Labor analgesia

Regional analgesia has become the most common method of pain relief used during labor in the United States. Epidural and spinal analgesia are two types of regional analgesia. With epidural analgesia, an indwelling catheter is directed into the epidural space, and the patient receives a continuous infusion or multiple injections of local anesthetic. Spinal injections are usually single injections into the intrathecal space. A combination of epidural and spinal analgesia, known as a walking epidural, also is available. This technique combines the rapid pain relief from the spinal regional block with the constant and consistent effects from the epidural block. It allows sufficient motor function for patients to ambulate. Complications with regional analgesia are uncommon, but may include postdural puncture headache. Rare serious complications include neurologic injury, epidural hematoma, or deep epidural infection. Regional analgesia increases the risk of instrument-assisted vaginal delivery, and family physicians should understand the contraindications and risks of complications. Continuous labor support (e.g., doula), systemic opioid analgesia, pudendal blocks, water immersion, sterile water injections into the lumbosacral spine, self-taught hypnosis, and acupuncture are other options for pain management during labor.     

Postoperative analgesia in patients with substance use disorders: Part I

The specific problems related to postoperative analgesia in patients with substance use disorders (SUD) concerning opioids, alcohol, benzodiazepines, barbiturates, cocaine, crack, amphetamines, amphetamine-like designer drugs (MDMA, ecstasy), LSD, and marijuana are described. Whereas SUD with only one substance rarely occurs, the number of polysubstance abusers is increasing. Patients with SUD may have multiple organic diseases, impaired immune response, psychiatric and behavioural abnormalities and substance-induced disorders (intoxication, withdrawal, delerium, psychotic disorders), often associated with low compliance and craving behaviour.The perioperative management should be focused on three problems: (1) on the prevention of physical withdrawal symptoms and stressful complications in patients with SUD using CNS-depressants, (2) on the symptomatic treatment of the predominant affective withdrawal symptoms in patients suffering from SUD with CNS-stimulants, and (3) on the effective pain treatment.The analgesic therapy is often difficult and required for longer periods of time than in other patients. However, the principles of multimodal analgesia are as valid as in non-addicts. To be effective, systemic analgesia with paracetamol, NSAIDs and opioids has to be adapted as usual, but regional analgesia techniques should be preferred for postoperative pain relief.Patients enrolled in preoperative maintenance programmes (methadone, buprenorphine) need their daily maintenance dose as baseline. Ths baseline therapy does not, however, induce analgesia. Therefore, these patients need additional short-acting opioids which have to be administered at higher doses than usual (which do not cause respiratory depression due to opioid tolerance). The additional opioid does not increase the risk of relapse into active SUD. On the other hand, regional analgesia in patients who are enrolled in a maintenance programme does not mean withdrawal prophylaxis. These patients have excellent analgesia, but they need their previously used maintenance opioid to prevent withdrawal. Special considerations will have to be made in patients with naltrexone.Recovering patients with a history of SUD have both an intensive fear of relapsing into the active SUD as well as fear of suffering from postoperative pain. These patients require an equally effective analgesia as other patients. Depending on the type of surgery and pain intensity they need atypical opioids (eg tramadol) or strong opioids (eg buprenorphine or morphine) as a part of balanced analgesia to the same degree as other patients. Withholding effective analgesic treatment can paradoxically lead to relapses in recovering patients. The common opinion of healthcare providers to withhold strong opioids from recovering patients with SUD is obsolete. However, in order to avoid psychotropic side effects the dosages of opioids, as well as the analgesic efficacy, should be monitored closely.     

Continuous morphine infusions for cancer pain in resource-scarce environments: comparison of the subcutaneous and intravenous routes of administration

Acute onset of severe pain in cancer patients may be due to multiple causes. Irrespective of the etiology, adequate analgesia has to be provided as quickly as possible. The standard practices of relieving pain by using syringe pumps (syringe drivers) or infusion pumps may not be feasible in resource-scarce developing nations where many cancer patients first present at advanced stages of disease for management. This study compared the efficacy of the subcutaneous and intravenous routes of morphine administration continuously using a simple and economic technique for cancer pain management. Both routes were found to be equally effective in producing good analgesia without side effects. The drip method is a cost-effective way of providing subcutaneous morphine infusion for cancer patients and is applicable for both inpatients and home care.     

