Opioids and nonopioids for postoperative pain control in patients with chronic kidney disease.

OBJECTIVES: To evaluate postoperative pain management (POPM) practices by anesthesiologists caring for patients with chronic kidney disease (CKD). DESIGN: Prospective one-time survey endorsed by the French Society of Anesthesia and Intensive Care (SFAR). SETTING: A self-administered online questionnaire was distributed to members of SFAR nationally. PARTICIPANTS: Three hundred seven SFAR members participated in the study. INTERVENTION: Close-ended questions concerned: standard test used to assess renal function, analgesic agent selection and dose adjustment based on the CKD functional stage, and the availability of standard operating procedures. MAIN OUTCOMES MEASURES: The primary end-point was to identify the most frequently prescribed analgesics in case of CKD, variations in practice based on different stages of CKD, and drug dosing adjustments. The secondary end-point was to identify the most commonly used tests to evaluate kidney function. RESULTS: The most commonly used postoperative analgesics were paracetamol (acetaminophen) and morphine. The most commonly used opioid was morphine, relative to oxycodone and sufentanil. Modification of diet in renal disease (MDRD) and Cockcroft equations were used by 39 and 40 percent of anesthesiologists, respectively, to measure kidney function. Six percent of anesthesiologists declared following standard operating procedures for POPM in patients with CKD. CONCLUSIONS: There is considerable variability in POPM practices for patients with all stages of CKD. Morphine is favored even in end-stage renal disease. Departments of anesthesiology are insufficiently involved in drafting standard operating procedures.

Combined Implantation of a Penile Prosthesis and Adjustable Continence Therapy ProACT in Patients with Erectile Dysfunction and Urinary Incontinence after Radical Prostatectomy: Results of a Prospective Pilot Study.

INTRODUCTION: The treatment of postradical prostatectomy erectile dysfunction (post-RP-ED) and stress urinary incontinence (post-RP-SUI) may require the combined implantation of a penile prosthesis and incontinence surgery. However, there is a lack of consensus regarding which incontinence surgery should be associated with a penile implant. AIMS: To evaluate the combined implantation of a penile prosthesis and the adjustable continence therapy ProACT in patients with post-RP-ED and post-RP-SUI. METHODS: We implanted the ProACT device and a penile prosthesis synchronously (n = 6) and asynchronously (n = 4) in 10 patients with moderate post-RP-SUI and severe post-RP-ED. We evaluated the effects on urinary incontinence using the ICIQ and PGI-I scores and pad use. We evaluated the effect on sexual function using the EHS and Global Assessment Questionnaire (GAQ), and we evaluated satisfaction with the penile prosthesis on a 5-point scale. Postoperative pain associated with each procedure was evaluated by a numeric rating scale. RESULTS: No cases of urinary retention or prosthesis infection were observed. Postoperative pain was mainly related to penile prosthesis implantation. After a mean follow-up of 22.7 ± 20.9 months (range: 6-53), significant improvements of the ICIQ score (15.3 ± 3.7 vs. 4.7 ± 2.3, P < 0.001) and pad use per day (2.8 ± 1.2 vs. 0.3 ± 0.5, P < 0.001) were observed compared with baseline. According to the PGI-I questionnaire, eight patients described a very much improved (n = 6) or much improved (n = 2) urinary condition. All patients declared an EHS = 4 with the use of penile prosthesis; all patients were very satisfied (n = 6) or satisfied (n = 4) with their penile prosthesis. All patients answered the GAQ positively. CONCLUSION: The combined implantation of a Pro-ACT device and penile prosthesis represents a feasible therapeutic option in patients with post-RP-SUI and post-RP-ED. The absence of postoperative pain associated with the ProACT procedure may represent the main interest in this therapy.

Is it worth continuing sexual rehabilitation after radical prostatectomy with intracavernous injection of alprostadil for more than 1 year?

