Prevention of Epidural Morphine – induced Pruritus and Nausea – Vomiting by Intranuscular nalbuphine 10 mg. in Caesarean Section patients.

Background : The  common  side  effects  of  epidural  morphine  are  prurits  discomfort.Objective : To  test  the  hypothesis  that  nalbuphine  can  prevent  epidural  morphine-induced  pruritus  and  nausea vomiting.Design : Randomized  controlled  trial.Setting : Srinagarind  hospital,  Khon  kaen  university.Subjects : Sixty – four  caesarean patients (ASA 1-2) were randomly assingned  into 2 groups.Intervention : Epidural  anesthesia with 2% lidocaine with adrenaline 1:200,000 18-20 ml. plus morphine 5 mg. was performed  in  every patient.  After delivery  of  the  babies  patients  in  group 1 (n=32) received  NSS 1 ml. and  patients  in  group 2 (n=32)  received  nalbuphine  10 mg.  intramuscularly.Measurements : Side  effects  of  epidural  morphine  were  observed  for  a  24 hour  period. Results : The  incidence  of  pruritus  and  nausea – vomiting were  not  different  significantly  between  the  two  groups.  No  respiratory  depression  occurred.Conclusion : We  concluded  that  nalbuphine  10 mg.  given  by  intramuscular  injection  could  not  prevent  epidural  morphine-induced  pruritus  and  nausea-vomiting.Key  words : Epidural  morphine,  Side  effects,  Prevention, Nalbuphine. 

The Treatment of Patients with Moderate to Severe Pain in the Recovery Room Using the Pain Algorithm

Background : Postoperative pain remains a common complaint among PACU patients so we developed guidelines for better pain control. Patients rated their pain using a numeric rating scale (NRS, from 0 to 10). According to the guidelines, PACU nurses knew that patients with a NRS score  were in severe pain and required medication.Objective : To determine the proportion of patients not receiving treatment according to the guidelines.Design : Descriptive studySetting : PACU at Srinagarind HospitalSubjects : April 2001 PACU recordsMeasurement : The PACU records were reviewed retrospectively for age, NRS score, sedation score, number of treatments given and types of medication used.Results : the PACU admitted 474 patients in the month of April and 338 them were included in our study. Pain assessment was performed on 246 of the sample (72.8%,95%Cl : 68-77%) although 92 were not documented. Most of the patients (95.5%) were able to rate their pain using the NRS. NRS scores  5 were reported by 156 patients (66.4%,95%Cl: 60-72%) but 40 of them (25.6%,95%Cl: 19-33%) did not receive any treatment because 10 refused it and 30 gave no outward sign of needing it. Prior to discharge, 54 patients (29.8%, 95% Cl: 23-37%) still had NRS score5.Conclusion : Pain assessment according to the guidelines was performed on 72.8% of the sample. About 60% of patients had a NRS score  5 but 25.6% did not receive any treatment. We concluded that the guidelines were useful for PACU pain management. For greater improvement in the quality of PACU care, a prospective study should determind provider compliance.Keywords:\ 1. Postoperative Pain\ \ 2. PACU\ \ 3. Pain algorithm

