Preoperative anxiolysis and postoperative recovery in women undergoing abdominal hysterectomy.

BACKGROUND: Every year, millions of patients receive sedatives for reduction of anxiety before surgery, but there is little objective data on the effect of this treatment on postoperative outcomes. To address this issue, the effects of benzodiazepine administration were evaluated in women undergoing abdominal surgery. METHODS: Patients were randomized to receive 1 mg of oral lorazepam the night before surgery and 5 mg of intramuscular midazolam on the morning of surgery (n = 34), or to receive a placebo the night before surgery and on the morning of surgery (n = 36). Postoperative pain (Visual Analogue Scale for pain, McGill Pain Questionnaire) and analgesic consumption (patient-controlled analgesia), and clinical recovery parameters such as time to discharge from hospital were evaluated after surgery. RESULTS: Patient-controlled analgesia use showed a marginal main effect of treatment group (F(1,51) = 2.8; P = 0.047). Post boc analysis demonstrated that patient-controlled analgesia consumption was significantly lower in the treatment group only during the first 4 h of patient-controlled analgesia use after surgery (P = 0.027). There were no significant group differences at any later postoperative time points (P = not significant). There were no group differences in the cumulative Percocet (Pfizer, New York, NY) consumption in the postoperative period (P = not significant). Further, self-reported postoperative pain did not differ significantly between groups at any of the time points (P = not significant). There were also no group differences with regard to any postoperative clinical recovery parameters. CONCLUSIONS: Benzodiazepines administered before surgery have minimal beneficial effects on the postoperative clinical course of women undergoing abdominal hysterectomy.

Sterility of epidural solutions--recommendations for cost-effective use.

BACKGROUND AND OBJECTIVES: Specific recommendations or guidelines for duration of use or "hangtime" for epidural solutions have not been established. Presently, most hospital policies limit expiration dating of these solutions to 24 hours at room temperature. Extending expiration dating would reduce or eliminate the manipulation of the epidural system during the course of therapy. The objective of this study was to assess the bacteriologic status over time of pharmacy-prepared epidural solutions to determine if longer expiration dating could be safely instituted. METHODS: Samples from both previously administered and nonadministered bags of epidural infusate solutions were retrieved for bacteriologic testing and maintained at room temperature. These solutions were tested every 5 to 7 days beginning 24 to 48 hours after preparation. RESULTS: Samples of 54 infusion bags were tested for a median duration of 63 days. One hundred fifteen samples were tested. Only 5 samples of 4 solutions reported positive cultures; no growth was reported for multiple subsequent cultures of these solutions. CONCLUSIONS: Samples of pharmacy-prepared epidural solutions remained sterile for greater than 42 days. A change from epidural solution expiration dating of 24 hours to 48 or 72 hours would translate into a cost savings of $36,375 to $48,450 at our institution.

The relative potency of oral transmucosal fentanyl citrate compared with intravenous morphine in the treatment of moderate to severe postoperative pain.

UNLABELLED: Pharmacokinetic studies have shown that oral transmucosal absorption of fentanyl is relatively rapid compared with gastrointestinal absorption, and it results in increased bioavailability. We designed this study to establish the relative potency of oral transmucosal fentanyl citrate (OTFC) compared with i.v. morphine in 133 postoperative patients. The morning after surgery, patients randomly received one dose of either OTFC (200 or 800 microg) and a placebo i.v. injection or i.v. morphine (2 or 10 mg) and an oral transmucosal placebo unit. Pain intensity, pain relief, time to meaningful pain relief, and time to remedication were recorded. Median time to onset of relief was approximately 5 min for all groups. Over the first hour, little difference among treatment groups was seen for pain intensity and pain relief. By 2 h after study drug administration, 800 microg of OTFC and 10 mg of i.v. morphine generally produced similar analgesia, which was better than the smaller doses. Duration of analgesia with the larger doses (800 microg of OTFC and 10 mg of morphine) was similar and longer that produced by the smaller doses. The larger doses of OTFC and morphine produced better and more sustained analgesia than 200 microg of OTFC or 2 mg of morphine. IMPLICATIONS: The relative potency of oral transmucosal fentanyl citrate (OTFC) to i.v. morphine was 8-14:1. In this postoperative setting, OTFC produced rapid pain relief similar to that produced by i.v. morphine. The larger doses of OTFC (800 microg) and morphine (10 mg) produced better and more sustained analgesia than 200 microg of OTFC or 2 mg of morphine.

