, the greater the degree of intubation difficulty, the greater the incidence and severity of complications. Sixth, simple noninvasive tests can predict difficult intubation. Seventh, use of/combining multiple noninvasive tests results in more powerful prediction of difficult intubation than any test alone. Eighth, and most important, prediction of ease/ difficulty of intubation remains an imperfect science since the tests fail to predict some difficult intubations and many predicted intubations turn out to be easy. Rose and Cohen use the qualitative terms (1) "easy"; (2) "troublesome," "awkward," and "less than or equal to two laryngoscopies"; (3) "difficult" and "more than

Management of status epilepticus

Abstract: We read with interest the case report of Borgeat et al. [i] about propofol management of refractory status epilepticus, since persistent epileptic discharges constitutes a relevant and frequent challenge in our clinical practice. We share with the authors the idea that propofol presents potential advantages over barbiturates in inducing and maintaining pharmacological burst suppression coma. On the other hand, the patient described by Borgeat et al. exhibited repeated clonic right facial movements, which were the clinical expression of EEG \"slow focal left-sided spike-wave discharges\". Such a clinical and electrophysiological pattern should be correctly defined as nonconvulsive, or partial motor, status epilepticus. According to our experience and clinical literature [2], drug coma is not indicated in this condition, which does not pose an immediate threat to the patient's health. This is a particularly important issue given the relevant metabolic and hemodynamic side effects of burst suppression drug coma. Moreover, in the patient of Borgeat et al. epileptic discharges began during anesthesia for the evacuation of a traumatic acute subdural hematoma: since epilepsia ensuing during general anesthesia is rather uncommon, we think that more specifications about the anesthesia procedure employed would be of interest.

Epidural analgesia in children

Abstract: The report in this issue by Wood et aL I chronicles the development of a paediatric epidural analgesia programme at Alberta Children's Hospital. In these authors' experience, epidural analgesia was associated with good analgesia and safety, though with a considerable incidence of side effects and technical difficulties. Readers should not be put off by the quoted incidence of \"complications\"; many of these occurrences were anticipated and relatively minor side effects. Recent interest in epidural analgesia in children occurs in the setting of an increased awareness of the need to provide improved pain relief for children following surgery and other forms of acute and chronic pain. Regional anaesthesia has become an important means for providing postoperative pain relief with an excellent safety and side-effect profde. 2.3 Peripheral nerve blocks are especially useful for children undergoing minor procedures as outpatients, 4 since these blocks provide analgesia with rapid emergence and a lower incidence of nausea than comparable analgesia produced by systemic opioids. Single shot caudal epidural blockade with bupivacaine is useful for providing analgesia following minor procedures below the umbilicus. With proper selection of concentration (e.g., bupivacaine 0.125 0.25%) and dose (no more than 2.5 mg-kg-J), caudal blocks cause minimal interference with urination and motor function, and can be used safely for outpatients. 5 For more major procedures, or for procedures involving the thorax and upper abdomen, single-shot caudal blockade using bupivacaine is less effective, and the duration of analgesia is quite short. Single-shot caudal morphine (roughly 0.03 mg. kg -l for lower dermatomes or 0.05 mg. kg -I for thoracic derrnatomes) provides more prolonged analgesia and is effective for pain arising from thoracic as well as lumbo-sacral dermatomes. 6,7 Caudal analgesia with opioids is not recommended for outpatients because of a high incidence of urinary retention and a rare, but real, chance of delayed respiratory depression. Several series suggest that epidural analgesia is particularly suitable for infants and children with respiratory

New developments in the assessment of pain in cancer patients

Abstract: Pain occurs in more than 80% of cancer patients before death. During recent years major progress has taken place in our techniques for the adequate assessment of cancer pain. Major prognostic factors associated with the pain syndrome have been recognized. In addition, other prognostic factors associated with the characteristics of the patient have been defined. Valid tools have been developed that allow for the assessment of most of the prognostic variables associated with analgesic response. During recent years a major effort has been made to integrate the pain syndrome within the other complex symptoms that are often present in patients with advanced cancer. The interaction of pain and analgesic treatment with other symptoms and their management is discussed. Finally, areas where future research should focus in the area of the diagnosis and assessment of pain are discussed.

Continuous intra-arterial blood gas monitoring.