INTRODUCTION: Intracavernous alprostadil injection (IAI) is a widely used treatment for sexual rehabilitation (SR) after radical prostatectomy (RP). It is unknown whether the continuation of IAI beyond 1 year continues to improve erectile function. AIMS: To assess evolution of sexual function in patients using IAI who are nonresponsive to phosphodiesterase type 5 inhibitors (PDE5i) between 12 (M12) and 24 (M24) months after RP. METHODS: We retrospectively studied 75 men with a nerve-sparing laparoscopic RP, who had normal preoperative erectile function, and who regularly used IAI for SR for at least 24 months. At M12, no patients had responded to PDE5i. MAIN OUTCOME MEASURES: At 12 and 24 months, sexual function was assessed with the UCLA Prostate Cancer Index (UCLA-PCI), International Index of Erectile Function (IIEF)-15, and erection hardness score (EHS) with and without IAI. We also assessed the satisfaction rate with IAI, injection-related penile pain, and satisfaction of treatment. Statistical analysis was performed by using t-tests for paired data and Spearman's rho correlation coefficients to assess the relationships between scores at M12 and M24. RESULTS: Improvement of nocturnal erection was noted (UCLA-PCI, question 25); however, no significant difference was found for IIEF-erectile function with (19.60 ± 9.80 vs. 18.07 ± 10.44) and without IAI (4.63 ± 2.93 vs. 4.92 ± 4.15), UCLA-PCI-sexual bother (37.14 ± 21.45 vs. 37.54 ± 19.67), nor the EHS score with (2.97 ± 1.30 vs. 2.57 ± 1.30) and without IAI (0.67 ± 1.11 vs. 0.76 ± 0.10). The rate of satisfaction with treatment decreased over time (66.6% vs. 46.7%, P = 0.013). Improved response to IAI at M12 was not correlated to improvement in spontaneous erections at M24. CONCLUSION: The response to IAI remained stable after 2 years of treatment, and no significant improvement of spontaneous erections during intercourse attempts was found between M12 and M24. Patients should be informed of the limited effect of IAI on natural erections after 1 year. Yiou R, Bütow Z, Parisot J, Binhas M, Lingombet O, Augustin D, de la Taille A, and Audureau E. Is it worth continuing sexual rehabilitation after radical prostatectomy with intracavernous injection of alprostadil for more than 1 year? Sex Med 2015;3:42-48.

Comprehensive evaluation of embarrassment and pain associated with invasive urodynamics.

AIMS: To evaluate pain and embarrassment associated with invasive urodynamics and to determine underlying factors. METHODS: One hundred seventy one consecutive patients referred to our department for invasive urodynamics were evaluated using visual numeric rating scales for sensations of apprehension, pain, and embarrassment during several steps of the procedure (scores ranging from 0 [no symptom] to 10 [worst imaginable symptom]). We also investigated the influence of sex, age, information provided before urodynamics, and medical indication on these sensations. The Spearman correlation, non-parametric test, and logistic regression analysis were performed to determine explicative factors for the most painful sensations. RESULTS: The mean age was 61.0 (standard deviation ± 15 years). The mean (95% confidence interval [CI]) apprehension level was 2.9/10 (2.4; 3.4). The mean (95% CI) pain levels at installation on urodynamic table, transurethral catheter insertion (cystometry), and catheter repositioning (urethral pressure profilometry) were 0.3/10 (0.1; 0.5), 1.9/10 (1.6; 2.3), and 1.3/10 (1.0; 1.7), respectively. At catheter insertion, 25% of patients reported a pain level ≥ 4/10. The mean embarrassment level due to urination in front of the doctor was 1.9/10 (1.4; 2.3). Painful sensations reported during the different steps were strongly correlated with each other and with levels of apprehension and embarrassment. Age <54 years (lower quartile) and apprehension level were the only factors associated with painful sensation. CONCLUSIONS: Our study confirms that invasive urodynamics is a well-tolerated procedure. However, some patients experience high levels of pain and embarrassment throughout the procedure. Younger age and apprehension were the most influential factors.

Radical prostatectomy with robot-assisted radical prostatectomy and laparoscopic radical prostatectomy under low-dose aspirin does not significantly increase blood loss.

