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Simplified postoperative patient-controlled analgesia on a gynecologic oncology service
GYNECOLOGIC ONCOLOGY
38, 55-58 (1990)
Simplified Postoperative Patient-Controlled Analgesia on a Gynecologic Oncology Service MICHAEL L. BERMAN, M.D.,’ GERALD G. BRIGGS, PHARM D.,* PAT BOGH, PHARM D.,* ROBERT MANNEL, ALBERTO MANETTA, M.D., AND PHILIP J. DISAIA, M.D.
M.D.,
Division qf Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine Medical Center, 101 City Drive, Orange, California 92668, and *Long Beach Memorial Medical Center, 2801 Atlantic Avenue. Long Beach, California 90801 Received
July 19, 1989
Many different PCA devices exist for pain management. In general their disadvantages include bulky size and weight, which impede early ambulation, and relatively complex programmable modules, which must be understood by the patient for their proper operation. The purpose of this study was to evaluate the usefulness of a lightweight disposable PCA device, the Travenol Infusor with Patient Control Module, which involves no programming by the patient or hospital personnel.
Twenty-nine women who underwent various abdominal operations for gynecologic malignancies self-administered postoperative analgesia by means of disposable Travenol Infusors with Patient Control Modules. Administration of morphine sulfate at a rate of 1 mg per injection and a maximum of 10 mg per hour via patient-controlled analgesia was judged satisfactory by all 29 patients. The mean dose rate administered ranged from 1.2 to 1.5 mg per hour per day during the first 3 days postoperatively. No respiratory depression occurred and excessive sedation was reported by only 2 patients after the first 24 hr postoperatively. If further surgeries were required, more than 90% of these patients would prefer patient-controlled analgesia to intramuscular injections. Q 1990AcademicPress,Inc.
MATERIALS
For this investigation, S-ml Travenol Infusors (Code 2C1073) and Patient Control Modules (Code 2C1079) were provided by Baxter Healthcare Corporation, Deerfield, Illinois. Together these form a lightweight unit which is secured to the patient’s wrist with a strap (Fig. 1). On patient demand, the infusor delivers a OS-ml bolus intravenously from an internal bladder through a filter (Fig. 2). The infusor takes 6 min to refill the bladder and if the button is pressed during this cycle the patient will receive a proportionate partial dose. This establishes a lockout interval of 6 min. Because the refill rate is constant, the dose administered per injection can be altered only by changing the concentration of narcotic being infused. Each patient was instructed in the use of the infusor 1 week preoperatively on enrollment and again just prior to surgery. Initial instruction included the use of a sample device to deliver a dose of sterile water into a receptacle. A patient information brochure was given preoperatively to further ensure postoperative understanding and compliance. Thirty-three patients were enrolled prior to abdominal operations on the Gynecologic Oncology service at Women’s Hospital of Memorial Medical Center, Long
INTRODUCTION
On many surgical services postoperative pain control has been undergoing major changes [ 1,2]. The standard approach of a decade ago, intermittent intramuscular narcotic injections either on schedule or on demand, has been replaced in many centers by patient-controlled analgesia (PCA), wherein relatively small doses of narcotic injections are self-administered intravenously by the patient when needed. The physician determines the maximum drug dose to be delivered over a reference time frame, thereby preventing narcotic overdosage. The advantages of PCA over nurse-administered intramuscular injections (im) include smoother, more steady-state pain control, less frequent patient oversedation, and reduced use of pharmacy and nursing personnel for preparation and administration of drugs [l-14]. In addition, the patient is permitted to take an active role in her own postoperative care, thereby accepting a certain measure of responsibility for her recovery. ’ To whom reprint
AND METHODS
requests should be addressed.
55 All
0090-X258/90 $ I.50 Copyright 0 1990 by Academic Press, Inc. rights of reproduction in any form reserved.
BERMAN ET AL.
56
FIG. 1. Travenol infusor and patient control module.
Beach, California. At enrollment a complete explanation of the study and PCA device was given and signature of informed consent obtained. Four patients were subsequently excluded: one whose surgery was canceled, one who was transferred to the Intensive Care Unit for an arrhythmia which occurred before initiation of PCA, and two who withdrew because of pain unrelieved by initial bolus injections prior to the use of the Travenol Infusor. Drug preparation was performed in a laminar airflow
hood under sterile conditions within 4 hr of initial patient use. The devices were filled with a 60-ml solution of 2 mg/ml morphine sulfate in 5% dextrose. Thus, a maximum of 1 mg per 6-min interval or 10 mg per hour could be infused by the patient. A replacement device was employed when the solution within the infusor was exhausted or 48 hr, whichever came first. The PCA device was filled and primed under sterile conditions and intravenous access was achieved via a 21-gauge l&in. needle through a running iv line at the port most proximal to the patient. For the study, time “0” began when analgesia was requested in the recovery room by the patient and approved by the anesthesiologist. An initial bolus of morphine sulfate 0.05 mg/kg ideal body weight was given intravenously and repeated as needed at lo-min intervals until satisfactory analgesia was achieved. Instructions in the use of the PCA device were again reviewed and all subsequent morphine injections were patient initiated. Vital signs were monitored at 15min intervals in the recovery room, hourly for 8 hr upon transfer to the ward, and every 4 hr thereafter. Each parameter-volume of drug solution infused, respiratory rate, sedation score (Table l), and pain score (Table 2)-was monitored at 4-hr intervals and evaluated independently by the study pharmacist and the patient’s nurse. The mean value of the two observations was employed in data analysis. The PCA device was continued until the patient required no further intravenous medication and was able to take oral medications. At time of discharge each patient completed a questionnaire to evaluate subjective assessment of pain relief and acceptance of the device. Patients were categorized as oversedated if the mean sedation score was 3 or greater for two consecutive daytime measurements. Patients who reported two consecutive pain rankings of 3 or higher while the infusor demonstrated over 3 mg/hr morphine use were interpreted as having achieved inadequate pain control. Pain and sedation scores less than or equal to 2 were determined to be evidence of satisfactory pain control. Respiratory depression was defined as a respiratory rate of less than 10 breaths per minute.