Abstract: The measurement of arterial blood gases and pH became practical with the developments of the Clark and StowSeveringhaus electrodes in the 1950s and their subsequent incorporation into commercial blood gas analyzers in the 1960s. Since then, these measurements have become indispensible in the assessment of oxygenation, ventilation and acid-base in critically ill patients. Presently, arterial blood gas analysis is one of the most frequently made laboratory measurements, with well over 150million analyses performed annually in the US alone. These analyses are sufficiently accurate for clinical purposes, but it is worth noting that substantial measurement differences exist between individual analyzers from the same or different manufacturers [1, 2]. There are a number of disadvantages associated with conventional blood gas analysis. Individual arterial punctures may result in discomfort and there are slight risks such as bleeding and infection. More importantly, the indications for sampling are rather vague [3], so that onty isolated \"snapshots\" of continuous physiologic events are obtained. Thus, a blood gas analysis is frequently performed after a deleterious event has occurred. Moreover, because there is considerable spontaneous variability in blood gases, it has been argued that infrequent sampling may be misleading and that clinical decisions should be made on the basis of trends in blood gases [4]. Since the blood gas laboratory is often located some distance from the patient, the therapeutic decision time (the time which elapses between an order for a blood gas and an action based on its result) can be substantial [5]. The time delay caused by sample transport may, in addition, increase the pre-analytic errors. Furthermore, contact with potentially infectious blood poses a hazard to hospital personnel and the sampling process itself increases the patient's risk of nosocomial line sepsis. Lastly, substantial blood loss may be associated with conventional arterial blood gas sampling [61. To circumvent the '.above limitations, major efforts have been exerted by numerous companies to develop continuous intra-arterial blood gas monitors. It is not my purpose to review these (mostly unsuccessful) efforts. However, it should be noted that in total, the developmental expenditures are (conservatively) estimated to have exceeded well over $100 million. Rather, a brief description of the inherent difficulties associated with continuous intra-arterial blood gas measurement is given. In addition, I will review the impact this and similar technology may have on patient care. Technologically, it is quite feasible to build probes that are capable of accurate continuous measurement of pH, PCO 2 and PO2, that are sufficiently small in size to allow passage through a 20-gauge radial artery cannula [7]. However, to reliably manufacture this type of probe at a competitive price is difficult. To avoid the traditional drift and miniaturization problems of conventional electrochemical methods, most blood gas probes have employed fluorescent dyes that are encapsulated in sensors located on optical fibers [8]. In essence, when these fluorescent dyes are excited by light of specific wavelengths, they emit fluorescent light with an intensity and/or frequency that is dependent upon the concentration of the particular analyte (pH, PCO 2 and POz) present in the blood. Aside from fluorescent dyes, blood gases may also be measured using absorbance sensors (in which the transmitted light intensity is measured) or phosphorescent sensors (in which decay times from excited states are measured). Fluorescent probes, also termed optodes, have been shown to perform well on the bench [8], in animals [9], in normal volunteers [10, 11] and in small groups of carefully selected patients [9, 12, 13]. Successful and accumate performance in a widely divergent group of critically ill patients has not yet been demonstrated due to a number of problems. Suitable biocompatible coatings that prevent thrombosis and deposition of blood constiuents on the sensor surfaces have to be employed. Furthermore, two kinds of aberrant low PO 2 values were observed in early studies [10, 11, 13]. The first consisted of intermittent slow decreases in PO 2. These were postulated to be caused by a longitudinal PO 2 gradient along the radial artery (possibly caused by reductions in flow due to bending at the wrist or intermittent arterial spasm). If present, these effects would be more prominent in hypotensive patients with vascular disease, so that a fundamental limitation of continuous blood gas monitoring 'via the radial artery might exist in these patients. The second type of aberrant PO 2 values consisted of more rapid

Use of antithrombin III in critical patients.

Abstract: Objective To evaluate the effect of the AT III concentrates upon the clinical evolution and hemostatic parameters.

Weaning from mechanical ventilation--the team approach and beyond.

