Patient-controlled analgesia

Using a portable infusion pump, intravenous opioid patient-controlled analgesia (PCA) permits a patient to self-deliver a small bolus of opioid to achieve prompt relief without over sedation. Use of PCA for pain management is increasing in hospitals, largely because it can provide equivalent or better analgesia than conventional nurse-administered opioid analgesia, and patients are more satisfied with its use. There is no decisive pharmacological or clinical argument for the choice of one opioid rather than another. Thus, morphine remains the most frequently used opioid in PCA. The adjunction of non-opioid drugs to morphine in the PCA reservoir is still very controversial. A new investigational PCA transdermal system using iontophoresis to deliver fentanyl seems to provide an adequate pain control with the advantages of needle-free, preprogrammed, self-contained device. Whatever drug or device used, the overall success of the PCA technique relies mainly on the expert supervision of nurses or anesthesiologists in an Acute Pain Service. Indeed, PCA is effective and significant only on the condition that there is careful preoperative patient education and strict postoperative monitoring. In addition, preoperative patient selection allows to exclude patients with evidence of cognitive dysfunction or physical disabilities, making the use of the patient-controlled device impossible. Caution is required among patients with respiratory or renal insufficiency. In the future, the indispensable improvement in the management of postoperative pain should lead to a greater expansion of PCA. However, more pharmaco-economic evaluations will be needed on the cost-effectiveness issue.     

Patient-controlled analgesia in burn patients: a critical review of the literature and case report

Although patient-controlled analgesia has been well documented as effective in various types of patients, it has not been adequately studied in burn patients. In this paper, the authors review the literature on PCA in burn patients and present two cases. Flaws in most published studies make it difficult to determine the efficacy of PCA in burn patients. Both the literature and experience indicate that many patients with acute burns are not suitable candidates for PCA. The cases illustrate the different methods patients may use to achieve adequate analgesia with PCA. Both patients and nurses face a steep learning curve in using PCA for management of procedural pain in burn care.     

瑞芬太尼静脉自控镇痛在分娩中的应用模式

目的探讨瑞芬太尼静脉自控镇痛的分娩镇痛模式及效果、对产程和母婴的影响及不良反应.方法单胎、头位、孕38～42周自然分娩初产妇65例,进入第1产程活跃期后分为3组,A组应用瑞芬太尼静脉电子泵镇痛,设置后自控按压给药每次0.5 μg·kg,锁定时间3 min;B组单次剂量同A组,复合瑞芬太尼0.05 μg·kg-1·min-1背景输注,宫口开全后AB组均停药;C组常规产科处理.记录宫缩疼痛视觉模拟评分(VAS),镇静评分(Ramsay)、呼吸循环指标、产妇宫缩、胎心监测情况、新生儿Apgar评分、催产素应用及器械助产情况、剖宫产率等指标.结果A和B组镇痛20 min后各时段疼痛评分均低于C组(P＜0.01),镇痛满意度均显著高于C组(A组为17/21,B组21/21,C组0/23),产力满意度三组间比较差异无统计学意义(P＞0.05).B组总按压次数(50次)＜A组(78次)(P＜0.01),A和B组用药量及疼痛评分比较,差异均无统计学意义.各组产程、催产素应用率、器械助产率、剖宫产率比较,差异均无统计学意义(P＞0.05).无胎儿宫内窘迫或新生儿呼吸抑制发生、无产妇循环抑制、镇静过度或低氧血症发生(鼻导管低流量吸氧下).结论瑞芬太尼静脉自控镇痛用于分娩镇痛安全有效,复合背景剂量的产妇可减少按压次数.     

Patient-controlled analgesia in the terminally ill cancer patient

Patient-controlled analgesia (PCA) is a relatively new therapeutic modality which has allowed postsurgical patients to safely and effectively self-administer doses of intravenous narcotics via a syringe pump and sequencing device. A pilot study was designed to evaluate PCA's safety and effectiveness in the terminally ill cancer patient. Eight patients whose chronic pain was not adequately controlled by oral narcotics were permitted to use PCA for a minimum of 48 hours. Respiratory rates, sedation rankings, and pain rankings indicated these patients achieved satisfactory analgesia with a minimum of sedation and experienced no respiratory depression. Three patients were switched to oral regimens using PCA dosing as a guide. Pain and sedation rankings were similar to those registered while exclusively on PCA. This self-dosing technique was judged to be safe, effective, and able to accommodate wide fluctuations in analgesic need when treating pain in the terminally ill cancer patient. The results obtained in these patients support further trials using PCA to individualize oral analgesic regimens.     