OBJECTIVE: To determine whether maintaining use of low-dose aspirin confers a higher risk of bleeding events in patients undergoing laparoscopic or robot-assisted radical prostatectomy. There is no consensus on maintaining or withdrawing aspirin in these patients. METHODS: Consecutive patients undergoing laparoscopic and robot-assisted radical prostatectomy between January 2009 and December 2010 were included in a prospective cohort study. Among them, 54 aspirin-treated patients were compared with 569 non-aspirin-treated patients. We evaluated the between-group difference in bleeding event: intraoperative blood loss ≥ 700 ml and/or need for transfusion and/or postoperative hemorrhagic complication (symptomatic abdominal wall hematomas, major bleeding requiring reoperation). Differences in each component of the bleeding event, in hemoglobin level changes, and hospital stay length were also evaluated. Patients' data were compared using the χ(2) or Fisher exact test for categorical variables and the Student t test or Mann-Whitney test for continuous variables. RESULTS: A bleeding event occurred in 18 (33.3%) aspirin-treated patients and 176 (32.5%) non-aspirin-treated patients (P = .66). Median blood loss was similar in the 2 groups (aspirin: 450 ml, 50-7100 ml; no aspirin: 450 ml, 100-2800 ml; P = .93). Aspirin was not associated with a significant hemoglobin level variation (median decrease, 2.9 g/dL with aspirin and 3.2 g/dL without aspirin, P = .23). Median hospital length of stay, rates of blood transfusion, and postoperative hemorrhagic complications were similar in the 2 groups. CONCLUSION: Laparoscopic and robot-assisted radical prostatectomy can be performed safely without discontinuing aspirin, as this policy does not increase significantly blood loss, blood transfusion requirements, postoperative hemorrhagic complications. or hospital length of stay.

Use of a validated reference tool to evaluate postoperative pain management through a quality-improvement program in a university hospital.

We audited the seven surgical departments of a university hospital before and after implementation of a program aiming to improve practices in postoperative pain management (POPM). Audits were conducted 2 years apart. During each evaluation, 10 medical charts from each surgical department (i.e., 70 charts) were analyzed for 9 quality criteria (five concerning anesthetist practices and four nursing practices). Two scores were calculated: one per department and the other per criteria. After the first audit, the seven departments received recommendations to improve their POPM. Targeted-training sessions were instituted for the three poorest performing departments (scores <4.5 out of 9 criteria). During the period between the two audits, all seven departments improved their scores; a statistically significant improvement was observed in five departments, including the three that had received targeted-training sessions. Moreover, overall scores for seven of the nine evaluated criteria improved, significantly for three criteria. Anesthetists significantly increased their overall score from 2.5 ± 0.8 to 3.7 ± 0.6 out of 5 points (p=.018), while surgical nurses' overall score did not change significantly from 2.3 ± 0.7 to 2.9 ± 0.7 out of 4 points (p=.128). In conclusion, using a standardized and validated instrument to evaluate POPM practices enables the identification of surgical departments requiring practice improvement and those quality criteria requiring reinforcement.

Sexual rehabilitation and penile pain associated with intracavernous alprostadil after radical prostatectomy.

