Effect of Entonox on reducing the need for Pethidine and the Relevant Fetal and Maternal Complications for Painless Labor

Exploring cost changes with time-driven activity-based costing after service delivery redesign in Dutch maternity care

The implementation of Value-Based Healthcare (VBHC) has spread across international healthcare systems, aiming to improve decision-making by combining information about patient outcomes and costs of care. Time-Driven Activity-Based Costing (TDABC) is introduced as a pragmatic yet accurate method to calculate costs of care pathways. It is often applied to demonstrate value-improving opportunities, such as interventions aimed at service delivery redesign. It is imperative for healthcare managers to know whether these interventions yield the expected outcome of improving patient value, for which TDABC is also suitable. However, its application becomes more complex and labour intensive if the intervention extends beyond activity-level changes in existing care pathways, to the implementation of entirely new care pathways. The complexity arises from the potential influence of such interventions on the costs of related care pathways. To fully comprehend the impact of such interventions on organizational costs, it is important to include these factors in the cost calculation. Given the substantial effort required for this analysis, this may explain the limited number of prior TDABC studies with similar objectives. This methodological development paper addresses this gap by offering a pragmatic enrichment of the TDABC methodology. This enrichment is twofold. First, it provides guidance on calculating a change in costs without the need for a total cost calculation. Second, to secure granularity, a more detailed level of cost-allocation is proposed. The aim is to encourage further application of TDABC to conduct financial evaluations of promising interventions in the domain of VBHC and service delivery redesign.

Relationship between COMT Gene Polymorphism, Anxiety, and Pain Perception during Labour

BACKGROUND

The COMT gene polymorphism is associated with neurological and psychiatric disorders and pain perception. The present study investigates the existence of anxiety and pain perception in relation to the COMT (catechol-O-methyltransferase) gene polymorphism in labouring women (during "natural" childbirth) with or without inhaled analgesia.

METHODS

A total of 181 women who chose vaginal birth were enrolled in this study. To present the difference in pain perception, the parturients were divided into one group (n = 90) that chose labour analgesia with inhaled nitrous oxide (50% nitrous oxide and 50% oxygen) and one group (n = 91) without analgesia. The blood samples were taken during the pregnancy as a part of routine pregnancy controls in the hospital. The COMT gene polymorphism was detected with the PCR technique. The pain perception of parturients was self-evaluated two times according to the VAS (Visual Analogue Scale), and anxiety as a personality trait was determined with the STAI-T (State Trait Anxiety Inventory). Pain perception as well as anxiety were compared according to COMT genotypes.

RESULTS

In the 181 pregnant women, there were 40 women (22%) of wild homozygotes (GG) of COMT, 95 women (53%) of mutant heterozygotes (GA), and 46 women (25%) of mutant homozygotes (AA). A negative association of pain perception with the GA (mutant heterozygote) polymorphism of the COMT gene versus the wild-type (GG polymorphism) was observed. The GA polymorphism of the COMT gene was associated with 0.46 units lower pain perception compared to the wild type (GG). The anxiety trait score in group AA was lower than in groups GA and GG. The difference reached statistical significance only when comparing AA versus GA (p > 0.042). Analgesic efficacy of nitrous oxide was noticed in 22% of labouring women who reported moderate pain (VAS score 4-7).

CONCLUSIONS

The COMT gene polymorphism was associated with pain perception and anxiety among parturients. The COMT gene polymorphism GA was associated with negative pain perception among labouring women. Nitrous oxide showed statistical significance in anxiolytic efficacy during labour in women with mild anxiety as a personality trait. Anxiolytic efficacy of nitrous oxide has shown better efficacy in parturients with the COMT gene polymorphism AA.

Early perioperative versus postoperative meloxicam for pain control in patients undergoing orthopedic surgery: a systematic review and Meta-analysis of randomized controlled trials

OBJECTIVE

Post-orthopaedic operative pain is a serious concern that often requires the administration of analgesics; however, the optimal time of analgesic administration is still inconclusive. Perioperative analgesia is administrating pre-emptive analgesia before and during the surgery followed by postoperative analgesia to decrease the procedure associated nociceptive response. We aim to assess perioperative meloxicam versus postoperative meloxicam for pain control after orthopaedic operations.

METHODS

A systematic review and meta-analysis involving randomized controlled trials from PubMed, Embase, Scopus, WOS, and Cochrane until 28th May 2022. We pooled dichotomous outcomes using risk ratio (RR) presented with a 95% confidence interval (CI) and continuous outcomes using mean difference (MD) with 95% CI. We registered our protocol in PROSPERO with ID: CRD42022336046.