Patient-controlled analgesia in the management of postoperative pain

Patient-controlled analgesia (PCA) is a delivery system with which patients self-administer predetermined doses of analgesic medication to relieve their pain. Since its introduction in the early 1980s, the daily management of postoperative pain has been extensively optimised. The use of PCA in hospitals has been increasing because of its proven advantages over conventional intramuscular injections. These include improved pain relief, greater patient satisfaction, less sedation and fewer postoperative complications. All PCA modes contain the following variables: initial loading dose, demand dose, lockout interval, background infusion rate and 1-hour or 4-hour limits. Morphine is the most studied and most commonly used intravenous drug for PCA. In spite of the fact that it is the 'first choice' for PCA, other opioids have been successfully used for this option. The most observed adverse effects of opioid-based PCA are nausea and vomiting, pruritis, respiratory depression, sedation, confusion and urinary retention. Although intravenous PCA is the most studied route of PCA, alternative routes have extensively been described in the literature. PCA by means of peridural catheters and peripheral nerve catheters are the most studied. Recently, transdermal PCA has been described. The use of peripheral or neuraxial nerve blocks is recommended to avoid the so called opioid tolerance observed with the intravenous administration of opioids. Numerous studies have shown the superiority of epidural PCA to intravenous PCA. The beneficial postoperative effects of epidural analgesia are more apparent for high-risk patients or those undergoing higher risk procedures. PCA with peripheral nerve catheters results in increased postoperative analgesia and satisfaction for surgery on upper and lower extremities. Serious complications occur rarely with these catheters. With the introduction of an Acute Pain Service, management of postoperative pain can be improved. This will also help to minimise adverse effects related to PCA and to avoid lethal mishaps.     

Patient-controlled analgesia: an appropriate method of pain control in children

Patient-controlled analgesia (PCA) is an analgesic technique originally used in adults but now with an established role in paediatric practice. It is well tolerated in children as young as 5 years and has uses in postoperative pain as well as burns, oncology and palliative care. The use of background infusions is more frequent in children and improves efficacy; however, it may increase the occurrence of adverse effects such as nausea and respiratory depression. Monitoring involves measurement of respiratory rate, level of sedation and oxygen saturation. Efficacy is assessed by self-reporting, visual analogue scales, faces pain scales and usage patterns. This is optimally performed both at rest and on movement. The selection of opioid used in PCA is perhaps less critical than the appropriate selection of parameters such as bolus dose, lockout and background infusion rate. Moreover, opioid choice may be based on adverse effect profile rather than efficacy. The concept of PCA continues to be developed in children, with patient-controlled epidural analgesia, subcutaneous PCA and intranasal PCA being recent extensions of the method. There may also be a role for patient-controlled sedation. PCA, when used with adequate monitoring, is a well tolerated technique with high patient and staff acceptance. It can now be regarded as a standard for the delivery of postoperative analgesia in children aged >5 years.     

初产妇PCEA分娩镇痛的临床观察

目的探讨硬膜外自控镇痛（PCEA）分娩镇痛对产痛、产程和新生儿的影响。方法将1200例产妇随机分为镇痛组和对照组,每组600例;镇痛组行舒芬太尼复合罗哌卡因连续硬膜外分娩镇痛,对照组常规分娩处理。观察记录两组产痛程度、产程时间、缩宫素使用率、产后出血量、剖宫产率以及新生儿情况。结果镇痛组镇痛后10min、30min、60min、宫口开全时产痛VAS评分分别为（43．1±11．2）、（33．2±13．7）、（13．6±6．7）、（10．3±4．1）,较对照组f（82．9±18．5）、（83．7±18．1）、（84．3±18．7）、（80．3±17．3）]明显降低（P〈0．05）;镇痛组第一产程活跃期[（157．7±31．9）mini明显短于对照组[（197．74-35．2）min]（P〈0．05）,第二、三产程两组差异无统计学意义（P〉0．05）;镇痛组剖宫产率（43％）明显低于对照组（53％）,缩宫素使用率（61％）明显高于对照组（31％）（P〈0．05）;两组产妇产后出血、新生儿Apgar评分差异无统计学意义（P〉0．05）。结论PCEA分娩镇痛安全有效,能满足产妇的镇痛需要,对母罂均无不良影响。     