INTRODUCTION: Intracavernous alprostadil injection (IAI) is widely used for sexual rehabilitation (SR) after radical prostatectomy (RP). However, the rate of spontaneous erection recovery with IAI remains unclear, and IAI causes pain that may hinder SR. AIMS: To assess SR in IAI users after RP and to evaluate the course and impact on SR of postinjection penile pain. METHODS: We prospectively studied 87 patients who underwent nerve-sparing laparoscopic RP, reported normal preoperative erectile function, and used IAI for 12 months. Patients started with 2.5 µg alprostadil and were advised to increase the dose gradually until erection hardness allowed vaginal penetration. MAIN OUTCOME MEASURES: At 6 and 12 months, the International Index of Erectile Function (IIEF-15) and Erection Hardness Score (EHS) were determined with and without IAI, and injection-related penile pain was assessed using a numeric rating scale. Correlations linking penile pain, IIEF-15, and EHS scores were evaluated. RESULTS: The mean alprostadil dose was 8.1 µg after 6 months and 9.9 µg after 12 months. With/without IAI, mean IIEF-15 scores for erectile and orgasmic function and mean EHS score were 14.6/4.6, 4.1/2.1, and 2.5/0.4, respectively, after 6 months; and 17.2/5.4, 4.9/2.6, and 2.7/0.9 after 12 months. Pain scores were 3.2±2.5/10 and 2.5±2.5/10 after 6 and 12 months, respectively. Pain intensity correlated with erectile function (r=-0.23), intercourse satisfaction (r=-0.23), and overall satisfaction (r=-0.24) after 6 months but not after 12 months. Follow-up was short and only patients who used IAI for 12 months were included. CONCLUSIONS: In patients who were willing and able to use IAI, erectile function improved after 1 year but remained below preoperative levels. The adverse impact of pain on SR was significant during the first 6 months and diminished over time. These data may help to counsel IAI users with painful erections.

[Morphine prescription and the nursing role]. / Prescription de morphine et rôle infirmier.

After having noted that 25% of prescriptions were not respected by nurses, the Henri-Mondor university hospital in Creteil (AP-HP, 94), carried out an investigation to understand the causes. The results were then circulated to doctors and nurses in order to establish best practice recommendations.

Care related pain in hospitalized patients: a cross-sectional study.

CONTEXT: Care-related pain includes pain occurring during transportation, movement, diagnostic imaging, physical examination, or treatment. Its prevalence has never been assessed in a large adult inpatient population. OBJECTIVE: To identify the procedures likely to induce or increase pain in hospital patients, attempting to separate the most painful from those reported as most frequently inducing pain. DESIGN: A single-day cross-sectional survey conducted in two large French teaching hospitals, including all hospitalized patients, free of communication problems. One third was randomly selected and interviewed about the painful episodes that had occurred or were associated with the procedures performed during the previous two weeks. Patients were interviewed using a structured questionnaire. RESULTS: Six-hundred-eighty-four patients were randomly selected. Six-hundred-seventy-one painful events were reported in 55% of the patients, with an average of 1.8 events/patient. Fifty-two percent of the painful events were associated with procedures performed by non-medical staff; 38% of the painful episodes occurred during procedures involving vascular puncture and 24% during patients' mobilization. In 57% of painful procedures, pain was rated as severe or extremely severe. The most painful procedures were invasive procedures, other than vascular and non vascular punctures (74% of severe and extremely severe painful episodes). Maximum pain intensity was rated higher for procedures that were repeated than for those experienced only once (62% versus 53%, p=0.02). CONCLUSION: This survey gives new insight into our daily practice. Proper management of care-related pain should be a major concern of all hospital staff to improve the quality of our health care.

Current practices in sedation and analgesia for mechanically ventilated critically ill patients: a prospective multicenter patient-based study.

BACKGROUND: The authors conducted a patient-based survey of practices to fully describe the assessment and the management of pain and sedation of a large cohort of mechanically ventilated patients during their first week of intensive care unit (ICU) stay. METHODS: A total of 1,381 adult patients were included in a prospective, observational study in 44 ICUs in France. Pain and sedation assessment, analgesic and sedative use, and analgesic management during procedural pain were collected on days 2, 4, and 6 of the ICU stay. RESULTS: The observed rates of assessment on day 2 for sedation (43%) and analgesia (42%) were significantly smaller than that of use of sedatives (72%) and opioids (90%), also noted on days 4 and 6. The use of protocols/guidelines for sedation/analgesia in the ICU reduced the proportion of patients who were treated, although not evaluated. A large proportion of assessed patients were in a deep state of sedation (40-50%). Minor changes in the dosages of the main prescribed agents for sedation (midazolam, propofol) and analgesia (sufentanil, fentanyl, morphine, remifentanil) were found across 6 days of the patient's ICU stay. Procedural pain was specifically managed for less than 25% of patients; during those procedures, the proportion of patients with pain significantly increased from the baseline pain evaluation. CONCLUSIONS: Excessively deep states of sedation and a lack of analgesia during painful procedures must be prevented. To facilitate systematic pain and sedation assessment and to adjust daily drug dosages accordingly, it seems crucial to promote educational programs and elaboration of protocols/guidelines in the ICU.