RESULTS

We included five RCTs with 964 patients. All the included trials showed high risk of performance and detection biases because of lack of blinding. Pooled analysis favored perioperative meloxicam in reducing pain score after six hours (MD: -0.42 with 95% CI [-0.63, -0.21], p = .0001), 12 h (MD: -0.54 with 95% CI [-0.69, -0.39], p = .00001), and 24 h (MD: -0.23 with 95% CI [-0.36, -0.10]. Pooled analysis favored perioperative meloxicam in improving patient global assessment scale after 12 h (MD: -0.66 with 95% CI [-0.86, -0.46], p = .00001), 24 h (MD: -0.30 with 95% CI [-0.49, -0.11, p = .002), and 48 h (MD: -0.17 with 95% CI [-0.33, -0.01], p = .04). Pooled analysis favored perioperative meloxicam in reducing patient-controlled analgesia (MD: -4.25 with 95% CI [-5.96, -2.54], p = .00001).

CONCLUSION

Short-term pain management after orthopaedic procedures is better accomplished with perioperative meloxicam than postoperative meloxicam. Before recommending perioperative meloxicam for pain control following orthopaedic surgeries, further multicentre trials are still warranted to examine the impact of perioperative meloxicam in different orthopaedic procedures.

Oliceridine- Opioid of the 21st Century

Oliceridine (Olinvyk® Trevena, PA, USA) was approved by the United States Food and Drug Administration for clinical use on Aug 8, 2020. Even though, the indication of its approval is very restrictive (to manage moderate-to-severe acute pain in adults when the pain is severe enough), for such an innovative opioid, off-label indications are bound to abound. What could be described as the "opioid of the century," it aims to overcome some of the stubbornest barriers to opioid prescribing, namely addiction liability, respiratory depression, and gastrointestinal (GI) side effects, just to name a few. The novel opioid accomplishes this by a unique mechanism of action. By selectively acting on the G-protein sub-pathway in preference to the beta-arrestin, it aims to mitigate these unwanted µ-opioid receptors-associated opioid side effects, while preserving its analgesic activity. What remains to be seen, however, is if these observations seen in phases 2 and 3 trials will be borne in actual large-scale clinical use, both inside and outside the USA. Unfortunately, the field of anesthesia is rife with innovations that have shown enormous promise at the research stage, only to end up as damp squibs when released to the clinicians for general use. Rapcuronium and althesin are some such examples. We aim to present some of the contentious and emerging issues associated with this drug and some of the potential pitfalls of this new opioid.

Entonox® versus Pethidine in Labor Pain Relief: A Randomized Controlled Trial

BACKGROUND

Pain relief during labor is a part of standard care in modern obstetrics. Several modalities used for pain relief have their own disadvantages and benefits in terms of side effects, effectiveness, availability, and satisfaction. The objectives of this study are primarily to compare the effectiveness and patients' satisfaction for pain relief during labor between pethidine and inhaled 50% nitrous oxide (Entonox^®).

METHODS

Laboring women at 37-41 + 6 weeks of gestation were randomly allocated to receive pethidine (50 mg intravenously) or Entonox^® for reducing labor pain. Pain scores were evaluated at 0, (baseline), 30, 60, 90, and 120 min after initiation, using the visual analog scale (VAS) and also satisfaction score after delivery using the verbal rating scale (VRS). The secondary outcomes were also assessed, including APGAR scores, labor course, side effects, and cesarean section rate.

RESULTS

A total of 136 laboring women underwent randomization into two groups, but only 58 and 65 in the pethidine group and the Entonox^® group were available for analysis. The median pain scores at baseline, 30, 60, and 90 min were comparable between both groups (p-value > 0.05); however, pain score at 120 min in the pethidine group was significantly higher (p-value: 0.038). The median of satisfaction score was significantly higher in the Entonox^® group (4 vs. 3; p-value 0.043). All of the secondary outcomes were comparable between the two groups.

CONCLUSIONS

Both have comparable effectiveness, but Entonox^® has a higher satisfaction score. Entonox^® could be an alternative to pethidine for reducing labor pain, because of its efficacy, ease for self-adjustment for satisfaction, and no serious effects on the labor course and newborns.

Comfort and Satisfaction Among Women Who Used Different Options for Analgesia During Labor and Birth

OBJECTIVE

To determine if comfort and satisfaction with the birth experience differed among women who used nitrous oxide (N₂O), epidural analgesia, or no analgesia during labor and birth.

DESIGN

Nonexperimental, cross-sectional, between-subjects.

SETTING

Maternity care units in three U.S. Midwest hospitals from June to October 2019.

PARTICIPANTS

A total of 84 women with spontaneous vaginal birth at term gestation (≥37 weeks).