Abstract: During the early 1980s I was caught up, as were many others, in the search for the answer to the decade old question \"Is Intermitent Mandatory ventilation (IMV) and Synchronized IMV (SIMV) better than AMV/T-piece for weaning patients from the ventilator?\" Vivid recollections remain of heated debates led by die hard advocates on either side of the controversy. Those in training during that period may still harbor the biases of their mentors who commonly disallowed, as a form of heresy, even the mention of \"the other method\". Most good controversies contain both fact and fantasy on either side of the debate; the truth usually lies somehere in between. A patient's reaction to IMV, SIMV, T-piece and Pressure Support Ventilation (PSV) weaning will vary, depending on patient pathophysiology and ventilator circuitry. For example, T-piece has the advantage of requiring no demand valve a potential benefit for a patient with marginal respiratory muscle reserve. On the other hand, a patient with auto-PEEP may benefit enough from the addition of CPAP through the IMV circuit to offset the imposed work of breathing from the ventilator demand valve [1]. A new development flow triggered ventilatory support reduces the work associated with a demand valve thereby allowing the potential for the combined advantages of T-piece and IMV. PSV is another successful and very popular modality for weaning, but it is not without the risk of the patient not synchronizing with the ventilator [2]. As editorial in Chest [3] by Petty entitled IMC vs CMC (intermittent mandatory cerebration versus continuous mandatory cerebration) seemed to be the first incisive commentary on the issue. Petty argued, in essence, that it was more important to understand the nuances of each ventilator mode so one could better select the modality best suited to the individual. He, by the way, preferred CMCI. What then is the \"best\" way to wean a patient from mechanical ventilation? Clearly, no ventilator mode has

Guidelines for training in intensive care medicine

Abstract: The present guidelines are presented with the aim of unifying the minimal requirements for training in intensive care medicine in Europe. These guidelines will serve as a basis to obtain the European Diploma of Intensive Care Medicine (by the ESICM). To be recognized as a specialist in intensive care medicine (\"intensivist\"), the candidate must present evidence of: a) a primary specialty in anaesthesiology, internal medicine (or specialty thereof), surgery, paediatrics (or in intensive care medicine), and b) a period of 2 years full-time training and experience in intensive care medicine. This 2 year period cannot be entirely included in the primary specialty, except in countries where a primary specialty in intensive care medicine (at least 5 years) has been formally recognized. During this latter training period, the candidate must have gained experience in the diagnosis and treatment of patients with: Q serious medical and surgical diseases, 9 polytrauma, 9 coronary artery disease, 9 neurosurgical diseases, 9 paediatric emergencies. For all candidates, experience is desirable but not mandatory in the following areas: 9 operating theatre (anesthetic procedures), 9 burns unit, 9 emergency room, 9 medicalized ambulance systems, 9 paediatric intensive care, 9 neonatology unit. The present document defines the minimum content of these 2 years of training in intensive care medicine, and

Stress ulcer prophylaxis--quo vadis?

Abstract: During the last decade stress ulcer prophylaxis has become a routine measure of ICU therapy in most hospitals throughout the world. Antacids, H2-antagonists, and more recently sucralfate, are some of the most widely prescribed drugs in many ICUs. However, in a few countries stress ulcer prophylaxis did not gain wide popularity. In this issue DF Zandstra and ChP Stoutenbeek [1] report the results of a large series of critically ill patients on prolonged mechanical ventilation treated without the use of stress ulcer prophylaxis. Based on the observed low incidence of clinically relevant stress ulcer bleeding (< l~ the authors raise the question whether stress ulcer prophylaxis should be administered to a large population of patients on prolonged mechanical ventilation. Thus, has the time come to abandon routine stress ulcer prophylaxis? Before this question can be answered, several others have to be discussed first. Most importantly, can we extrapolate the results obtained by Zandstra and Stoutenbeek to other ICUs? During the last five years only few studies on stress ulcer prophylaxis have been performed in mechanically ventilated patients. Labattnt et al. [2] investigated 398 ICU patients randomized to either sucralfate or control. Thirty patients developed macroscopically visible stress ulcer bleeding (SUB) and all in a subgroup of 181 patients with a total risk score (TRS) > 10. The same risk score [3] has been used by Zandstra and Stoutenbeek. Of the patients who developed SUB 70% were in the subgroup of 62 patients on mechanical ventilation for more than 24 h. In patients with a TRS > 10 SUB occurred significantly more frequently in the control group (22.8%, 95O/o C1 15-33%) than in the treatment group (10.1%, 95% C1 5-18%). In the control group SUB requiring transfusion occurred in seven patients (7.6%, 95% C1 3-15%) and in two patients (2.3%, 95% C1 0 -8%) of the sucralfate group. Thus, clinically important SUB occurred significantly more frequently in the control group than in the Netherlands study (0.6%, 95% C1 0-3%), although the TRS was significantly higher in the latter. In a series of 140 critically [4] ill children randomized to either antacids, sucralfate, ranitidine or control significantly more patients in the control group (20%0, 95% C1 8-37O/o) developed clinically important SUB (transfusion required, hypotension or decrease of haematocrit > 15%) than in the treatment groups (5.7%, 95% C1 2-12%). Three further studies in mechanically ventilated patients published after 1990 confirm that clinically important SUB still occurs despite administration of prophylactic treatment. In trauma patients Simms et al. [5] observed two patients out of 89 (2.2%, 95% C1 0 -8%) with SUB requiring transfusion. In a large study [6] in severely injured patients 15 out 278 patients (5.4%, C1 3 9%) required blood transfusion due to SUB, and in a further prospective study [7] two out of 97 long-term ventilated patients (2.1%, 95 % C10 7 % ) developed clinically important SUB. Thus, in five recent studies of critically ill patients, the majority of whom were mechanically ventilated, 27 clinically important SUB occurred in 628 patients (4.3%, 95% C1 3-6%) despite prophylactic treatment. Three of these studies [2, 4, 7] also included a total of 157 control patients with 14 clinically important SUB (8.9%, 95% C1 5-15%). These data clearly demonstrate that one has to be cautious to extrapolate the results reported by Zandstra and Stoutenbeek to other ICUs. Thus, the question arises why the Netherlands study differs from the known experiences of many other ICUs throughout the world. The authors discuss three major factors: i) infection prevention by SDD; ii) suppression of inflammation with corticosteroids; iii) aggressive fluid management in combination with vasodilators. Sepsis has been identified as a major risk factor of SUB [3, 8]. Thus, infection prevention might be considered as a logical approach in the prevention of SUB. SDD has been used as a basic measure in all ventilated patients in one study [2]. Nevertheless, 70% of the patients with SUB were on mechanical ventilation. Furthermore, sucralfate significantly reduced SUB compared with controls. Recent studies suggest that not sepsis but septic

