Ferne B. Sevarino

Preoperative anxiety and postoperative pain in women undergoing hysterectomy. A repeated-measures design.

OBJECTIVES To determine whether psychological variables such as preoperative anxiety can serve as predictors for the postoperative pain response. METHODS The study sample included women who underwent elective abdominal hysterectomy (n=53). Two weeks prior to surgery, characteristics such as trait anxiety, coping style, and perceived stress were evaluated. Throughout the perioperative period, state anxiety, pain, as well as analgesic consumption were assessed at multiple time points. The anesthetic and surgical management were carefully controlled for and postoperative pain management was standardized. RESULTS Path analysis demonstrated that there are both direct and indirect effects of preoperative state anxiety on postoperative pain. Preoperative state anxiety is a significant positive predictor of the immediate postoperative pain (beta=0.30), which, in turn, is a positive predictor of pain on the wards (beta=0.54). Pain on the ward, in turn, is predictive for pain at home (beta=0.30). CONCLUSION The results of this study indicate that preoperative anxiety may have a critical role in the chain-of-events that controls the postoperative pain response.

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.

Attenuation of the preoperative stress response with midazolam: effects on postoperative outcomes.

Background. Previously, effects of preoperative sedatives were assessed mainly with respect to preoperative outcomes such as anxiety and compliance. The purpose of this investigation was to evaluate the effects of preoperative sedatives on postoperative psychological and clinical recovery. Methods Patients undergoing general anesthesia and outpatient surgery were enrolled in a double-blind, randomized, placebo-controlled trial. Subjects (n = 55) were randomly assigned to receive either 5 mg intramuscular midazolam (n = 26) or a placebo injection (n = 29) at least 30 min before surgery. The anesthetic technique was controlled. Postoperative anxiety, pain, analgesic consumption, clinical recovery parameters, and global health (SF-36) were evaluated up to 1 month after surgery. Results Surgery length did not differ significantly between the treatment and placebo groups (118 ± 45 min vs 129 ± 53 min;P = NS). Throughout the first postoperative week, subjects in the treatment group reported a greater reduction in postoperative pain compared with subjects in the placebo group (F1,50= 3.5;P = 0.035). Moreover, at 1 week, ibuprofen use was reported by less subjects in the treatment group than in the placebo group (0%vs 17.2%;P = 0.026). Subjects in the treatment group also reported a greater reduction in postoperative anxiety throughout the follow-up period (F1,53 = 9.2;P = 0.04). However, global health indexes (SF-36) did not detect any significant differences between the two experimental groups (multivariate F1,45 = 0.44;P = 0.51). Conclusion Subjects treated with midazolam preoperatively self-report improved postoperative psychological and pain recovery. However, the clinical significance of these findings is unclear at the present time.

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.

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.

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 μg sufentanil (group A), 5 mg morphine (group B), or 30 μg 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<0.05). Group B subjects experienced the longest duration of analgesia (B us A and C, P<0.05) and required significantly less patient‐controlled analgesia (morphine) than patients in group A (P<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.

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 hoc 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.

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.

Transdermal Fentanylfor 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.

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.