METHODS

Women were grouped according to self-selected pain management method: N₂O and oxygen (50%/50% mixture) only (n = 28), epidural analgesia (may have been in combination with other analgesia options; n = 28), or no analgesia (n = 28). We collected data within 6 hours after childbirth using the Birth Satisfaction Scale-Revised and the researcher-modified Childbirth Comfort Questionnaire. We analyzed data for differences in comfort and satisfaction scores among the three groups of women using analysis of variance.

RESULTS

We found no statistically significant differences related to comfort during labor and birth among women who used N₂O only, epidural analgesia, or no analgesia during labor and birth, F(2, 81) = 1.11, p = .34. We also found no statistically significant differences related to satisfaction with the birth experience among women who used N₂O only, epidural analgesia, or no analgesia during labor and birth, F(2, 81) = .084, p = .92.

CONCLUSION

Our finding of no statistically significant differences in comfort and satisfaction with the birth experience across groups highlights the need to present comprehensive pain management options to women for labor and birth, such as N₂O.

Efficacy and safety of intravenous paracetamol in management of labour pains in a low resource setting: a randomized clinical trial

OBJECTIVE

To assess the use of single dose of paracetamol intravenously in management of labour pains.

BACKGROUND

Pain during labour is a complex, subjective and multi-faceted physiological phenomenon that varies in intensity among women and is subjected to many social and cultural modifiers.

SUBJECTS AND METHODS

This randomized clinical study was conducted in Obstetrics and gynecology department from March 2019 to March 2020 including 96 primiparous women randomized into paracetamol group (n = 48) received 1000 mg of paracetamol IV infusion and pethidine group (n = 48) received 50 mg of pethidine given slowly IV. Primary outcome is the change of the intensity of perceived labor pain. Pain score was followed and recorded by visual analogue scale (VAS). Our study protocol was registered at ClinicalTrials.gov; NCT04744727.

RESULTS

VAS score was highly significant improved gradually after 30 min, 1, 2 and 3 h of paracetamol and pethidine taken compared at start study, but participants in paracetamol group had lower pain after 2 and 3 h (3.92 ± 1.42 and 5.69 ± 1.07) than those of the pethidine groups (4.42 ± 1.87 and 5.38 ± 1.34). Also, 2.1% of paracetamol group developed dizziness and 4.2% developed nausea and vomiting, while there was 29.2% of pethidine group developed dizziness and 37.5% developed nausea and vomiting.

CONCLUSIONS

Intravenous paracetamol as labour analgesia is effective, safe, inexpensive, available and with no maternal or fetal side effects as compared to Pethidine. Paracetamol needs to have more chance in comparison to other forms as a labour pain analgesia, especially in our communities.

Efficiency and safety: comparison between preoperative analgesia and postoperative analgesia using non-steroidal anti-inflammatory drugs in patients receiving arthroscopic knee surgery in a multicenter, randomized, controlled study

BACKGROUND

This study aimed to compare the efficiency regarding postoperative pain control, consumption of rescue drug, patients' satisfaction and the safety of preoperative analgesia versus postoperative analgesia using non-steroidal anti-inflammatory drugs (NSAIDs) in patients who received arthroscopic knee surgery (AKS).

METHODS

Four hundred and sixty-four patients who received AKS were recruited in this multicenter, randomized, controlled study. Subsequently, they were randomized into PRE group (N = 232) and POST group (N = 232). In PRE group, patients received celecoxib, meloxicam or rofecoxib from 2 h pre-operation (Pre (- 2 h)) to 48 h post-operation for analgesia. In POST group, patients received celecoxib, meloxicam or rofecoxib from 4 to 48 h post-operation for analgesia.

RESULTS

h and 12 h; pain VAS at passive movement was reduced in PRE group than POST group at 6 h, 12 h and 24 h. Additionally, consumption of rescue drug (pethidine) was decreased, while overall satisfaction was increased in PRE group compared to POST group. As for adverse events, the incidences of nausea, vomiting, constipation, drowsiness and dizziness were similar between PRE group and POST group. In subgroup analysis, the pain VAS score at passive movement at 6 h and nausea and constipation incidences were distinctive among subgroups categorized by meloxicam, celecoxib and rofecoxib administration. However, no difference of other assessments was found among subgroups categorized by meloxicam, celecoxib and rofecoxib administration.

CONCLUSION

Preoperative analgesia using NSAIDs is more efficient and equivalently tolerable compared to postoperative analgesia using NSAIDs in patients who receive AKS.

Association of Self-Administered Nitrous Oxide for Labor Analgesia With Maternal and Neonatal Process and Outcome Measures

OBJECTIVE

To describe patterns of use of self-administered nitrous oxide (N₂O) during labor and to determine if maternal and neonatal process and outcome measures differ for women who use N₂O compared to women who do not use N₂O.

