Acute Pain最新文献

Background and objective

Epidural analgesia (EA) is a gold-standard in post-operative pain control. Therefore, modern treatment concepts targeting early patient recovery regularly implement EA. Due to its increasing impact, EA should meet high quality standards in respect to application and maintenance. Though, daily practice often reveals EA-related problems, our investigation aimed to improve EA quality by assessing incidence and reasons of undeliberate, premature termination of post-operative EA.

Methods

In the first step all patients with post-operative EA were retrospectively studied covering a 6-month period (group 1). We analysed incidences and reasons of undeliberate termination of EA. Thereafter we modified our treatment protocols (preferential thoracic EA, continuous peripheral blocks, low concentrated local anaesthetic solutions, standardized co-medication). This was followed by a prospective analysis of all EA patients for another 6 months (group 2).

Results

777 patients were included (group 1 n = 400, group 2 n = 377). Undeliberate termination of post-operative EA was documented in 24.3% of group 1 patients (group 2: 14.1%; p < 0.05). In all patients, pain was the leading reason of premature termination (group 1: 52%; group 2: 68%), followed by motor block (group 1: 21%; group 2: 7.5%) and catheter dislocation (group 1: 10%; group 2: 16.7%).

Discussion

Modified treatment protocols reduced the rate of premature termination of EA from 24% to 14%. Particularly, we noted less motor impairment but still this rate is disappointing. The increasing rate of catheter dislocations underlines that a continuous analysis of all treatment aspects must be compulsatory.

Phantom limb pain is defined as pain localised in a body part that is no longer there (Mishra et al. [1]; Flor et al. [2]; Mayo Clinic Staff [3]). It is believed that amputation of an extremity is required for phantom pain and sensations to occur (Nikolajsen and Jensen [5]). However, we report a case in which a severed nerve to an “intact extremity” resulted in phantom limb-like pains and sensations which responded to a treatment regimen identical to that for phantom limb pain. It is important for clinicians to entertain the idea of phantom limb-like pain in cases when a nerve is severed to any extremity and as such, provide pain relief to this subgroup of patients.

Background

Opioids are very effective as postoperative analgesics, influencing emotional aspects of pain as well as reducing the actual pain threshold. Fentanyl, a phenylpiperidine derivative and potent opioid agonist, has already been studied for postoperative analgesia. Butorphanol, a synthetic morphinan derivative – agonist–antagonist, has few studies to substantiate its use. The present study was undertaken to compare the effects of the two drugs on postoperative pain relief in terms of efficacy and safety.

Methods

A prospective, randomized controlled study of 100 patients [ASA I and II] undergoing total abdominal hysterectomies was conducted. Group F of 50 patients received fentanyl [0.4 μg/kg/h] and group B received butorphanol [4 μg/kg/h] as postoperative pain treatment via intravenous patient controlled analgesia [i.v. PCA]. Parameters monitored were pain score [VAS], pulse, blood pressure, respiratory rate, sedation score and side effects. The infusion rate, number of boluses, PCA demands and requirement of rescue analgesia were noted.

Results

Butorphanol had a better maintenance phase than fentanyl. The VAS scores were found to be reduced in the butorphanol group when compared with fentanyl group, significantly at 8 h [F: 1.16 ± 1.037; B: 0.78 ± 0.582; p-value: 0.026]. The incidences of complications were comparable in both the groups.

Conclusion

Both the drugs are equally effective and safe as postoperative analgesics with i.v. PCA. The dose of 4 μg/kg/h of butorphanol appeared effective but the dosage of fentanyl used, 0.4 μg/kg/h, was not as effective as evidenced by the increased number of boluses taken by patients and needs to be increased.