Postoperative analgesia and patient satisfaction.

Abstract: Opioids continue to be the mainstay of postoperative pain control after surgery. "As required" (PRN) scheduling of intramuscular (or intravenous) opioid administration by health care attendants has been shown to be inadequate for postoperative analgesia. The shortcomings of traditional methods of opioid administration for postoperative analgesia have been reviewed by Oden. 1 Recent major improvements in postoperative pain control are related mostly to alternative methods of opioid administration, in particular the use of spinal opioids 2 or patientcontrolled administration (PCA) of opioids. 3 In general, these and other modalities of postoperative analgesia are best provided at an institution by a dedicated team of health care professionals comprising an Acute Pain Service.4 Anaesthetists have played a leading role in developing Acute Pain Services worldwide. s The best choice of anallgesic technique for each patient's postoperative requirements is not always clear now that we have an impressive array of effective modalities. These include different opioid administration techniques, e.g., spinal opioids, PCA (edidural, intravenous), intravenous infusions, ~s­ buccal, sublingual, rectal, nasal, etc.; local anesthetic agents (spinal, regional); non-steroidal anti-inflammatory agents (NSAIDS); alpha-adrenergic agents (systemic, spinal); and combinations of two or more of the above regimens.6 Collaborative research between anaesthesia and psychology may help to determine the particular method of postoperative analgesia best suited for a given patient. Recent studies have highlighted the relationship between specific emotional and psychological factors and satisfaction with iv-PCA.710 One of the more interesting implications of this work is that it may be possible to improve satisfaction and analgesic effectiveness by sele~tively matching specific patient characteristics with aspects of the postoperative analgesia delivery system. For example, the multidimensional health locus of control (MHLC) scale measures the extent to which individuals believe

