Patient-controlled oral analgesia versus nurse-controlled parenteral analgesia after caesarean section: a randomised controlled trial

Placenta accreta spectrum part I: anesthesia considerations based on an extended review of the literature

"Placenta accreta spectrum" (PAS) describes abnormal placental adherence to the uterine wall without spontaneous separation at delivery. Though relatively rare, PAS presents a particular challenge to anesthesiologists, as it is associated with massive peripartum hemorrhage and high maternal morbidity and mortality. Standardized evidence-based PAS management strategies are currently evolving and emphasize: "PAS centers of excellence", multidisciplinary teams, novel diagnostics/pharmaceuticals (especially regarding hemostasis, hemostatic agents, point-of-care diagnostics), and novel operative/interventional approaches (expectant management, balloon occlusion, embolization). Though available data are heterogeneous, these developments affect anesthetic management and must be considered in planed anesthetic approaches. This two-part review provides a critical overview of the current evidence and offers structured evidence-based recommendations to help anesthesiologists improve outcomes for women with PAS. This first part discusses PAS management in centers of excellence, multidisciplinary care team, anesthetic approach and monitoring, surgical approaches, patient safety checklists, temperature management, interventional radiology, postoperative care and pain therapy. The diagnosis and treatment of hemostatic disturbances and preoperative prepartum anemia, blood loss, transfusion management and postpartum venous thromboembolism will be addressed in the second part of this series.

PROSPECT guideline for elective caesarean section: updated systematic review and procedure-specific postoperative pain management recommendations

Caesarean section is associated with moderate‐to‐severe postoperative pain, which can influence postoperative recovery and patient satisfaction as well as breastfeeding success and mother‐child bonding. The aim of this systematic review was to update the available literature and develop recommendations for optimal pain management after elective caesarean section under neuraxial anaesthesia. A systematic review utilising procedure‐specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language between 1 May 2014 and 22 October 2020 evaluating the effects of analgesic, anaesthetic and surgical interventions were retrieved from MEDLINE, Embase and Cochrane databases. Studies evaluating pain management for emergency or unplanned operative deliveries or caesarean section performed under general anaesthesia were excluded. A total of 145 studies met the inclusion criteria. For patients undergoing elective caesarean section performed under neuraxial anaesthesia, recommendations include intrathecal morphine 50–100 µg or diamorphine 300 µg administered pre‐operatively; paracetamol; non‐steroidal anti‐inflammatory drugs; and intravenous dexamethasone administered after delivery. If intrathecal opioid was not administered, single‐injection local anaesthetic wound infiltration; continuous wound local anaesthetic infusion; and/or fascial plane blocks such as transversus abdominis plane or quadratus lumborum blocks are recommended. The postoperative regimen should include regular paracetamol and non‐steroidal anti‐inflammatory drugs with opioids used for rescue. The surgical technique should include a Joel‐Cohen incision; non‐closure of the peritoneum; and abdominal binders. Transcutaneous electrical nerve stimulation could be used as analgesic adjunct. Some of the interventions, although effective, carry risks, and consequentially were omitted from the recommendations. Some interventions were not recommended due to insufficient, inconsistent or lack of evidence. Of note, these recommendations may not be applicable to unplanned deliveries or caesarean section performed under general anaesthesia.

Factors associated with success and failure of patient-controlled oral analgesia after total hip and knee arthroplasty: a historical comparative cohort study

PURPOSE

Patient-controlled oral analgesia (PCOA) is a novel method of oral opioid administration using set doses of short-acting oral opioids self-administered by patients with a "lockout" period as part of a multimodal regimen. Failure of PCOA can result in severe postoperative pain necessitating use of intravenous patient-controlled analgesia (IV-PCA) with its potential complications. This study evaluated factors related to success or failure of PCOA following total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

We conducted a retrospective cohort study of all adults who underwent THA and TKA at our institution by extracting data from the proprietary database of our acute pain service. Patient, anesthetic, and surgical variables associated with PCOA failure defined as inadequate analgesia requiring conversion to IV-PCA within 24 hr following THA and TKA were evaluated. Univariable and multivariable logistic regression analyses were performed to identify predictors of PCOA failure.