TABLE 1 Sedation Scores Description
FIG. 2. Patient activating intermittent infusion.
Alert Drowsy Intermittently dozing Asleep more than 50% of time Only awakens when aroused
Numerical score 1 2 3 4 5
SIMPLIFIED
PATIENT-CONTROLLED
Numerical score 24-hr period
I 2 3 4 5
No pain Mild pain Moderate pain Severe pain Very severe pain
57
DEVICE TABLE 4 Mean Daily Morphine
TABLE 2 Pain Scores Description
ANALGESIA
First” Second Third Fourth Fifth Sixth
RESULTS
Mean morphine usage h-w) 34.2 28.9 29.2 16.9 13.3 9.3
f k ik + 5
20.6 21.1 23.0 13.7 9.1 6.4
Use
Mean hourly usage (mg)
Number of patients
1.4 1.2 I.2 0.7 0.6 0.4
29 28 26 20 II 3
’ Excludes initial boluses at time 0 in recovery room.
The 29 evaluable patients ranged in age from 26 to 6.5, with a median of 47 years. Median weight was 149.6 pounds (range, 96-318) and median height 63.5 in. (range, 5.9-71.5). Racial distribution included 21 caucasians, 4 Orientals, and 4 Hispanics. Operations performed are summarized in Table 3. The mean daily morphine use varied little during the first 72 postoperative hr. from 1.4 mg/hr for the first 24 hr to 1.2 mg/hr on Days 2 and 3 (Table 4). Mean total morphine use, excluding initial boluses in the recovery room, was 106.6 mg (range, 18-375). The mean hours of PCA usage was 91.0 (range, 24-143). Ninety percent of patients (N = 26) remained on PCA for at least 72 hr. Pain control was evaluated by a simple scoring scheme (Table 2). Pain was most severe during the initial 4 hr of the study, with a mean value of 2.8. Subsequently, the mean score never exceeded 2.0. Pain scores plateaued after a progressive fall for each 24-hr interval of the first 3 days (Table 5). The declining numbers of patients on the fourth and subsequent days reflect cessation of all parenteral narcotics. All 29 patients who completed the study had satisfactory pain control as defined under Materials and Methods. Despite the relatively low hourly and daily doses of self-administered morphine, patients experienced varying degrees of narcosis. As expected, the highest mean
sedation scores occurred during the first 16 hr postoperatively, ranging from 3.4 to 2.2 for the four different observation periods. Twenty-eight percent of patients were highly sedated (score 4 or 5, Table 1) during this time. Subsequently, the highest sedation scores occurred at 2400 and 0400 hr daily. Excluding those hours during which highest sedation was expected, mean sedation scores were consistently less than 2.0. Only two patients had isolated instances of excess sedation during daytime hours after the first 16 hr postoperatively. No patients had respiratory depression as defined previously. Patient response at the poststudy exit interview revealed a high degree of satisfaction. Only 14% (N = 4) reported severe pain in the postoperative period while 93% (N = 26) said they preferred the PCA over im injections. The four patients who reported severe pain also reported relief after use of the PCA device, and indicated that they utilized the infusor less frequently than permitted. Seventy-one percent of patients (N = 20) stated that they slept well and only 18% (N = 5) indicated insomnia secondary to pain. On further questioning, 60% (N = 17) did not remember waking to give themselves a bolus of medication. Only one patient felt it was inconvenient to self-medicate during sleeping hours. Overall, 82% (N = 23) felt no redesign of the device was necessary in an effort to avoid the need for self-medication while trying to sleep.
TABLE 3 Operations Performed Procedure Radical hysterectomy with nodes Ovarian tumor debulking Abdominal hysterectomy with nodes Abdominal hysterectomy without nodes Exploratory laparotomy Colostomy Incisional hernia repair/vulvar laser Total
Number of patients 6 I 3 7 4 1 I 29
TABLE 5 Pain Score at End of Each 24-hr Interval Interval
(hr)
Mean pain score
24 48 72 96 120 144
1.7 1.5 1.2 I .3 1.4 1.0
+ 0.9 k 0.6 + 0.4 -+ 0.5 + 0.5 k 0.0
following
Surgery Number of patients 29 28 26 18 IO 2
58
BERMAN ET AL.