Postoperative analgesia in patients with substance use disorders: Part II

The specific problems related to postoperative analgesia in patients with substance use disorders (SUD) concerning opioids, alcohol, benzodiazepines, barbiturates (Part I), cocaine, crack, amphetamines, amphetamine-like designer drugs (MDMA, ecstasy), LSD, and marijuana (Part II) are described. Whereas SUD with only one substance rarely occurs, the number of polysubstance abusers is increasing. Patients with SUD may have multiple organic diseases, impaired immune response psychiatric and behavioural abnormalities, and substance-induced disorders (intoxication, withdrawal, delerium, psychotic disorders), often associated with low compliance and craving behaviour.

The perioperative management should be focused on three problems: (1) on the prevention of physical withdrawal symptoms and stressful complications in patients with SUD using CNS-depressants, (2) on the symptomatic treatment of the predominant affective withdrawal symptoms in patients suffering from SUD with CNS-stimulants, and (3) on the effective pain treatment.

The analgesic therapy is often difficult and required for longer periods of time than in other patients. However, the principles of multimodal analgesia are as valid as in non-addicts. To be effective, systemic analgesia with paracetamol, NSAIDs and opioids has to be adapted as usual, but regional analgesia techniques should be preferred for postoperative pain relief.

Patients enrolled in preoperative maintenance programmes (methadone, buprenorphine) need their daily maintenance dosage as baseline. This baseline therapy does not, however, induce analgesia. Therefore, these patients need additional short-acting opioids which have to be administered at higher dosages than usual (which do not cause respiratory depression due to opioid tolerance). The additional opioid does not increase the risk of relapse into active SUD. On the other hand, regional analgesia in patients who are enrolled in a maintenance programme does not mean withdrawal prophylaxis. These patients have an excellent analgesia, but they need their previously used maintenance opioid to prevent withdrawal. Special considerations will have to be made in patients with naltrexone.

Recovering patients with a history of SUD have both an intensive fear of relapsing into the active SUD as well as fear of suffering from postoperative pain. These patients require an equally effective analgesia as other patients. Depending on the type of surgery and pain intensity they need atypical opioids (eg tramadol) or strong opioids (eg buprenorphine or morphine) as a part of balanced analgesia to the same degree as other patients. Withholding effective analgesic treatment can paradoxically lead to relapses in recovering patients. The common opinion of healthcare providers to withhold strong opioids from recovering patients with SUD is obsolete. However, in order to avoid psychotropic side effects the dosages of opioids, as well as the analgesic efficacy, should be monitored closely.     

Relationship between nurses'' pain knowledge and pain management outcomes for their postoperative cardiac patients

Nurses' knowledge and perceived barriers related to pain management have been examined extensively. Nurses have evaluated their pain knowledge and management practices positively despite continuing evidence of inadequate pain management for patients. However, the relationship between nurses' stated knowledge and their pain management practices with their assigned surgical cardiac patients has not been reported. Therefore, nurses (n=94) from four cardiovascular units in three university-affiliated hospitals were interviewed along with 225 of their assigned patients. Data from patients, collected on the third day following their initial, uncomplicated coronary artery bypass graft (CABG) surgery, were aggregated and linked with their assigned nurse to form 80 nurse-patient combinations. Nurses' knowledge scores were not significantly related to their patients' pain ratings or analgesia administered. Critical deficits in knowledge and misbeliefs about pain management were evident for all nurses. Patients reported moderate to severe pain but received only 47% of their prescribed analgesia. Patients' perceptions of their nurses as resources with their pain were not positive. Nurses' knowledge items explained 7% of variance in analgesia administered. Hospital sites varied significantly in analgesic practices and pain education for nurses. In summary, nurses' stated pain knowledge was not associated with their assigned patients' pain ratings or the amount of analgesia they received.     

Pain management in the ambulatory surgical population

Effective postoperative analgesia is a fundamental goal of patient management in the ambulatory surgery setting. There is a physiologic, psychological, and economic cost to unrelieved pain in the postoperative patient. Understanding (1) the individual experience of pain, (2) common barriers to effective pain management, (3) the concept of balanced analgesia, (4) the types and modes of action of various analgesics available to the ambulatory population, and (5) the importance of thorough and organized means of pain assessment will help the perianesthesia nurse optimize analgesia for the postoperative patient. Severe postoperative pain continues to be a problem in ambulatory patients once they are discharged to the home environment. This article looks at fundamental concepts in pain management and integrates these ideas into a comprehensive strategy for the management of postoperative pain in the ambulatory patient.     