Postoperative Schmerztherapie auf Allgemeinen Krankenpflegestationen

Abstract: Despite major advances in knowledge and development of efficient techniques for pain control, many patients on surgical wards suffer from modest to severe pain following surgery or trauma. Therefore, in the University Hospital of Kiel, Germany, an anaesthesiology-based acute pain service (APS) was started in 1985 to improve this situation. Organization of an APS. The anaesthesiologist in training who manages the recovery unit serves as an APS for surgical wards and is supervised by a consultant. The anaesthesists on call are responsible after regular working hours. The activities of the APS are as follows: 1. Induction of sufficient postoperative analgesia in the recovery unit for all surgical patients. 2. Clinical rounds on all patients receiving epidural analgesia (EA), other forms of regional analgesia, or patient-controlled analgesia (PCA) every morning and throughout the day if necessary. 3. Additional consultations for postoperative pain management for other patients on request. 4. Assessment and documentation of the clinical status of the patient, quality of analgesia, and side effects. 5. Writing orders for further treatment. 6. Continuing consultations and informal education for ward nurses, physiotherapists, and surgical staff; formal medical training for ward nurses in postoperative pain management. Activity of the APS. From 1985 to 1992, 1947 patients on normal wards were treated (EA: 1736, PCA: 183). Epidural analgesia was performed using a standard protocol with bupivacaine 0.175% – 0.25% infused continuously with top-ups if needed (mean 240 mg/day, range 75 – 600 mg; median duration 7 days, range 1 – 53, Table 1). Demand for further treatment was proved by day-to-day withdrawal. Since the introduction of an APS, complications of EA such as hypotension (1985/1986: 5.1%; 1987/1992: 0.5%, Table 3) and insufficient analgesia due to dislocation or other technical complications could be reduced significantly (Table 3). Dermal infections were seen in 2.6% of patients, with a significantly higher incidence in patients with arteriosclerotic diseases (4.1%). Epidural opioids were used in only 46 selected cases on surgical wards. Nevertheless, 2 cases of marked respiratory depression occurred. The overall risk of complications during postoperative EA could be reduced from 1 : 11 cases in the first 2 years to 1 : 20 in the last 6 years since introducing the APS. For other regional procedures (e.g., interpleural analgesia) no complications were recorded. PCA was performed using a standard protocol with tramadol or piritramide without background infusion (Table 6). The loading dose was titrated in the recovery unit. The median duration of PCA was 4 days (range 1 – 23); the median dose of piritramide was 45 mg/day (range 3 – 226 mg). Two cases of somnolence and respiratory depression occurred. In this period there were 8 potential life-threatening complications due to postoperative pain therapy; 4 occurred during standard surgical pain management (3 cases of severe respiratory depression after i.m. and i.v. piritramide (unsuccessfull resuscitation), tramadol, and buprenorphine; 1 small child with multiorgan failure after paracetamol intoxication). In those cases the APS was not involved. Conclusions. There are insufficient data for comparison of the incidence of complications following standard management of postoperative pain relief without an APS, i.e., i.m. injections of opioids on request, but severe and sometimes lethal complications have been reported. Since the majority of patients used EA or PCA for several days, it is again emphasised that these techniques should not be restricted to high-dependency areas such as intensive care or recovery units. The introduction of an APS is an adequate approach to more efficient and safer pain management on surgical wards. This requires standard protocols (Table 7), standardised monitoring and trained ward nurses. Based on our experience, most complications develop slowly, and risk factors can be recognised early enough to avoid severe sequelae. The routine use of epidural opioids on surgical wards is not recommended unless special monitoring (e.g., pulse oximetry) is provided. Establishing an APS is a major future challenge for anaesthesiologists. Nevertheless, surgeons should also participate to improve the standard of pain management. We should be aware that this service can not be run efficiently during simultaneous activity in the operating room.

Assessment of cancer pain: a continuous challenge

Abstract: A comprehensive assessment of cancer pain is the first and perhaps most important step toward pain relief. Yet, this assessment is frequently neglected in patients with cancer pain. This paper addresses five important aspects of cancer pain assessment: (1) What constitutes cancer pain assessment? (2) Why is it important? (3) Why is it frequently overlooked? (4) How can a cancer pain assessment program be implemented? (5) What changes can be expected as a result of routine cancer pain assessments? The fundamental assumptions underlying this discussion are that health-care providers must understand the intensity of their patients' pain and the likely etiology of that discomfort to direct an appropriate diagnostic evaluation and to initiate and evaluate the success of therapy. Instituting a routine pain assessment program need not be difficult. The recommended procedures must be simple, quantifiable, relevant, and recorded in the medical record. Routine pain assessment will promote a heightened sense of awareness and responsibility about cancer pain issues in health-care providers, improved communication between the patient and the healthcare provider, the development of cancer pain quality-assurance programs, and improved care for patients with cancer and pain.

Adult respiratory distress syndrome complicating a systemic capillary leak syndrome

Abstract: al., \"may override the beneficial effects that pI--I correction may have on hemodynamics\". It is additionally worth mentioning that earlier results in adult dogs [4, 5] are in contrast to the findings of Cooper and coworkers. Interestingly, Bell et al. [31 in a piglet model recently confirmed our findings. While equimolar sodium solutions had a comparable effect on cardiac output and cerebral blood flow, saline in contrast to bicarbonate significantly reduced the fraction of systemic blood flow directed to the brain. In conclusion, there are indications that in neonatal humans and animals with metabolic acidosis cautious administration of sodium bicarbonate increases cardiac output, reduces systemic and pulmonary vascular resistance, and improves cerebral blood flow and brain intracellular pH [2, 3, 6]. The exact reason for the elevation in cardiac output still needs to be clarified.