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.

A Randomized Control Trial of Patient-Controlled Intravenous Analgesia (PCIA) with and Without a Background Infusion Using Sufentanil for Cesarean Section Analgesia

Purpose: Patient-controlled intravenous analgesia (PCIA) is an option for pain cesarean section analgesia. However, the effect of a background infusion on the analgesic requirements of parturients is still debated. In order to attempt to identify the optimal cesarean section analgesia infusion regime, we evaluated the benefit of the background infusion in this randomized study.Patients and methods: 60 Parturients had a PCIA analgesia protocol initiated consisting of a 0.5mL bolus, and compared 2 Groups: no background infusion, 6 min lockout time (Group A). 2 mL/h infusion, 10 min lockout time (Group B). The total amount of sufentanil consumed, two categories of pain scores, sedation score, postpartum hemorrhage, Injection/attempt (I/A) ratio, side effects, satisfaction were calculated for both groups.Results: Group B significantly reduce visual analog scale（VAS）pain scores 6, 12h. Group A and Group B were not significantly different regarding wound pain at rest (VAS-R) and uterine cramping pain (VAS-U) at postoperative 24, 36 hours. In terms of I/A, Group A was lower than Group B, there was no significant difference. Group B showed significantly higher satisfaction than Group A. Total consumption of sufentanil at 36 hours postoperative was much greater in Group B. Group B can significantly reduce the postpartum hemorrhage within 1 hour. The minimal respiration rates were not significantly different among groups. The side effect were not observed among groups. All parturients had the same Ramsey sedation score.Conclusion: In comparison with the without background infusion, total consumption of sufentanil at 36 hours postoperative was much greater in the background infusion, but it can significantly reduce the uterine contraction pain and wound pain of 12 hours after cesarean section, significantly improve patient satisfaction, reduce the postpartum hemorrhage within 1 hour, and does not increase the incidence of PONV and respiratory depression in parturients.

The Optimizing Background Infusion Mode Decreases Intravenous Patient-Controlled Analgesic Volume and Opioid Consumption Compared to Fixed-Rate Background Infusion in Patients Undergoing Laparoscopic Cholecystectomy: A Prospective, Randomized, Controlled, Double-Blind Study

Background and objectives: The fixed-rate continuous background infusion mode with bolus dosing is a common modality for intravenous patient-controlled analgesia (PCA). However, some patients suffer from inadequate analgesia or opioid-related adverse effects due to the biphasic pattern of postoperative pain. Therefore, we investigated the postoperative analgesic efficacy of PCA using an optimizing background infusion mode (OBIM) where the background injection rate varies depending on the patient’s bolus demand. Materials and Methods: We prospectively enrolled 204 patients who underwent laparoscopic cholecystectomy in a randomized, controlled, double-blind study. Patients were allocated to either the optimizing (group OBIM) or the traditional background infusion group (group TBIM). The numeric rating scale (NRS) score for pain was evaluated at admission to and discharge from the recovery room, as well as at the 6th, 24th, and 48th postoperative hours. Data on bolus demand count, total infused volume, and background infusion rate were downloaded from the PCA device at 30-min intervals until the 48th postoperative hour. Results: The NRS score was not significantly different between groups throughout the postoperative period (p = 0.621), decreasing with time in both groups (p < 0.001). The bolus demand count was not significantly different between groups throughout (p = 0.756). The mean total cumulative infused PCA volume was lower in group OBIM (84.0 (95% confidence interval: 78.9−89.1) mL) than in group TBIM (102 (97.8−106.0) mL; p < 0.001). The total cumulative opioid dose in fentanyl equivalents, after converting sufentanil to fentanyl using an equipotential dose ratio, was lower in group OBIM (714.1 (647.4−780.9) μg) than in group TBIM (963.7 (870.5−1056.9) μg); p < 0.001). The background infusion rate was significantly different between groups throughout the study period (p < 0.001); it was higher in group OBIM than in group TBIM before the 12th postoperative hour and lower from the 18th to the 48th postoperative hour. Conclusions: The OBIM combined with bolus dosing reduces the cumulative PCA volume and opioid consumption compared to the TBIM combined with bolus dosing, while yielding comparable postoperative analgesia and bolus demand in patients undergoing laparoscopic cholecystectomy.

The Optimizing Background Infusion Mode Decreases Intravenous Patient-Controlled Analgesic Volume Compared to Fixed-Rate Background Infusion in Patients Undergoing Laparoscopic Cholecystectomy: A Prospective, Randomized, Controlled, Double-Blind Study