Epidural techniques for cancer pain management: When, why, and how?

Epidural analgesia is an important tool in the management of intractable cancer pain. Fundamental questions surrounding the use of epidural catheters in cancer pain management include: When is epidural analgesia appropriate?, Why is epidural analgesia beneficial?, and How does the clinician implement and manage epidural catheters in patients with cancer pain? This clinical review addresses these questions through a discussion of patient selection criteria, the advantages and disadvantages of the epidural route, the concept of functional analgesia, cost issues, device selection, treatment planning, and complications. The author concludes that achieving an optimal outcome with epidural techniques in a patient with cancer involves a negotiation between patient and provider.     

急性疼痛服务组织对开胸术后病人疼痛控制的方法与效果

目的探讨术后急性疼痛服务组织对肺癌病人行开胸术后的病区镇痛管理模式的应用与效果。方法 2009年建立及运用急性疼痛服务组织,并实施包括培训医护人员、病人及家属的健康教育、预见性疼痛评估和急性疼痛护士及时镇痛反馈等方法进行疼痛护理,并与实施前肺癌开胸术病人镇痛满意度、肺部并发症、远期慢性疼痛发生率等进行比较。结果实施急性疼痛服务组织后,开胸术后病人镇痛满意度提高(P<0.01),肺部并发症、远期慢性疼痛发生率下降(P<0.01或P<0.05)。结论融合病区规范化镇痛管理模式的急性疼痛服务组织能提高病人镇痛满意度,有利于降低由于开胸手术导致的肺部并发症和急、慢性疼痛的发生率。     

Schmerztherapie mit implantierten Medikamentenpumpen bei chronischen Schmerzen

Epidural or intrathecal opiate analgesia, combined with bupivacain by means of an implanted pump, represents a possibility for providing good pain management for cancer patients as well as other chronic pain patients. Several indications, for implantation of a percutanously refillable pump are demonstrated in 27 patients. Twenty-four patients were treated with epidural and 3 with intrathecal catheters. Nineteen patients were suffering from chronic pain, and 8 had pain because of cancer. Four patients with chronic pain have been treated with continuous epidural opiate analgesia by means of an implanted pump for more than 2 years and 1 patient for more than 5 years. In the course of 2 years there has been no significant increase in the daily dose of buprenorphin given epidurally to patients with chronic pain. There were no addiction problems with opiates given epidurally or intrathecally by means of implanted pumps. Because of a 13% complication rate, pumps and epidural or intrathecal catheters should only be implanted by an experienced team.     

Severe unexplained loin pain (loin pain haematuria syndrome): management and long-term outcome

BACKGROUND: The intractable and unexplained loin pain of severe 'loin pain haematuria syndrome' (LPHS) causes great psychosocial distress and disability. AIM: To examine the psychological factors in LPHS patients who had failed to respond to non-opiate analgesia, and explore the feasibility of conservative management. DESIGN: Retrospective review of case notes, medical and GP records, with follow up. METHODS: We studied 21 consecutive patients referred from specialist renal centres to a regional pain clinic. All records were reviewed, and patients received a comprehensive psychiatric and social assessment. Medication with pain-coping strategies was emphasized, and surgical solutions were discouraged. RESULTS: Patients' median age was 43 years (range 21-64) and duration of symptoms 11 (1-34) years. Sixteen were receiving opiates, and none had enduring benefit from surgery. Patients were divisible into three groups: twelve (57%) gave a history of recurrent, unexplained symptoms involving other parts of the body (somatoform disorder); seven had chronic loin pain; dissimulation was suspected in two. At follow-up (median 42 months), eight (38%) rated their pain absent or improved. Of the 11 whose pain was the same or worse, all were on opiates and seven had a somatoform disorder. A further two patients had developed 'other' medical problems. Despite our advice, three patients underwent major surgery for pain. DISCUSSION: We recommend that patients be managed in a regional pain clinic, where a multidisciplinary approach promotes self-management of pain. Patients who were able to accept conservative treatment, and taper or withdraw opiate analgesia, had a better prognosis.     

Cancer pain management at home (II): does age influence attitudes towards pain and analgesia?