Evaluation of hemostasis by the Clot Signature Analyzer: a potentially valuable device for the anesthesiologist.

Rapid detection of hemostatic defects presents a challenge for the anesthesiologist who must balance anesthetic and surgical considerations for maintaining adequate platelet and coagulant factors, while keeping allogenic blood exposure to a minimum. The Clot Signature Analyzer, a point-of-care device capable of rapid response and easy interpretation is described here. Its applicability in two obstetrical patients with platelet dysfunction is discussed.

Postoperative analgesia with parenteral opioids: does continuous delivery utilizing a transdermal opioid preparation affect analgesic efficacy or patient safety?

STUDY OBJECTIVES: To compare, in patients who underwent major orthopedic surgical procedures, the efficacy of intravenous (IV) patient-controlled analgesia (PCA) with morphine combined with continuous administration of two doses of fentanyl or placebo via transdermal therapeutic system with fentanyl (TTSF) patches. DESIGN: Randomized, double-blind, placebo-controlled study. SETTING: University teaching hospital. PATIENTS: 62 patients aged 18 to 65 years, presenting for elective orthopedic surgery and general anesthesia. INTERVENTIONS: Patients were randomized to one of three groups: group 1 received two placebo patches; group 2 received a 20 cm2 active patch delivering 50 micrograms/hr of fentanyl and a 30 cm2 placebo patch; group 3 received a 30 cm2 active patch delivering 75 micrograms/hr of fentanyl and a 20 cm2 placebo patch. All patches were placed approximately two hours prior to induction of general anesthesia. General anesthesia was induced with thiopental, intubation facilitated by the use of vecuronium or pancuronium, and anesthesia was maintained with isoflurane in an oxygen/nitrous oxide mixture (O2/N2O). Following surgery, IV morphine was provided using IV PCA with 1.5 mg of morphine with a 6-minute lockout and a 4-hour maximum dosage of 30 mg. MEASUREMENTS AND MAIN RESULTS: The time and dosage of morphine administered was recorded. Vital signs, pain intensity at rest, level of sedation, and arterial oxygen saturation (SpO2) were measured at intervals throughout the 72-hour study period and at 6 and 12 hours following patch removal. The presence of side effects was noted. Visual analog pain scores throughout the 72 hours of the study were not significantly different among groups. Patients receiving active TTSF required less IV PCA morphine at all time intervals. However, total opioid consumption was comparable among groups. The incidence of side effects was similar in all groups. CONCLUSIONS: There is no significant advantage to the routine use of continuous transdermal opioid delivery in patients receiving IV PCA after major orthopedic surgery.

Subarachnoid meperidine-morphine combination. An effective perioperative analgesic adjunct for cesarean delivery.

BACKGROUND AND OBJECTIVES: Low-dose subarachnoid morphine provides effective perioperative analgesia but may be associated with a transient period of inadequate pain relief between the regression of local anesthetic block and the onset of morphine's analgesic effect. We hypothesized that this period of suboptimal analgesia could be avoided by adding meperidine, a rapid-acting, intermediate-duration opioid. METHODS: In a double-blind, randomized trial, 49 patients scheduled for elective cesarean delivery received subarachnoid 0.75% bupivacaine, 12 mg in 8.25% dextrose, with either meperidine 10 mg, morphine 0.15 mg, or meperidine 10 mg plus morphine 0.15 mg. Visual analog scale scores for pain and satisfaction were obtained at skin incision, delivery, uterine exteriorization, on arrival in the postanesthesia care unit, and 2, 4, 6, 12, and 24 hours after drug administration. Neonatal Apgar scores and adverse effects were also noted. Postoperative intravenous patient-controlled analgesia (PCA) requirements were recorded for 24 hours. The data were analyzed by chi-square analysis Fisher's exact test, the Wilcoxon rank sum test, and analysis of variance with Tukey's adjustment for multiple comparisons. RESULTS: There were no significant differences in the incidence and severity of side effects, including nausea, vomiting, pruritus, and sedation. Respiratory depression was not observed. Patients treated with morphine alone were least comfortable (P < .006), expressed the lowest satisfaction scores at early observations (P < .002), and required more PCA meperidine (P < .001) than any other group. Patients treated with meperidine alone were comfortable at early observations but required the greatest total amount of PCA meperidine over the first 24 hours (P < .05). Patients in the meperidine-morphine combination group reported the lowest pain scores and highest satisfaction scores at 4-hour and 6-hour observations (P < .03) and required the least total amount of PCA meperidine. CONCLUSION: The subarachnoid combination of meperidine-morphine provided more uniform analgesia, higher satisfaction, and a lower requirement for intravenous narcotic supplementation than either morphine or meperidine alone in patients recovering from cesarean delivery.