RESULTS

Of the 926 patients who underwent THA or TKA (n = 411 and 515, respectively), 147 (15.9%) patients (67 THA and 80 TKA patients) had PCOA failure with moderate-to-severe pain. Multivariable regression analysis showed that PCOA failure occurred in those with younger age (adjusted odds ratio [aOR] per year of age, 0.97; 99% CI, 0.95 to 0.99; P < 0.001), preoperative chronic use of controlled-release opioids (aOR, 3.45; 99% CI, 1.60 to 7.35; P < 0.001), and with the use of general anesthesia vs spinal anesthesia (aOR, 2.86; 99% CI, 1.20 to 6.84; P = 0.002).

CONCLUSION

The use of PCOA provides adequate analgesia to a majority of patients undergoing THA and TKA. Factors predictive for PCOA failure should be considered when choosing the primary breakthrough analgesic modality following THA/TKA.

A Prospective Randomized Trial of an Oral Patient-Controlled Analgesia Device Versus Usual Care Following Total Hip Arthroplasty

BACKGROUND

Multimodal pain management for surgery patients may include the use of a combination of scheduled oral pain medications with as-needed (PRN) oral opioids. Multiple concurrent time demands on nursing staff frequently cause delays in the delivery of oral PRN pain medication compromising pain management.

PURPOSE

Postoperative pain control was compared using a wireless oral patient-controlled analgesia device for the delivery of oxycodone with a control group receiving PRN oxycodone from nursing staff.

METHODS

Thirty patients were prospectively randomized into each of 2 groups after total hip arthroplasty. Patient demographics, pain scores, drug dose data, and physical therapy data were collected from chart reviews. Additional data were obtained from patient and nursing surveys.

RESULTS

Device patients recorded statistically lower pain scores while taking lower doses of oxycodone on postoperative Day 1 as compared with the control group. Patient surveys indicated that those in the device group reported lower pain scores 24 hours prior to discharge, albeit not statistically different from the control group. Men in the device group reported statistically lower pain scores with physical therapy than men in the control group. Findings from the nursing survey indicate that nurses favored the device over nurse-administered PRN.

CONCLUSION

Patients using the wireless patient-controlled analgesia (PCA) (oral) device had less pain at rest and with activity (men) while taking lower doses of oxycodone with each dose. Nursing surveys indicated that nursing staff in this orthopedic postoperative unit found the device easy to use, reliable, and efficient. They also recommended its adoption for those capable of using it.

The Effect of Patient-Controlled Oral Analgesia for Acute Abdominal Pain after Discharge

BACKGROUND

During hospitalization, patients who were admitted with acute abdominal pain must be prepared to care for themselves at home after discharge to continue established treatment, promote recovery, and avoid readmission.

AIMS

Our aim was to investigate the quality of pain management after discharge, when patient-controlled oral analgesia was compared with standard care for patients admitted to hospital with acute abdominal pain. The primary outcome measures were pain intensity and patient perception of care. The secondary outcome measures were pain interference with activity, affective experiences, side effects, and use of analgesics.

DESIGN

A questionnaire study measuring the effect of an intervention on patient-controlled oral analgesics.

SETTINGS

An emergency department and a surgical department in Denmark.

PARTICIPANTS

Patients admitted to hospital with acute abdominal pain.

METHODS

A pre- and postintervention study was conducted in an emergency department and a surgical department with three subunits. Data were collected using a Danish modified Revised American Pain Society Patient Outcome Questionnaire with five subscales (scale 0-10) completed in weeks 1 and 4 after discharge.