Goals of work  Older patients experience a higher prevalence of pain, including cancer pain, than other age groups and tend to receive poorer pain management. The reasons for unnecessary suffering resulting from pain among older patients are not well understood. This study aimed to identify barriers to cancer pain management for older patients living at home and to compare these with a younger control group. Patients and methods  Patients newly referred to community-based palliative care services were interviewed about their pain and related issues. Data included pain impact (BPI), mood (HAD), health (EuroQol), and barriers to reporting of pain and analgesic use (Barriers Questionnaire). Main results  Fifty-eight patients aged 75 or over and 32 people aged 60 or under were interviewed. Both groups reported that beliefs about the use of analgesics was the greatest barrier to effective pain management. Older patients reported that beliefs about the use of analgesics and communicating with medical staff were significantly more important barriers to pain management than for younger patients. Overall, factors such as communication with medical staff and fatalism were ranked lower than barriers related to medication. Younger patients reported significantly greater sleep disturbance due to pain and greater anxiety. Conclusions  Older age appears to influence attitudes towards pain and analgesia. Factors such as poorer knowledge about taking analgesia, reluctance to communicate with medical staff, poorer performance status, and being more likely to live alone suggest that older patients may require greater support in the management of their cancer pain than younger patients. Targeted interventions are needed to test this proposition.     

Effects of reflexotherapy on acute postoperative pain and anxiety among patients with digestive cancer

Even after receiving analgesia, patients with gastric and liver cancer still report moderate levels of postoperative pain. The purpose of the study was to investigate the efficacy of foot reflexotherapy as adjuvant therapy in relieving pain and anxiety in postoperative patients with gastric cancer and hepatocellular cancer. The study design was a randomized controlled trial. Data were collected from 4 surgical wards of a medical center in 2005 in Taipei, Taiwan. Sixty-one patients who had received surgery for gastric cancer or hepatocellular carcinoma were randomly allocated to an intervention (n = 30) or control (n = 31) group. Patients in the intervention group received the usual pain management plus 20 minutes of foot reflexotherapy during postoperative days 2, 3, and 4. Patients in the control group received usual pain management. Outcome measures included the short-form McGill Pain Questionnaire, visual analog scale for pain, summary of the pain medications consumed, and the Hospital Anxiety and Depression Scale. Results demonstrated that studied patients reported moderately high levels of pain and anxiety postoperatively while patients were managed with patient-controlled analgesia. Using generalized estimation equations and controlling for confounding variables, less pain (P < .05) and anxiety (P < .05) over time were reported by the intervention group compared with the control group. In addition, patients in the intervention group received significantly less opioid analgesics than the control group (P < .05). Findings from this study provide nurses with an additional treatment to offer postoperative digestive cancer patients.     

超前镇痛护理在食管癌术后病人疼痛控制中的应用

[目的]探讨超前镇痛在食管癌术后病人疼痛控制中的效果。[方法]随机将240例食管癌手术病人分为对照组组和观察组各120例,对照组实施常规镇痛护理,即术前行疼痛知识宣教,术后应用疼痛数字评价量表(NRS)评分法定时评估病人疼痛,根据评分行针对性镇痛处理;观察组在常规镇痛护理基础上,增加术前超前镇痛知识宣教,术后在执行各临床操作前行预见性疼痛评估,根据评分行预见性镇痛处理。比较两组病人术后24h,48h,72h内疼痛评分,术后肺部并发症发生率。[结果]两组病人术后疼痛程度低于对照组(P0.01),肺部并发症发生率低于对照组(P0.05)。[结论]超前镇痛可减轻食管癌病人术后疼痛程度,减少肺部并发症的发生,有利于病人早日康复。     

对护士癌痛管理认知的质性研究

目的探讨护士对癌痛管理中药物、非药物疗法的认知现状。方法采用半结构式访谈的方法,采集了10名肿瘤相关科室护士的信息,用质性研究内容分析法对资料进行分析。结果护士普遍同情癌痛患者;护士对“三阶梯止痛方案”有一定的认识和理解;在药物疗法止痛中护士主要是执行者的角色;护士对非药物疗法的认识局限;护士获取癌痛管理知识的途径较少,缺乏正规的培训和教育;医护人员及患者和家属对癌痛控制的重视程度不足、消极治疗等阻碍了癌痛管理方法的更好实施。结论目前,护士对癌痛管理仍缺乏全面的认识,癌痛管理中还有不理想的环节存在。要达到每个患者都享有无痛权利的目标,还需要全社会尤其是医护人员的进一步努力。     

The value of thorough assessment in the management of cancer pain

The number of patients likely to require management of cancer pain is increasing. However, although modern analgesia can help most patients achieve complete pain relief, some studies report widespread under-treatment of all types of pain. This paper describes approaches that health professionals can employ to ensure optimum pain management.     