Background and objectives: Traditional intravenous, patient-controlled analgesia (PCA) uses a fixed-rate continuous background infusion mode. However, some patients suffer from inadequate analgesia or opioid-related adverse effects due to the biphasic pattern of postoperative pain. Therefore, we investigated the postoperative analgesic efficacy of PCA using an optimizing background infusion mode (OBIM), where the background injection rate varies depending on the patient's bolus demand. Materials and Methods: We prospectively enrolled 204 patients who underwent laparoscopic cholecystectomy in a randomized, controlled, double-blind study. Patients were allocated into either the optimizing (group OBIM) or the traditional background infusion group (group TBIM). The numeric rating scale (NRS) score for pain was evaluated at admission to and discharge from the recovery room, as well as at the 6th, 24th, and 48th postoperative hours. Data of bolus demand count, total infused volume, and background infusion rate was downloaded from the PCA device at 30-min intervals until the 48th postoperative hour. Results: The NRS score was not significantly different between groups throughout the postoperative period (P = 0.621), decreasing with time in both groups (P &lt; 0.001). The bolus demand count was not significantly different between groups throughout (P = 0.756). The mean cumulative infused PCA volume was lower in group OBIM [84.0 (95% confidence interval: 78.9&minus;89.1) mL) than in group TBIM [102 (97.8&minus;106.0) mL] (P &lt; 0.001). The background infusion rate was significantly different between groups throughout (P &lt; 0.001); it was higher in group OBIM than in group TBIM before the 12th postoperative hour, and lower from the 18th to the 48th postoperative hours. Conclusions: The OBIM combined with bolus dosing is useful in that it reduces the cumulative PCA volume compared to the TBIM combined with bolus dosing, while yielding comparable postoperative analgesia and bolus demand in patients undergoing 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.

Continuous Fentanyl Background Infusion Regimen Optimised by Patient-Controlled Analgesia for Acute Postoperative Pain Management: A Randomised Controlled Trial

Owing to a lack of studies investigating the effect of adjustments in fentanyl background infusion (BI) with patient-controlled analgesia (PCA) on postoperative analgesia, we evaluated three BI regimens with fentanyl PCA for acute postoperative pain management. This randomised controlled trial enrolled 105 patients, who were assigned to three parallel groups: constant rate BI of 2 mL/h (CRBI group); time-scheduled decremental BI of 6, 2 and 1 mL/h (TDBI group); and BI rates optimised to the demand of PCA (POBI group). The incidence of insufficient analgesia, visual analogue scale (VAS) pain score and side effects were evaluated. The incidence of insufficient analgesia in the post-anaesthesia care unit was lower in the TDBI and POBI groups than the CRBI group. Incidence of insufficient analgesia in the ward was lower in the POBI group than the CRBI group. Postoperative VAS scores were significantly lower in the TDBI and POBI groups for up to 4 h and 24 h, respectively, compared with the CRBI group. Side effects and infused fentanyl dose were highest in the CRBI group. Adjusting BI rate based on time or patient demands could improve postoperative analgesia and reduce side effects. Compared to a constant BI rate, PCA-optimised BI achieved higher patient satisfaction.

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

Incidence of Hemidiaphragmatic Paralysis with Patient Controlled Infusion of Low Volume of Ropivacaine after Ultrasound Guided Low Dose Interscalene Brachial Plexus Block, A Prospective Observational Study

BACKGROUND Hemidiaphragmatic paralysis is a complication of single shot and continuous interscalene brachial plexus block that can be minimised by ultrasound guided extrafascial catheter placements and by limiting the amount of local anaesthetic administered. We hypothesized that patient controlled infusion of low volume of ropivacaine for a period of 24 hours would not cause hemidiaphragmatic paralysis and would provide adequate analgesia.METHODS 54 patients aged 18-65 years undergoing surgery for shoulder dislocation or proximal humerus fracture were recruited and allocated into two groups of 27 each, patient controlled interscalene analgesia (PCIA) and multimodal analgesia (MA). Interscalene catheter was inserted at end of surgery and 10 ml of 0.5% ropivacaine was administered as single bolus dose. PCIA was initiated after four hours to deliver background infusion of 2 ml/hr, bolus of 5ml (0.2% of ropivacaine) with lockout interval of 30 minutes for a total duration of 24 hours. Incidence of hemidiaphragmatic paralysis using M-mode ultrasonography was recorded at extubation,4,6,12 and 24hrs. Numerical rating scale (NRS) for pain, patient satisfaction score and complications were also recorded. Acetaminophen (1 gm) and diclofenac 75 gm were used in MA group.RESULT No diaphragmatic paresis was reported in patients administered the background infusion or single bolus doses of ropivacaine and scanned at 4, 6,12 and 24 hrs. Partial paresis was noted in all patients in which two bolus doses/hour were administered 30 minutes after the second bolus. All patients with paresis had diaphragmatic excursion normalized in the next recording made at 4 hours and no complication was reported in any patient. NRS was below 3 at all time points in PCIA and the cumulative fentanyl and tramadol consumption was significantly higher in MA group. The incidence of complete and partial paresis of diaphragm was 85%and 3.7% after single shot bolus dose respectively and had resolved before start of infusion after 4 hours.CONCLUSION Patient controlled low volume continous infusion of ropivacaine (2 ml/hr of 0.2% of ropivacaine) with administration of a single bolus dose of 5ml in an hour does not cause unilateral phrenic paresis. Partial paresis is reported with two bolus doses/hour.Clinical trial number NCT03081728 (clinicaltrials.gov;)