Patient-controlled analgesia with sufentanil: a comparison of two different methods of administration.

STUDY OBJECTIVE: To examine the safety and analgesic efficacy of sufentanil administered via either epidural or intravenous (i.v.) patient-controlled analgesia (PCA) in patients recovering from gynecologic surgery. DESIGN: Randomized, double-blind comparison. SETTING: Patient care unit at a university medical center. PATIENTS: 29 healthy women presenting for major intraabdominal gynecologic surgery with epidural anesthesia who requested postoperative PCA. INTERVENTIONS: Following completion of surgery performed using epidural anesthesia with 2% lidocaine and i.v sedation, patients were assigned to one of three treatment groups: Group 1-epidural PCA (EPCA) with sufentanil: 0.3 microgram/kg bolus followed by 8 micrograms/hr infusion plus epidural PCA boluses of 4 micrograms every 6 min as needed; Group 2-i.v. PCA with sufentanil: 0.3 microgram/kg bolus followed by 8 micrograms/hr infusion plus IV PCA boluses of 4 micrograms every 6 min as needed; or Group 3-i.v. PCA with morphine: 0.1 mg/kg bolus followed by 0.5 mg/hr infusion plus i.v. PCA boluses of 1 mg every 6 min as needed. MEASUREMENTS AND MAIN RESULTS: Patients were observed at regular intervals during a 24-hour evaluation period. Visual analog scale (VAS) scores were used to assess analgesia and satisfaction with therapy. Pulmonary function was assessed by monitoring respiratory rate, oxygen (O2) saturation, and forced expiratory flow. Total opioid dose delivered and the presence/severity of side effects was also collected. Sufentanil plasma levels were measured in a subset of eight patients. Patients receiving either EPCA or i.v. PCA sufentanil experienced equivalent analgesia that was more rapid in onset than i.v. PCA morphine. Total dose administered and plasma concentration of drug were similar in both sufentanil groups; however, a greater number of patients in the i.v. delivery group experienced clinically significant O2 desaturation. CONCLUSIONS: The main advantage of EPCA sufentanil in this postsurgical setting was its ability to provide a more rapid onset of analgesia than traditional i.v. PCA with morphine while offering greater safety than i.v. sufentanil.

Intravenous ketorolac as an adjunct to patient-controlled analgesia (PCA) for management of postgynecologic surgical pain.

STUDY OBJECTIVE: To determine whether intravenous (IV) doses of ketorolac tromethamine provide safe and effective augmentation of postsurgical analgesia for patients using IV patient-controlled analgesia (PCA) with morphine. DESIGN: Randomized, double-blind, placebo-controlled, dose-response evaluation. SETTING: Patient care unit at a university medical center. PATIENTS: 62 ASA physical status I-III females recovering from intra-abdominal gynecologic surgery with general anesthesia who requested postoperative PCA. INTERVENTIONS: Following initial pain assessment in the recovery room, patients were randomized to receive either IV saline (placebo) followed by IV saline every 6 hours (Group 1); IV ketorolac 30 mg loading dose followed by IV ketorolac 15 mg every 6 hours (Group 2); or IV ketorolac 60 mg loading dose followed by IV ketorolac 30 mg every 6 hours (Group 3). All patients were provided IV PCA, which was programmed to provide 1.2 mg of morphine with a 6-minute lockout interval. MEASUREMENTS AND MAIN RESULTS: Visual analog scale (VAS) resting pain and satisfaction scores were measured every 2 to 12 hours. Cumulative PCA with morphine and the frequency and severity of side effects also were assessed. IV ketorolac showed no clinically significant side effects. Group 2 patients experienced significant reductions in VAS resting pain scores (p < 0.05), and a trend toward decreased morphine self-administration in both active groups was noted. Group 2 and Group 3 patients reported greater satisfaction with postsurgical analgesia than Group 1 patients. (p < 0.05). CONCLUSIONS: IV ketorolac used as an analgesic adjunct provided safe and effective augmentation of PCA with morphine in patients recovering from intra-abdominal gynecologic surgery.

