M. Binhas

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.

Predictors of catheter-related bladder discomfort in the post-anaesthesia care unit ☆

BACKGROUND Catheter-related bladder discomfort (CRBD) is often reported to be stressful and resistant to conventional opioid therapy in the post anaesthesia care unit (PACU). Tolterodine or oxybutynin or gabapentin given orally 1 hour before induction reduce the incidence and severity of CRBD postoperatively. Nevertheless, side effects may occur with these drugs. Thus, preadministration of these different drugs should be selective in patients with predictors of moderate or severe CRBD. The goal of this study was to determine the incidence and predictors of early postoperative CRBD in post-anesthesia care unit. METHODS We designed a prospective observational study in two teaching hospitals. Consecutive adult patients undergoing surgery under general anaesthesia necessitating intraoperative urinary catheterization were included during a 6-month period. Bladder discomfort was assessed with a simple four-step severity scale: no pain; mild pain (revealed only by interviewing the patient); moderate (a spontaneous complaint by the patient) and severe discomfort (agitation, loud complaints and attempt to remove the bladder catheter). Predictors of CRBD were identified by univariate and multivariate analysis. RESULTS 164 patients were included, of which 47% complained of CRBD (mild CRBD: 20%; moderate or severe CRBD: 27%). Multivariate logistic regression analysis showed the diameter of the Foley catheter superior than 18 G Fr (OR=2.2, CI95 [1.0-5.1], P=0.06) and male gender (OR=3.2, CI95 [1.0-10.5], P<0.06) to be independent predictors of moderate or severe CRBD in the PACU. CONCLUSION This observational study identified the incidence and predictive factors of moderate and severe CRBD in the PACU. Future studies are warranted to assess the impact of preoperative antimuscarinic drugs or Gabapentin on males or patients with 18 G Fr Foley catheters.

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

BackgroundPostoperative 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.MethodsWe 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.ResultsIn 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.ConclusionsIntraoperative propacetamol administration with remifentanil based-anesthesia improved significantly early postoperative pain by sparing morphine and shortening the delay to achieve pain relief.

Ultrasound-guided regional anesthesia

Ultrasound guided regional anesthesia (UGRA) is a recent practice requiring prior training and the acquisition of a specific device and equipment that many anesthesiologists and emergency physicians do not necessarily master. Because nerve simulation remains an effective procedure, the purpose of these guidelines is not to impose ultrasound technique as the only valid technique. These recommendations provide a framework to help with learning UGRA in proper conditions of safety and efficacy. A GRADE consensus procedure consisting of three rounds was conducted. The guidelines represent the best current evidence based on literature serach and professional opinion.

Analgésie par voie générale pour la prise en charge des douleurs postopératoires chez l’adulte

Severe postsurgical pain contributes to prolonged hospital stay and is also believed to be a risk factor for the development of chronic pain. Locoregional anesthesia, which results in faster patient recovery with fewer side effects, is favored wherever feasible, but is not applicable to every patient. Systemic analgesics are the most widely used method for providing pain relief in the postoperative period. Improvements in postoperative systemic analgesia for pain management should be applied and predictive factors for severe postoperative pain should be anticipated in order to control pain while minimizing opioid side effects. Predictive factors for severe postoperative pain include severity of preoperative pain, prior use of opiates, female gender, non-laparoscopic surgery, and surgeries involving the knee and shoulder. Pre- and intraoperative use of small doses of ketamine has a preventive effect on postoperative pain. Multimodal or balanced analgesia (the combined use of various analgesic agents) such as NSAID/morphine, NSAID/nefopam, morphine/ketamine improves analgesia with morphine-sparing effects. Nausea and vomiting, the principle side effects of morphine, can be predicted using Apfels simplified score; patients with a high Apfel score risk should receive preemptive antiemetic agents aimed at different receptor sites, such as preoperative dexamethasone and intraoperative droperidol. Droperidol can be combined with morphine for postoperative patient-controlled anesthesia (PCA). When PCA is used, dosage parameters should be adjusted every day based on pain evaluation. Patients with presurgical opioid requirements will require preoperative administration of their daily opioid maintenance dose before induction of anesthesia: PCA offers useful options for effective postsurgical analgesia using a basal rate equivalent to the patients hourly oral usage plus bolus doses as required.

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.

Incidences et causes d’insatisfaction des patients vis-à-vis de la prise en charge de la douleur postopératoire

INTRODUCTION Patient satisfaction regarding postoperative pain management (POPM) is not always correlated with pain level relief. OBJECTIVE To evaluate the percentage of satisfied patients while splitting satisfaction related with nurses, anaesthesiologists and surgeons during 48h postoperative period. PATIENTS AND METHODS The study was performed in 2007 by two investigators in six different surgical suites in a university hospital. Approximatively 15 patients have been randomly selected in each surgical ward. Each patient received during the first or second postoperative day an anonymous questionnaire and was required to complete it with the investigator assistance if necessary. Questions requiring a yes-or-no reply assessed the patients satisfaction with POPM performed by nurses, surgeons, and anaesthesiologists. In case of dissatisfaction, patients were invited to explain the reasons. RESULTS Ninety-two patients were included, 5% of the patients were not satisfied with nurse POPM and nearly 15% were not satisfied with anaesthesiologist or surgeon POPM. The main reasons of dissatisfaction with nurses were the excessive delays between requesting and receiving an analgesic and because of the significant discrepancies in POPM between nurses. Patient discontent regarding surgeons was explained by the lack of interest of the latter for POPM. Patient discontent regarding anaesthesiologists was explained by the lack of anaesthesiologist visit in the postoperative period. CONCLUSION There is a relationship between patient dissatisfaction and the lack of attention for POPM by surgeons and the lack of postoperative visit by the anaesthesiologist. A postoperative visit by a team of anaesthesia nurses should improve patient satisfaction with POPM.