Background This review examines the evidence from published data concerning the incidence of moderate-severe and of severe pain after major surgery, with three analgesic techniques; intramuscular (i.m.) analgesia, patient controlled analgesia (PCA), and epidural analgesia. Methods A MEDLINE search of the literature was conducted for publications concerned with the management of postoperative pain. Over 800 original papers and reviews were identified. Of these 212 papers fulfilled the inclusion criteria but only 165 provided usable data on pain intensity and pain relief. Pooled data on pain scores obtained from these studies, which represent the experience of a total of nearly 20 000 patients, form the basis of this review. Results Different pain measurement tools provided comparable data. When considering a mixture of three analgesic techniques, the overall mean (95% Cl) incidence of moderate-severe pain and of severe pain was 29.7 (26.4–33.0)% and 10.9 (8.4–13.4)%, respectively. The overall mean (95% Cl) incidence of poor pain relief and of fair-to-poor pain relief was 3.5 (2.4–4.6)% and 19.4 (16.4–22.3)%, respectively. For i.m. analgesia the incidence of moderate-severe pain was 67.2 (58.1–76.2)% and that of severe pain was 29.1 (18.8–39.4)%. For PCA, the incidence of moderate-severe pain was 35.8 (31.4–40.2)% and that of severe pain was 10.4 (8.0–12.8)%. For epidural analgesia the incidence of moderate-severe pain was 20.9 (17.8–24.0)% and that of severe pain was 7.8 (6.1–9.5)%. The incidence of premature catheter dislodgement was 5.7 (4.0–7.4)%. Over the period 1973–1999 there has been a highly significant (P Conclusions These results suggest that the UK Audit Commission (1997) proposed standards of care might be unachievable using current analgesic techniques. The data may be useful in setting standards of care for Acute Pain Services.

Effectiveness of acute postoperative pain management: I. Evidence from published data

The dose of opioid prescribed for postoperative pain relief has traditionally been based on the weight of the patient. Although a reduction in dose is often suggested for elderly patients over 70 years of age, age-related alterations to dose are generally not considered for younger patients. The records of 1010 patients, under 70 years old, prescribed morphine via patient-controlled analgesia (PCA) after major operations were examined to see what factors might best predict the amount of morphine used in the first 24 h after surgery. Factors included were age, sex, weight, operative site, verbal numeric pain score (at rest and on movement) and a nausea/vomiting score. In a subgroup of 78 of these patients, the effects of intraoperative and recovery room doses of opioid ('clinical' loading dose) were analysed. Although the interpatient variability in PCA morphine doses was large (differences of up to 10-fold in each age group), the best predictor of PCA morphine requirement in the first 24 h after surgery (the amount required in the 24 h after the initial loading dose) was the age of the patient. An estimate of these requirements for patients over the age of 20 years can be obtained from the formula: average first 24 h morphine requirement (mg) = 100 - age. PCA allows patients the flexibility to titrate their own opioid dose; if conventional analgesic regimens are to become more effective, they too need to allow for the wide interpatient variation in dose requirements. Although previous studies have noted a correlation between patient age and the amount of opioid needed, this study quantifies this correlation and provides guidelines for opioid dosing. Prescriptions for conventional analgesic regimens should include a dose range centred on values obtained from the above formula to allow for the large interpatient variation in each age group. While initial morphine dose should be guided by patient age and not weight, subsequent doses must still be titrated according to effect.

Age is the best predictor of postoperative morphine requirements

Patient-controlled iv delivery of opioids for postoperative pain management is a popular alternative to the traditional im route of administration. However, occasional patients receiving opioids in this manner develop severe respiratory depression. The purpose of this paper is to determine the incidence of, and factors contributing to, the development of this complication. To do this, the Office of Medical Quality Improvement retrospectively searched for reports of respiratory depression in a database compiled from the charts of approximately 1600 patients who had received PCA at the University of Alberta Hospitals in 1992. Eight cases of serious respiratory depression were detected. Factors associated with the occurrence of respiratory depression included the concurrent use of a back-ground infusion, advanced age, concomitant administration of sedative/hypnotic medications, and pre-existing sleep apnoea syndrome. No cases were attributed to operator error or equipment malfunction. In conclusion, the risk of respiratory depression with patient-controlled opioid administration is similar to that observed when opioids are delivered by the traditional im or spinal routes. The safe and effective use of patient-controlled analgesia depends upon knowledgeable medical and nursing staff, clearly defined nursing policy and procedures, and frequent patient follow-up.

/pdf/respiratory-depression-associated-with-patient-controlled-3670ev5a5a.pdf

Respiratory depression associated with patient-controlled analgesia: a review of eight cases

Patient-controlled analgesia for mucositis pain in children: A three-period crossover study comparing morphine and hydromorphone☆☆☆★★★

Intravenous morphine is the treatment of choice for severe pain during vaso- occlusive crisis in sickle cell disease (SCD). However, side effects of morphine may hamper effective treatment, and high plasma levels of morphine are associated with severe complications such as acute chest syndrome. Furthermore, adequate dosing remains a problem since no objective measurement of pain severity exists and analgesia should be titrated upon the patient's reported pain. Patient-controlled analgesia (PCA) may therefore be an interesting alternative since patients can titrate the level of analgesia themselves. In this randomized controlled study, the efficacy of intravenous morphine administration with PCA was compared with continuous infusion (CI) of morphine in patients with SCD during vaso-occlusive crisis. Twenty five consecutive episodes of vaso-occlusive crisis in 19 patients with SCD were included in the study. Patients in the PCA-group had a markedly and significant lower mean and cumulative morphine consumption when compared with the patients in the CI-group (0.5 mg/hr versus 2.4 mg/hr (P < 0.001) and 33 mg versus 260 mg (P = 0.018, respectively). The mean daily pain scores were comparable (4.9 versus 5.3). The lower mean and cumulative morphine consumption in the PCA-group led to significant less nausea and constipation during treatment when compared with the CI-group (area under the curve, respectively, 11 versus 18 (P = 0.045) and 30 versus 45 (P = 0.021). Furthermore, a nonsignificant reduction in the duration of hospital admission of 3 days was observed in the PCA-group. PCA results in adequate pain relief at a much lower morphine consumption and should considered to be the first choice in morphine administration to sickle cell patients admitted with vaso-occlusive crisis.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/ajh.20944

Patient-controlled analgesia versus continuous infusion of morphine during vaso-occlusive crisis in sickle cell disease, a randomized controlled trial.

Introduction to patient-controlled analgesia PCA as a clinical program the pain management team logistical and economic issues.

Patient-controlled analgesia

Effects of Alkalinization of Lidocaine on the Pain of Skin Infiltration and Intravenous Catheterization

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Patient-controlled analgesia

Effects of Alkalinization of Lidocaine on the Pain of Skin Infiltration and Intravenous Catheterization