Cardiopulmonary arrest in the pregnant patient: a report of a successful resuscitation.

We report the case of a pregnant patient who suffered cardiac arrest and was initially unresponsive to resuscitative measures. Prompt emergent cesarean delivery of the infant was carried out, and both mother and infant were then successfully resuscitated. We believe that prompt cesarean delivery is the key to maternal and infant survival in such cases.

ST segment depression during labor and delivery.

ECG changes suggestive of myocardial ischemia are common during cesarean delivery under regional anesthesia. To determine the time course, duration, and significance of these ECG changes, we monitored 111 parturients with continuous ambulatory ECG (Holter) during and after cesarean delivery. Twenty-two parturients undergoing vaginal delivery were similarly monitored. ST segment depression was present in 25% of patients undergoing cesarean delivery but was not found in those patients delivering vaginally. ST segment elevation was not detected in either group. The incidence of ST segment depression during cesarean delivery was similar with epidural (29%), spinal (17%), and general (18%) anesthesia, occurring most commonly in the 30 min following delivery (P less than 0.001). Transthoracic echocardiographic imaging was performed in 23 patients undergoing cesarean section. Five of the 23 patients had seven episodes of intraoperative ST segment depression. Regional wall motion abnormalities were not present in any patient. A decrease in ejection fraction area greater than 15% from baseline or from previous interval ejection fraction area was present during four episodes of ST change. Three episodes of ST depression were not associated with significant decreases in ejection fraction area. Precordial Doppler monitoring for detection of venous air embolism in 25 patients revealed no association between the occurrence of venous air embolism and ST segment depression. We conclude that although significant myocardial impairment during cesarean delivery does not occur, episodes of ST depression may not all be merely an artifact of parturition.

Transdermal fentanyl for postoperative pain management in patients recovering from abdominal gynecologic surgery.

The current placebo-controlled double-blinded study was undertaken to assess the safety and efficacy, as well as the potential clinical role, of the transdermal therapeutic system (TTS) of fentanyl delivery in the postoperative setting. TTS patches releasing 25 micrograms.h-1 or 50 micrograms.h-1 or placebo were applied to 95 women 1 h before abdominal gynecologic surgery during general anesthesia. Postoperatively, patients self-administered intravenous morphine as required using patient-controlled analgesia with a 1-mg incremental dose and a 6-min lockout interval. Each was assessed upon admission to the postanesthesia care unit and at intervals over the following 72 h with respect to vital signs, visual analogue scale pain and satisfaction scores, side effects, and cumulative morphine use. Data were analyzed using analysis of variance, Kruskal-Wallis, and chi-square. P less than 0.05 was considered significant. There were no demographic differences among groups. Beginning 32 h after TTS application, a statistically significant morphine-sparing effect was seen with the 50 micrograms.h-1 patch. There were no significant differences among groups with regard to visual analogue scale pain scores at rest, patient satisfaction, or the incidence of side effects; a significant reduction in pain upon movement was noted at 24 h in patients treated with TTS 50 micrograms.h-1. This finding constituted the only benefit noted with this form of analgesic therapy in the present investigation.

The efficacy of intramuscular ketorolac in combination with intravenous PCA morphine for postoperative pain relief.