[Full version of the 2005 Standards, Options and Recommendations for the management of procedure-related pain (lumbar puncture, bone marrow aspiration or biopsy, blood sampling) in adult patients with cancer]. / Recommandations pour la pratique clinique 2005 : Standards, Options et Recommandations pour la prise en charge des douleurs provoquées lors des ponctions lombaires, osseuses et sanguines chez l'adulte atteint de cancer (rapport intégral) ,Validation du rapport original : janvier 2005.

The << Standards, Options and Recommendations >> (SOR) project, started in 1993, is a collaboration between the Federation of French Cancer Centres (FNCLCC), the 20 French cancer centres, and specialists from French public universities, general hospitals and private clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and the outcome of cancer patients. The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery. Objectives : To establish the Standards, Options and Recommendations clinical practice guidelines for the management of procedure related pain (lumbar puncture, bone marrow aspiration or biopsy, blood sampling) in adult oncology patients. To define, on the basis of the critical appraisal of the best available evidence and expert agreement, the clinical situations in which a pain preventive strategy should be implemented. Methods. Medline(R) was searched using specific search strategies from January 1966 to August 2003. Literature monitoring was performed to identify controlled clinical trials published between August 2003 to September 2004. In addition several Internet sites were searched in July 2003. Results. A total of 12 references, corresponding to 10 randomised clinical trials, were identified. Clinical guidelines have been defined for each invasive procedure.

Comparative effect of intraoperative propacetamol versus placebo on morphine consumption after elective reduction mammoplasty under remifentanil-based anesthesia: a randomized control trial [ISRCTN71723173].

BACKGROUND: Postoperative administration of paracetamol or its prodrug propacetamol has been shown to decrease pain with a morphine sparing effect. However, the effect of propacetamol administered intra-operatively on post-operative pain and early postoperative morphine consumption has not been clearly evaluated. In order to evaluate the effectiveness of analgesic protocols in the management of post-operative pain, a standardized anesthesia protocol without long-acting opioids is crucial. Thus, for ethical reasons, the surgical procedure under general anesthesia with remifentanil as the only intraoperative analgesic must be associated with a moderate predictable postoperative pain. METHODS: We were interested in determining the postoperative effect of propacetamol administered intraoperatively after intraoperative remifentanil. Thirty-six adult women undergoing mammoplasty with remifentanil-based anesthesia were randomly assigned to receive propacetamol 2 g or placebo one hour before the end of surgery. After remifentanil interruption and tracheal extubation in recovery room, pain was assessed and intravenous titrated morphine was given. The primary end-point was the cumulative dose of morphine administered in the recovery room. The secondary end-points were the pain score after tracheal extubation and one hour after, the delay for obtaining a Simplified Numerical Pain Scale (SNPS) less than 4, and the incidence of morphine side effects in the recovery room.For intergroup comparisons, categorical variables were compared using the chi-squared test and continuous variables were compared using the Student t test or Mann-Whitney U test, as appropriate. A p value less than 0.05 was considered as significant. RESULTS: In recovery room, morphine consumption was lower in the propacetamol group than in the placebo group (p = 0.01). Pain scores were similar in both groups after tracheal extubation and lower in the propacetamol group (p = 0.003) one hour after tracheal extubation. The time to reach a SNPS < 4 was significantly shorter in the propacetamol group (p = 0.02). The incidence of morphine related side effects did not differ between the two groups. CONCLUSIONS: Intraoperative propacetamol administration with remifentanil based-anesthesia improved significantly early postoperative pain by sparing morphine and shortening the delay to achieve pain relief.