RESULTS

In total, 117 patients were included. The median scores at week 1 and week 4 in the control and intervention groups were, respectively, 2/1 and 1/0 on the pain subscale (p = .11/.16), 3/0 and 3/0 on the activity subscale (p = .19/.80), 1/0 and 0/0 on the emotional subscale (p = .02/.72), 1/0 and 1/0 on the side effect subscale (p = .95/.99), and 8/5 and 7/7 on the patient perception subscale (p = .35/.49). There was no significant difference in the use of analgesics at week 1.

CONCLUSIONS

Patient-controlled oral analgesia during the hospital stay did not improve the quality of pain management after discharge.

Absorption of ibuprofen orodispersible tablets in early postoperative phase - a pharmacokinetic study

OBJECTIVE

Patient-controlled oral analgesia has gained popularity in postoperative pain management. Anesthesia and surgery delay gastrointestinal tract function and this may therefore decrease bioavailability of drugs taken by mouth. To hasten absorption, an orodispersible ibuprofen tablet has been developed. In this study, we evaluated the pharmacokinetics and feasibility of orodispersible ibuprofen tablets in spine surgery patients.

METHODS

The study design was a prospective clinical trial where each patient served as her/his own control. Fifteen patients aged 19-75 years were given two orodispersible ibuprofen 200 mg tablets the day before surgery and two more tablets immediately after surgery. Blood samples for ibuprofen concentrations were taken at intervals for 6 hours following pre- and postsurgical administration of ibuprofen.

RESULTS

The mean preoperative area under time-concentration curve for ibuprofen (AUC_0-360) was 4806 (SD 1104) min·mg/L, and after surgery it was 2141 (583) min·mg/L (mean difference 2664, 95% CI for difference 2003 to 3325, p < .001). The mean of the maximum preoperative plasma concentration of ibuprofen was three times higher, 26.7 (7.7) mg/L, than the postoperative value of 8.6 (2.1) mg/L (mean diff. 18.1, 95% CI 13.9 to 22.4, p < .001). Times to maximum concentration were similar pre- and postoperatively at 155 (58) minutes and 169 (113) minutes (p = .67). No serious or unexpected adverse events were recorded.

CONCLUSIONS

While orodispersible ibuprofen tablets were feasible, ibuprofen absorption decreased immediately after surgery compared to the day before surgery. Thus, further studies are needed to establish the adequate initial postoperative dose.

Patient-controlled oral analgesia for acute abdominal pain: A before-and-after intervention study on pain intensity and use of analgesics

AIM

To compare the use of patient-controlled oral analgesia with nurse-controlled analgesia for patients admitted to hospital with acute abdominal pain. The primary outcome measure was pain intensity. The secondary outcome measures were the use of analgesics and antiemetics.

BACKGROUND

Inadequate pain management of patients with acute abdominal pain can occur during hospital admission. Unrelieved acute pain can result in chronic pain, stroke, bleeding and myocardial ischemia.

METHODS

A before-and-after intervention study was conducted in an emergency department and a surgical department with three subunits. Data were collected from medical charts and analyzed using chi-squared and Kruskal-Wallis tests.

RESULTS

A total of 170 patients were included. The median pain intensity score, using the numeric ranking scale, was 2.5 and 2 on Day 2 (p = 0.10), 2 and 2 on Day 3 (p = 0,40), 2.5 and 0 on Day 4 (p = 0.10), 2 and 0 on Day 5 (p = 0.045) in the control and intervention group, respectively. The percentage of patients receiving analgesics was 93 and 86 on Day 2 (p = 0.20), 91 and 75 on Day 3 (p = 0.02), 89 and 67 on Day 4 (p = 0.009) and 80 and 63 on Day 5 (p = 0.39). The use of antiemetics was similar in the two groups.

CONCLUSION

Patient-controlled oral analgesia significantly reduced the numerical ranking pain scale score on Day 5 and the consumption of analgesics on Days 3 and 4 after hospital admission. Patient-controlled oral analgesia is feasible as pain management for patients, but only with minor impact on experienced pain intensity and use of analgesics.