DESIGN

Retrospective, full-census, observational cohort.

SETTING

An upper midwestern U.S., urban, 75-bed quaternary perinatal center with more than 5,000 annual births.

PARTICIPANTS

The participants included two groups of women: 400 who used N₂O during labor and a comparison group of 6,733 who met N₂O eligibility but did not use N₂O.

METHODS

We used descriptive statistics to examine patterns of use of N₂O during labor between January 2015 and March 2017. We examined associations of N₂O with process (length of first and second stages of labor, time from hospital admission to birth, time from birth to hospital discharge, and total length of stay) and outcome measures (shoulder dystocia, instrumentation, vaginal lacerations, Apgar scores at 5 minutes, nursery disposition) using multivariate linear, logistic, and ordinal regression models.

RESULTS

Three percent (12/400) of women who used N₂O discontinued because of side effects. Among participants with vaginal births who used N₂O, 17.6% (62/352) used N₂O as the only form of pain medication during labor. We found no significant differences in maternal and neonatal outcome measures between the two groups. Among the process measures examined, we found a mean 2-hour-longer time from admission to birth and total length of stay in the N₂O group (p < .05) compared to the non-N₂O group.

CONCLUSION

Most participants who used N₂O (290/352, 82.3%) transitioned to other pain modalities during labor. Maternal and neonatal process and outcome measures were comparable relative to other pain management modalities, with the exception of longer time durations for two measures.

Comparison of ropivacaine combined with sufentanil for epidural anesthesia and spinal-epidural anesthesia in labor analgesia

BACKGROUND

To compare the application and efficacy of ropivacaine combined with sufentanil for continuous epidural anesthesia (CEA) and combined spinal-epidural anesthesia (CSEA) in labor analgesia.

METHODS

Three hundred sixty pregnant women requesting labor analgesia from October 2017 to August 2018 were selected retrospectively. According to the anesthetic method, subjects were divided into CSEA group and CEA group. Ropivacaine combined with sufentanil were used in all subjects. The labor time, visual analogue scale (VAS), Apgar score of newborn, adverse pregnancy outcomes and adverse drug reactions were observed.

RESULTS

There was no significant difference in pre-analgesia (T₀) VAS scores between the two groups (P > 0.05). VAS scores of first stage of labor (T₁), second stage of labor (T₂) and third stage of labor (T₃) in CSEA group were significantly lower than CEA group (P < 0.01). The onset time, T₁ and total labor time in CSEA group were significantly shorter than CEA group (P < 0.01). There were no significant differences between T2 and T3 (P > 0.05). There were no significant differences in adverse pregnancy outcomes and Apgar scores at 1, 5 and 10 min after birth between the two groups (P > 0.05). The incidence of adverse drug outcomes in CSEA group was significantly lower than CEA group (P < 0.01). Maternal satisfaction in CSEA group was significantly higher than CEA group (P < 0.01).

CONCLUSION

Considering ropivacaine combined with sufentanil for CSEA achieved a shorter onset time and labor period, significant analgesic effect, lower adverse drug reactions rates and higher subject satisfaction than CEA, it may be worthy of clinical promotion and application.

A comparison of the effects of ENTONOX inhalation and spinal anesthesia on labor pain reduction and apgar score in vaginal delivery: a clinical trial study

INTRODUCTION

The purpose of the present study was to compare the effect of ENTONOX inhalation and spinal injection on the reduction of labor pain, the Apgar score of the neonates, and their side effects on new-born children and pregnant women.

MATERIAL AND METHODS

The present clinical trial study is conducted among the pregnant women in the maternity ward of a child delivery hospital in Iran. All Participants were divided in two groups ENTONOX Inhalation and Spinal Anesthesia. Visual Analogue Scale (VAS) was implemented to measure the pain level experienced by the participants during the procedure. Moreover, the Apgar scale was used to measure the general physical health of the neonates in both groups. In addition, the participants receiving ENTONOX were asked to report the side effects they underwent during gas inhalation. However, the participants in the spinal anesthesia were checked three times. Statistical analysis was performed using SPSS version 22.

RESULTS

The findings showed that the spinal anesthesia technique was significantly more effective than gas inhalation in that it reduced as much as 3 points more than did the inhalation (P-value: 0.001). Moreover, the comparison of the mean Apgar scores showed that the mean Apgar score of the neonates of spinal anesthesia mothers was 0.36 point lower than that of the neonates in the gas inhalation group. However, this difference was not statistically significant at P- value = 0.06.

CONCLUSIONS

the result of the present study indicated that spinal anesthesia was more effective than ENTONOX inhalation in reducing the labor pain.