Role of epidural and intrathecal narcotics and peptides in the management of cancer pain

The spinal administration of opioids may provide analgesia of long duration to patients with bilateral or midline lower abdominal or pelvic cancer pain. However, cross-tolerance to orally and parenterally administered narcotics and the rapid development of tolerance to spinal narcotics have limited their usefulness. Opioids have extensive distribution in the CSF and plasma when administered into the epidural or intrathecal space, and delivery of drug to brain stem sites may account for many of the toxic and therapeutic effects of spinal opioids. Further clinical and pharmacokinetic studies are required to provide the information regarding: the optimal opioids for use as spinal analgesics; equieffective dose ratios of spinal opioids in comparison to parenteral or oral opioids; strategies useful to forestall the development of tolerance of spinally administered opioids; the analgesic efficacy of this therapy in opioid-tolerant patients; and the role of spinally administered nonopioid analgesics in the management of cancer pain in the tolerant patient. These questions will need resolution before this therapy can be recommended for routine use in the management of cancer pain.     

Transdermal fentanyl: informed prescribing is essential.

While morphine is historically the gold standard for the management of severe cancer pain, some patients either do not achieve adequate analgesia, or suffer intolerable side-effects. For these patients an alternative opioid is recommended. One such alternative is the potent mu opioid agonist fentanyl, delivered in a transdermal controlled release formulation. Similar to morphine, transdermal fentanyl is effective for the management of moderate to severe cancer pain. However, inappropriate prescribing of transdermal fentanyl, particularly in the clinical setting of unstable pain, can cause significant opioid toxicity, as highlighted in the case reports described.     

Can regional analgesia reduce the risk of recurrence after breast cancer?: Methodology of a multicenter randomized trial

Surgery is the primary and most effective treatment of breast cancer, but minimal residual disease is probably unavoidable. Whether residual disease results in clinical metastases depends on numerous factors, including anti-tumor cell mediated immunity and angiogenic and growth signals in sites of residual disease. At least three perioperative factors adversely affect these: 1) the neuroendocrine stress response to surgery, 2) volatile anesthetics, and 3) opioids. Animal studies indicate that regional anesthesia and optimum postoperative analgesia independently reduce the metastatic burden in animals inoculated with breast adenocarcinoma cells following surgery. Retrospective studies in humans also suggest that regional analgesia may reduce recurrence risk after cancer surgery. We will test the hypothesis that local or metastatic recurrence after breast cancer surgery is lower in patients randomized to paravertebral or high-thoracic epidural analgesia combined with sedation or light anesthesia than in patients given intraoperative volatile anesthesia and postoperative opioid analgesia. In a Phase III, multi-center trial, Stage 1-3 patients having mastectomies for cancer will be randomly assigned to thoracic epidural or paravertebral anesthesia/analgesia, or to sevoflurane anesthesia and morphine analgesia. The primary outcome will be cancer recurrence. Enrolling 1100 patients over 5 years will provide 85% power for detecting a 30% treatment effect at an alpha of 0.05. We plan four equally spaced interim analyses, each evaluating efficacy and futility. Confirming our hypothesis will indicate that a small modification to anesthetic management, one that can be implemented with little risk or cost, will reduce the risk of cancer recurrence - a complication that is often ultimately lethal.     

Neuraxial analgesia for labor and birth: implications for mother and fetus

Women are better educated today on issues related to labor and childbirth. Pain management options for the woman in labor have changed dramatically over the last decade. Systemic analgesia and dense-motor-blockade regional analgesia/anesthesia have become less common for childbirth while the use of newer neuraxial and regional techniques, with minimal motor blockade, have become more popular. The shift from regional anesthesia with significant motor-blockade during labor, where the woman is a passive participant during the labor and birth, to a collaborative approach for pain management, where the woman becomes an active participant, has resulted in a new philosophy of analgesia for labor and birth. This article provides a review of current neuraxial analgesia/anesthesia techniques used for pain management in labor and birth and their implications for the perinatal nurse.