Survey of Postoperative Pain Management Orders at Srinagarind Hospital

Background : Inappropriate medications, or doses, routs and duration of appropriate medications for control of acute postoperative pain have both physical and psychological sequelae.Objective : To survey the orders given over the first 24 hours for postoperative pain control at Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Thailand.Methods: cross-sectional descriptive study.Setting: Post Anesthesia Care Unit (PACU), Srinagarind HosptialMaterials and Methods: We inventoried the orders given for the first 24 hours of postopetrative pain control for patients admintted to PACU between June 21 and 22, 2001.  Excluded were patients transferred to ICU postoperatively, outpatients and those given anesthesia by local infiltration. Results: 225 patients were admitted to PACU during the sampling period.  The types of pain control medication given included : Tramadol 37.4%, Pethidine 29.6% Paracetamol 22.3%, Morphine 10.2%,and Fentanyl 0.5% No jpain treatment was ordered in 8.4% of the cases.  The predominant pain control orders from the Department of Surgery was Pethidine 46.4% from Orthopedics, Tramadol Tramadol 76.6%, from ENT, Paracetamol 46.4%,  form OB-GYN, Pethidine Pethidine 67.6%, from Ophthalmology, Paracetamol 100%, and from Dentistry, Pethidine (100%). The most common administration routes ordered were: intravenous by the Department of Surgery (82%), intramuscular by Orthopedics (63.6%), intravenous by ENT (48%), intramuscular by OB-GYN (91%), oral by Ophthalmology (100%), and intramuscular by Dentistyr (100%). Differences in dose and duration of administration occurred when both appropriate and inappropriate orders were given.Conclusion: The postoperative pain orders at Srinagarind Hospital have many differences in medications, doses, and duration.  It was up to level of pain and many factors in individual patients.  This research was designed for survey of the basic information and for development of next research. Keyword: 1. Postoperative pain 2. Doctor’s order 3. Analgesic drugs

Cancellation on the Day of Surgery in Srinagarind Hospital

Background: Preoperative preparation for elective surgery is time and resource-consuming processes for patients, their families as well as hospital personnel.  Cancellations do have emotional and economic impact.  Knowing the rater and causes is useful for improving hospital service.Objectives: To determine the rate and rationales for cancellation of elective surgery Study design: Prospective Descriptive StudySetting : Srinagarind Hospital, Faculty of Medicine, Khon Kaen UniversitySubjects: Elective surgical patients whom were schedule from September 1, 1999 to January 31, 2000.Main outcome measures: The total number of patients scheduled for  elective surgery as well as the number of cancellation cases was daily recorded.  The reasons for cancellation were explored by interviewing surgeons, anesthesiologists and scrub nurses who were responsible within the same day of cancellation.  The reasons were divided into 3 groups according to the main factors; group 1: doctor’s factor, group 2: patient’s factor and group 3: hospital service’s factor.Results: There were 4, 121 patients scheduled for elective surgery during the study period.  Four hundred and nine cases were cancelled which resulted in 9.9% (95% CI: 9.0%-10.9%) cancellation rate.  Most of the cases were from department of surgery.  The main reasons for cancellation were from doctor 57.4%, from patients 40.1% and from hospital service 2.4%.  Overscheduled cases for surgery in a limited time was the most common reason found in the doctor group while, in the patient group, the reason were associated medical problems which were unsuitable for anesthesia and surgery.Conclusion: The study shows that Srinagarind hospital has 9.9% cancellation rate.  In order to decrease emotional and economic impact for patients and their families as well as to maximize resource utilization, appropriate strategies should be developed to prevent unnecessary 

Insertion of Preformed flexible endotracheal tubes through the Intubating LMA on a Manikin

Objective:  To assess the success rate of blind tracheal intubation with flexible endotracheal tube through the intubating laryngeal mask airway (ILMA) on a manikin. Design: Descriptive study.Methods:  Thirty unskilled volunteers were assigned to insert a preformed flexible endotracheal tube (SheridanTM) through the inserted ILMA on the manikin which optimal positioning was already confirmed by fiberoptic bronchoscope. The success rate and time of the insertion were recorded, also difficulty of the insertion was graded by both intubator using VAS and by observer using 3- point rating scale as well.Results: Blind tracheal intubation through the ILMA was successful in all intubators. The time for intubation ranged from 7.50 to 13.28 sec. (mean 10.14 + 1.58 sec.) and the intubation was graded as easy either assessed by the observer (grade 1) or by the intubators (mean VAS =2.39+ 1.20).     Conclusion: Blind tracheal intubation through the optimal position of ILMA using a preformed flexible endotracheal tube is easy to perform by unskilled personnel with high success rate. This technique may be useful for patients whose airway management is expected to be difficult. Keywords: 1. Intubating LMA, 2. Techniques, 3. Preformed endotracheal tubes,                  4. Unskilled personnel,  5. Manikin