布托啡诺与舒芬太尼在肺叶切除术后镇痛效果的比较

目的比较布托啡诺和舒芬太尼在电视辅助胸腔镜(VATS)下小切口肺叶切除术后患者静脉自控镇痛(PCIA)的效果。方法择期全麻下行VATS肺叶切除术患者75例(22～57岁),ASAⅡ级,随机分成布托啡诺Ⅰ组(BⅠ组)、布托啡诺Ⅱ组(BⅡ组)、舒芬太尼组(S组),每组25例。在手术结束前30min,BⅠ、BⅡ组给予布托啡诺负荷量30μg/kg,S组给予舒芬太尼负荷量0.1μg/kg,术毕BⅠ、BⅡ组分别予布托啡诺3μg·kg-1·h-1,4μg·kg-1·h-1维持PCIA,S组予舒芬太尼0.05μg·kg-1·h-1维持PCIA。观察并记录术后1h、6h、12h、18h、24h、36h、48h的平均动脉压、心率、呼吸频率、脉搏氧饱和度、患者平静时的视觉模拟(VAS)疼痛评分及Ramsay镇静评分,术后12h、24h、36h、48h的恶心评级和呕吐评级。并记录患者术后36h和48h咳嗽时的VAS疼痛评分。结果术后48h内三组患者各观察时点的呼吸循环指标、Ramsay镇静评分、恶心、呕吐评级比较无显著性差异。在术后6～24h各时点,BⅡ组与S组间VAS评分差异无显著性,但BⅡ组和S组VAS评分均低于BⅠ组(P<0.05)。术后36h、48h患者咳嗽时VAS评分,BⅡ组和S组均低于BⅠ组(P<0.05),但BⅡ组与S组间无显著差异。结论VATS手术结束前30min缓慢静注布托啡诺负荷量30μg/kg,术后给予4μg·kg-1·h-1的维持量,与舒芬太尼PCIA同样安全有效。     

Patient-controlled intravenous analgesia with remifentanil in nulliparous subjects in labor

Objective: in this study we controlled the efficiency and safety of using remifentanil combined with two different supplementary background infusions for labor analgesia in nulliparous patients. Research design and methods: 60 subjects were allocated to two groups. After programming the patient-controlled analgesia device to deliver a fixed load and demand doses of intravenous remifentanil for all subjects, group r (n = 30) received a background infusion of remifentanil 0.1 μg/kg/min and group R (n = 30) received a supplementary infusion of remifentanil 0.15 μg/kg/min. Visual analogue scale for analgesia, hemodynamic parameters, sedation scales and fetal heart rates were recorded at the 5th, 10th, 20th and 30th min of the study and measurements continued every 15 min during 90 min of labor and delivery. Side effects, Apgar and satisfaction scores were obtained for every subject. Results: visual analogue scale scores of group R were significantly lower than those of group r throughout labor and delivery (p < 0.05). Hemodynamic parameters and fetal heart rates of the two groups were not different (p > 0.05). Most subjects were awake and only nausea was obtained (p > 0.05). The increase in the Apgar and satisfaction scores was not statistically significant (p > 0.05). Conclusion: it was determined that remifentanil with a 15-μg demand dose and 0.15 μg/kg/min supplementary continuous infusion is an effective choice for patient-controlled analgesia during labor in nulliparous subjects.     