STUDY OBJECTIVE: To examine the efficacy of intramuscular (IM) ketorolac used in combination with intravenous (IV) patient-controlled analgesia (PCA) morphine for postoperative pain relief following intra-abdominal gynecologic surgery. DESIGN: Randomized, double-blind, placebo-controlled study. SETTING: Patient care unit at a university medical center. PATIENTS: Thirty-five healthy women undergoing intra-abdominal gynecologic surgery who requested postoperative PCA. INTERVENTIONS: Postoperatively, all patients received IV PCA morphine, with the PCA device programmed to deliver a maximum of 1 mg every 6 minutes (maximum of 30 mg over 4 hours). In addition, patients received one of three regimens: (1) IM saline every 6 hours; (2) IM ketorolac 30 mg while in the postanesthesia care unit (PACU), followed by 15 mg every 6 hours; or (3) IM ketorolac 60 mg while in the PACU, followed by 30 mg every 6 hours. MEASUREMENTS AND MAIN RESULTS: Patients were assessed at regular intervals. Visual analog scale (VAS) scores were used to assess analgesia and patient satisfaction with therapy. Data on morphine usage were obtained from the PCA device, and the frequency and severity of adverse effects were assessed for the presence or absence of side effects. Cumulative morphine dosages were lower (p less than 0.05) in both ketorolac groups at 12, 18, and 24 hours. VAS scores and the frequency of side effects did not differ significantly among groups. CONCLUSIONS: IM ketorolac significantly decreased PCA morphine requirements. The analgesic effects of the two drugs appear to be additive.

Influence of promethazine on symptom-therapy scores for nausea during patient-controlled analgesia with morphine.

We assessed whether adding promethazine to the syringe containing morphine for patient-controlled analgesia (PCA) decreases nausea after gynecologic surgery. Patients were assigned randomly to receive PCA (morphine 1.5 mg, 6-min lockout interval) with or without promethazine (0.625 mg/PCA dose, providing an average of 17.6 mg/24 h). Assessments included a visual analogue scale (VAS) for nausea (0 = none, 10 = worst possible) at scheduled times, rescue therapy requirements, and a maximum symptom-therapy score that provided an aggregate assessment of nausea intensity, duration, and response to rescue therapy (0 = no nausea; 1 = mild; 2 = moderate, requiring droperidol; 3 = severe or persistent, requiring droperidol; 4 = requiring droperidol+transdermal scopolamine; 5 = unrelieved). Nausea scores on the visual analogue scale at 2, 6, 8, and 24 h and use of rescue droperidol identified no significant differences between the groups. However, symptom-therapy scores differed significantly, with median values of 0 and 2, respectively, for the promethazine-treated and control groups. We conclude that simultaneous titration of morphine and promethazine decreases nausea associated with PCA therapy; the difference may best be appreciated with use of the combined symptom-therapy score.

Nausea prophylaxis using transdermal scopolamine in the setting of patient-controlled analgesia.

We evaluated the effectiveness of transdermal scopolamine in patients receiving morphine via patient-controlled intravenous analgesia following intra-abdominal gynecologic surgery. Soon after arrival in the post-anesthesia recovery unit (time 0), patients were randomized either to receive or not receive a postauricular transdermal scopolamine patch. Nausea and vomiting were scored on a 0-3 scale at this time and at 2, 4, 6, and 24 hours. Patients were treated with droperidol as deemed necessary by the primary care nurse. Within 2-4 hours, transdermal scopolamine patients evidenced less nausea and vomiting and required less droperidol than their counterparts who did not receive transdermal scopolamine. A significant decline in the severity of nausea was noted in the transdermal scopolamine group between 2-24 hours; significant inter-group differences were noted for changes in nausea severity during the 0-6-hour and 0-24-hour intervals. Transdermal scopolamine patients evidenced a significant (P less than .05) decrease in the severity of vomiting during the first 2 hours, significantly different from the increase in the non-transdermal scopolamine patients. After the 4-hour assessment, no transdermal scopolamine patients required droperidol; nine doses were administered to the patients who were not given transdermal scopolamine (P less than .05). Thus, transdermal scopolamine therapy appears to be an effective means of treating the nausea and vomiting that are encountered after gynecologic surgery.

Epidural fentanyl does not influence intravenous PCA requirements in the post-caesarean patient.