Pediatric Pain Service In Srinagarind Hospital

Background:\  Compared to adults, pain in children is under-treated; however, the need to improve pain service to the pediatric population is receiving greater attention.\  We retrospectively reviewed our pain service for children in our hospital in order to ascertain the current service and to improve it where inadequate.Objective:\  To study the characteristics of pediatric pain service in Srinagarind Hospital.Design:\  Retrospective descriptive study.Subjects:\  Pediatric patients receiving pain service from the Department of Anesthesiology between September 2002 and August 2003.Method:\  We reviewed medical records of the patients.\  Outcome measurements including age, sex, admission ward, pain type, pain treatment, pain assessment, result of treatment, complications and problems occurring during service were recorded.\  The results were analyzed using descriptive statistics and presented as means and percentages.Results:\  Service was rendered 42 times for 39 patients; 21 of whom were male.\  The children averaged 7.14  4.83 years of age.\  Twenty six patients (66%) were from the Pediatric Ward, 8 (12.8%) from the Surgical Ward and 5 (12.8%) from Orthopedic Ward.\  Seventy-nine and 21% of the services provided were for acute and chronic pain management, respectively.\  The most common drug used was opioids (fentanyl).\  The technique used for acute pain management was continuous infusion, PCA or intermittent injection.\  By comparison, chronic pain was managed using a combination of methods.\  Most pain assessment (54.76%) was observation by nurses.\  Complications from pain management occurred in 9.5% of cases, mostly nausea and vomiting or sedation, which were successfully controlled.\  Pain control was considered satisfactory in 90.5% of the patients.\  Four patients (9.5%) died due to disease progression.\  The shortage of opioids was the greatest problem we encountered.Conclusion:\  Pediatric pain service at Srinagarind Hospital was established in September 2002.\  Over the one-year study, 39 patients were served, most for acute pain.\  The duration of service was usually between 1 and 3 days.\  Fentanyl was the most commonly used medication.\  We encountered no serious complications from pain management.Keywords: Pain Service; Pediatric

A Development of Pain Assessment and Pain Documentation as a Fifth Vital Sign in a University Hospital

Background: Pain assessment and documentation can be used as vital sign for the improvement of postoperative pain management; however, these systems have never been adopted for use at Srinagarind Hospital.Objectives:1.     To develop a systematic postoperative pain assessment and documentation as the fifth vital sign; and,2.     To implement a revised graphic sheet for pain documentation at Srinagarind Hospital.Design:  Descriptive studySetting:  Srinagarind Hospital, Faculty of Medicine, Khon Kaen UniversityMethods:  Researchers explored the ward nurses’ attitudes and practices vis-à-vis the pain assessment and documentation in a pilot ward.  Subsequently, systematic pain assessment and documentation using the old graphic sheet, originally developed for recording four other vital signs, were re-designed to include the new sign, tested and revised for its practicality.  The revised graphic sheet was re-tested in two other wards and finally the system was implemented throughout the hospital.Measurement:  Pain assessment tools, frequency of pain documentation and the number of patients assessed before and after the study were recorded.  The ward nurses were asked to give their comments on the practicality of the new system for pain assessment and documentation.Results:  In the pilot ward, misunderstanding regarding the pain assessment tools was found among some ward nurses. The frequency of pain assessment and documentation significantly increased after using the revised graphic sheet (43.2% vs. 57.3%, p=0.039).  The prevalence of no pain assessment also decreased significantly (12.1 vs. 2.2%, p=0.008).  Most of the nurses (87.5%) could complete the pain record form within one minute.  The new system, as reported by 62.5% of the ward nurses, nominally increased their workload.  Re-testing this system in the other two wards increased the number of pain assessments and documentations on the first post-operative day from 67% to 98 %.  The revised graphic sheet was then accepted by the policy makers for use throughout the hospital.Conclusion:  The system of post-operative pain assessment as the fifth vital sign was developed.  A revised graphic sheet was used for pain documentation and accepted for routine use.  The new system increased the number of pain assessments and documentations of post-operative patients.