右美托咪定联合舒芬太尼在胸腔镜下食道癌根治术术后自控镇痛中的应用效果

目的 探究右美托咪定联合舒芬太尼在胸腔镜下食遁癌根治术术后目控镇痛中的应用效果.方法 抽取2013年10月至2016年1月于本院择期行食管癌根治术的患者64例,根据麻醉方式不同分为对照组(n=32)和研究组(n=32).对照组给予舒芬太尼+生理盐水术后自控镇痛,研究组给予舒芬太尼+右美托咪定术后自控镇痛.对比术后不同时间段两组疼痛评分(VAS)、镇静评分(Ramsay),并统计两组不良反应发生率.结果 术后1h、4h、12 h、1d,研究组VAS评分分别为(2.29±0.46)分、(2.01±0.39)分、(1.32±0.26)分、(1.17±0.21)分,均明显优于对照组,差异有统计学意义(均P＜0.05);术后1h、4h,研究组Ramsay评分分别为(3.11 ±0.40)分、(2.71±0.40)分,均明显优于对照组,差异有统计学意义(均P＜0.05);研究组不良反应发生率(6.26％)明显低于对照组(31.26％),差异有统计学意义(P＜0.05).结论 在胸腔镜下食道癌根治术术后自控镇痛中联合应用右美托咪定及舒芬太尼效果显著,可有效提高镇痛及镇静效果,且能降低不良反应发生率.     

舒芬太尼自控镇痛联合丙泊酚镇静在烧伤换药中的应用

目的：研究舒芬太尼自控镇痛（PCA）联合丙泊酚镇静在烧伤换药中的应用。方法：选取ASAⅠ或Ⅱ级,烧伤面积20%～50%的Ⅱ～Ⅲ度烧伤患者60例,随机分为3组：1μg组、3μg组和5μg组,每组20例。换药前5 min静脉注射舒芬太尼0.25μg/kg,3 min后丙泊酚靶控输注（TCI）,最初效应室浓度为1.5μg/kg,调整其浓度使BIS值较基础值降低15%～20%后开始换药。PCA：舒芬太尼浓度为1μg/mL,维持为2 mL/h,3组按压锁定给药量分别为1 mL、3 mL和5 mL,锁定时间为5 min。记录丙泊酚和舒芬太尼用量、每10 min平均按压次数、给药次数和计算按压次数/给药次数比值;采用VAS法进行疼痛评分,评定手术医生和患者满意度及不良事件情况。结果：5μg组丙泊酚用量较3μg组和1μg组减少（P〈0.01,P〈0.05）,而3μg组较1μg组减少（P〈0.05）;舒芬太尼总使用量5μg组和3μg组较1μg组增多（P〈0.01）。换药中平均VAS评分、每10 min按压次数、按压次数/给药次数比值1μg组显著高于3μg组和5μg组（P〈0.01）。5μg组和3μg组患者和医生满意度较1μg组高（P〈0.01）,5μg组和3μg组比较无统计学差异（P〉0.05）;5μg组眩晕发生率显著高于1μg和3μg组（P〈0.01,P〈0.05）。结论：舒芬太尼0.25μg/kg负荷量后PCA,持续2 mL/h,按压泵量3 mL（3μg）,锁定时间5 min,联合丙泊酚镇静用于烧伤病人换药是安全、可行的。     