Forty ASA physical status I or II patients scheduled for elective Caesarean delivery were studied to determine the effect of epidural fentanyl on post-Caesarean delivery analgesic requirements as administered by intravenous patient-controlled analgesia (PCA). Following delivery of the infant, under epidural anaesthesia with lidocaine 2% with 1/200,000 epinephrine, patients were randomly assigned to receive either 10 ml of preservative-free normal saline via the epidural catheter or 100 micrograms of fentanyl with 8 ml preservative-free normal saline in a double-blinded fashion. On arrival in the post-anesthesia recovery room (PAR), patients were provided with intravenous PCA meperidine 12.5 mg every eight minutes as needed. Patients were visited at intervals over the next 24 hr to determine if any differences in narcotic requirements, demands for narcotics, or severity of pain were noted. No differences were observed in any values between the groups. It is concluded that a single bolus of epidural fentanyl does not provide an advantage for postoperative pain relief in this patient population.

The clinical effectiveness of epidural bupivacaine, bupivacaine with lidocaine, and bupivacaine with fentanyl for labor analgesia.

STUDY OBJECTIVE: To examine the efficacy of bupivacaine alone and in combination with lidocaine or fentanyl for epidural analgesia during labor. DESIGN: Randomized, single-blind study. SETTING: Labor and delivery unit at a university medical center. PATIENTS: Forty-five primiparas requesting epidural analgesia. INTERVENTIONS: Following epidural placement at L3-4 interspace, patients received either bupivacaine 0.5% (Group 1, n = 15), bupivacaine 0.25% with lidocaine 1% (Group 2, n = 15), or bupivacaine 0.5% with fentanyl 50 micrograms in 10 ml of saline (Group 3, n = 15). Patients in Groups 1 and 2 received 6 to 10 ml of local anesthetic depending on patient height, while patients in Group 3 received 5 ml of local anesthetic plus 50 micrograms of fentanyl in 10 ml of saline. All solutions contained epinephrine 1:200,000. MEASUREMENTS AND MAIN RESULTS: Patients were assessed at regular intervals following administration of the epidural solution. Visual analog scale (VAS) scores were used to measure onset of analgesia, time to complete pain relief, duration of analgesia, and patient satisfaction with therapy. The frequency of shivering and pruritus and the extent of sensory/motor block also were evaluated. There were no intragroup differences in time to complete pain relief or patient satisfaction. However, patients in Group 3 noted the most rapid onset and longest duration of pain relief. Patients in Group 3 also experienced significantly less shivering and had the lowest degree of motor block. Two patients in Group 3 experienced mild pruritus. CONCLUSIONS: Epidurally administered fentanyl safely extended the duration of labor analgesia while reducing bupivacaine dose requirements and magnitude of motor block. In this setting, the combination of bupivacaine and lidocaine offered no clinical advantage over bupivacaine alone.

Comparison of epidurally administered sufentanil, morphine, and sufentanil-morphine combination for postoperative analgesia.

Postoperative analgesia provided by epidurally administered sufentanil and/or morphine was evaluated in 45 patients recovering from major gynecologic surgery. At the first complaint of pain in the Postanesthesia Care Unit, patients received a single epidural bolus of 30 micrograms sufentanil (group A), 5 mg morphine (group B), or 30 micrograms sufentanil plus 3 mg morphine (group C) in a randomized blinded fashion. Analgesic efficacy was assessed throughout the 24-h study period with 10-cm visual analog scales. The need for additional postoperative analgesia (patient-controlled analgesia, 1 mg of morphine every 6 min as necessary) and the incidence of adverse effects were also assessed. Patients receiving sufentanil (groups A and C) had significantly faster onset of analgesia than did patients given morphine alone (group B, P less than 0.05). Group B subjects experienced the longest duration of analgesia (B vs A and C, P less than 0.05) and required significantly less patient-controlled analgesia (morphine) than patients in group A (P less than 0.05). No patient developed clinically significant respiratory depression or excessive sedation, and there were no intergroup differences in incidence of pruritus or nausea (P value not significant). The data indicate that a mixture of sufentanil and morphine provides either a more rapid onset of epidural analgesia or reduced patient-controlled analgesia narcotic requirement than respective doses of each agent administered alone.