氟比洛芬酯复合芬太尼用于功能性鼻内窥镜术后静脉自控镇痛

目的：探讨氟比洛芬酯复合芬太尼用于功能性鼻内窥镜术(FESS)后静脉自控镇痛的可行性及安全性。方法：40例择期行FESS要求术后镇痛的患者,随机分为芬太尼组（F组）和氟比洛芬酯复合芬太尼组（KF组）,每组20例。术毕前30 min静注负荷量,F组芬太尼0.05 mg,KF组氟比洛芬酯50 mg,连接镇痛泵。F组药液为芬太尼1.0 mg+昂丹司琼8 mg+0.9%氯化钠注射液共100 mL,KF组为氟比洛芬酯100 mg+芬太尼0.5 mg+昂丹司琼8 mg+0.9%氯化钠注射液共100 mL。均设定背景速度2.0 mL&#8226;h-1,患者自控剂量2.0 mL,锁定时间15 min。观察并记录术后2,6,24 h的视觉模拟疼痛评分（VAS）、Ramsay镇静评分、PCA按压次数、呼吸频率（RR）、脉搏氧饱和度(SpO2)、血压(BP)及心率(HR),同时记录有无呼吸抑制、头晕、恶心、瘙痒、异常出血等不良反应。结果：2组患者术后各时间点的VAS评分、HR、BP以及SpO2无显著差异;术后2,6,24 h的Ramsay评分KF组均低于F组,而RR均高于F组（P<0.01）;不良反应KF组头晕、恶心的发生率明显低于F组(P<0.05)。结论：氟比洛芬酯复合芬太尼用于FESS术后静脉自控镇痛,能够达到满意的镇痛效果,避免芬太尼可能造成的呼吸抑制及过度镇静。     

Patient-controlled analgesia with nalbuphine,a new narcotic agonist-antagonist,for the treatment of postoperative pain

Summary Patient-controlled analgesia (PCA, intravenous self-application of narcotics) has been studied during the early postoperative period in 40 ASA I–III patients recovering from elective major and minor surgery (20 abdominal and 20 orthopaedic operations). Doses of 3.7 mg of the new agonist-antagonist opiod analgesic nalbuphine were available on demand, whenever the patients felt that pain relief was necessary, delivered by a microprocessor-controlled injection pump (On-Demand Analgesia Computer, ODAC) in response to use of a patient-controlled manual switch. The maximum dose/h was set at 28.2 mg, with a refractory time of 1 minute between successful demands. A continuous nalbuphine infusion (0.44 mg·h^–1) was administered in addition in order to prevent obstruction of the catheter.The duration of the PCA period was 17.9 (0.4–28.0) h (median, range). During that time, 13.3 (1–45) demands per patient were recorded, resulting in median individual nalbuphine consumptions of 51.3 (8.1–1050.5) µg·kg^–1·h^–1. Self-administration was characterized by considerable intra- and interindividual variability. Following abdominal surgery significantly more nalbuphine was needed compared to orthopaedic patients, but it resulted in poorer pain relief. There were no statistically significant differences in drug requirements or pain scores between the sexes.Overall efficacy and patient acceptance proved to be good. When compared with previous conventional postoperative analgesia, the effectiveness of PCA was judged superior by about 57% of patients. Side effects (nausea, sweating) occured in about 10% of patients but were usually of minor intensity. No serious circulatory or respiratory problems were observed during the period of PCA.Patient-controlled analgesia is a promising technique for the treatment of acute pain and for clinical pain research.     

氟比洛芬酯联合舒芬太尼用于脊柱手术后静脉自控镇痛

目的研究氟比洛芬酯联合舒芬太尼用于脊柱手术后静脉自控镇痛（PCIA）的临床效果和安全性。方法择期全麻下行脊柱手术患者90例,随机分为3组,每组30例,术后均行PCIA,A组：舒芬太尼2μg.kg-1;B组：舒芬太尼1.5μg.kg-1;C组：舒芬太尼1.5μg.kg-1＋氟比洛芬酯2mg.kg-1。三组均加入恩丹西酮8mg,用0.9%氯化钠稀释至100mL。PCIA持续剂量2.0mL.h-1,追加剂量1.0mL,锁定时间15min。术后2、6、12、24、48h双盲对照观察各组视觉模拟评分（VAS）,镇静评分（Ramsay）、满意度评分和镇痛泵按压情况以及不良反应发生情况。结果 A组和C组各时点镇痛评分无统计学差异、平均值都小于3分,均小于B组（P〈0.05）;A组和C组镇痛满意度高、镇痛泵按压次数少且有效按压率高,与B组比较有统计学差异（P〈0.05）。A组术后2、61、2h Ramsay评分较高、呼吸抑制、恶心呕吐等不良反应的发生率高于B组和C组（P〈0.05）。结论氟比洛芬酯联合舒芬太尼用于脊柱患者手术后PCIA,镇痛效果好并可减少单纯用舒芬太尼的剂量,安全可靠,不良反应少,为理想的镇痛方法。