DISCUSSION
ACKNOWLEDGMENT
The authors thank Lanie M. Adamson, M.S., for editorial support Postoperative patient-controlled analgesia (PCA) has in the preparation of the manuscript. been evaluated in a number of studies [l-14]. Several advantages have been seen with this form of pain control over nurse-administered intramuscular or intravenous bolus medication, including reduced total drug use and REFERENCES smoother pain control with less oversedation. There are no delays in administration of analgesia, which reduces 1. Bennett, R. L., Batenhorst, R. L., Bivins, B. A., Bell, R. M., anxiety. Travenol Infusors with Patient Control ModGraves, D. A., Foster, T. S., Wright, B. D., and Griffen, W. 0. ules, unlike many other patient-controlled analgesic dePatient-controlled analgesia: A new concept of postoperative pain relief, Ann. Surg. 195(6), 700-705 (1982). vices, are lightweight and simple to use, requiring no 2. Bennett, R. L., Batenhorst, R. L., Graves, D. A., Foster, T. S., patient or hospital personnel programming. The current Baumann, T., Griffen, W. O., and Wright, B. D. Morphine titration study evaluated this device for effectiveness, patient acin postoperative laparotomy patients using PCA, Curr. Ther. Res. ceptance, and complications. 32(l), 45-52 (1982). Utilizing the previously outlined criteria, pain control 3. Rayburn, W. F., Geranis, B. J., Ramadei, C. A., Woods, R. E., was successful in all 29 patients who completed the and Patil, K. D. Patient-controlled analgesia for post-cesarean section pain, Obstet. Gynecol. 72, 136-139 (1988). study. This was accomplished with a dose rate of 1.2 to 4. Dahl, J. B., Daugaard, J. J., Larson, H. V., Mouridsen, P., Niel1.5 mg/hr, which falls within the range established by sen, T. H., and Kristoffersen, E. Patient-controlled analgesia: A previous PCA studies [9-l 11.The two patients who withcontrolled trial, Acta Anaesthesiol. Stand. 31, 744-747 (1987). drew from the study within the initial 12 hr because of 5. Gallion, H. H., Wermeling, D. P., Foster, T. S., van Nagell, J. R., poor pain control did so because good analgesia was not and Donaldson, E. S. Patient-controlled analgesia in gynecologic achieved with the initial bolus injections of the drug prior oncology, Gynecol. Oncol. 27, 247-253 (1987). to use of the infusor. 6. Graves, D. A., Foster, T. S., Batenhorst, R. L., Bennett, R. L., Analysis of sedation data reveals that 30% (N = 10) and Baumann, T. J. Patient-controlled analgesia, Ann. Intern. Med. 99, 360-366 (1983). of the patients were oversedated at some time in their I. Urquhart, M. L., Klapp, K., and White, P. F. Patient-controlled postoperative course. After excluding the first 12 hr after analgesia: A comparison of intravenous versus subcutaneous hysurgery, which may be complicated by the carryover dromorphone, Anesthesiology 69, 428-432 (1988). effect of general anesthesia, only two patients met the 8. Reedy, M. E., Morris, L. E., Brown, D. L., Snow, D., Koehl, criteria for excess daytime sedation. This translates into M., and Stone, C. K. Double-blind comparison of butorphanol and effective pain control without excessive sedation over morphine in patient-controlled analgesia, Acute Care lZ,(Suppl. 90% of the time, comparable to that for other PCA deI), 40-46 (1988). vices [12-141. The poststudy questionnaire substantiates 9 Bollish, S. J., Collins, C. L., Kirking, D. M., and Bartlett, R. H. Efficacy of patient-controlled versus conventional analgesia for this objective assessment, with 90% subjective reports postoperative pain, C/in. Pharmacol. 4, 48-52 (1985). of preference for this mode of pain control to nurse10 Graves, D. A., Batenhorst, R. L., Bennett, R. L., Wettstein, administered im or iv injections. J. G., Griffen, W. O., Wright, B. D., and Foster, T. S. Morphine This study confirms that the Travenol PCA device is requirements using patient-controlled analgesia: Influence of diurcomparable to other PCA devices with regard to pain nal variation and morbid obesity, C/in. Pharmacol. 2,49-53 (1983). control, side effects, and patient acceptance. Its use was 11. Wermeling, D. P., Foster, T. S., Rapp, R. P., and Kenady, D. E. easily taught to all patients. In addition, it represents an Evaluation of a disposable, nonelectronic, patient-controlled-analgesia device for postoperative pain, C/in. Pharmacol. 6, 307-314 inexpensive disposable system which separates it from (1987). other more complex, expensive and bulky PCA systems. Lange, M. P., Dahn, M. S., and Jacobs, L. A. Patient-controlled 12. Because the patient assumes an active role in the mananalgesia versus intermittent analgesia dosing, Heart Lung 17,495agement of postoperative pain, nursing and pharmacy 498 (1988). personnel labor is reduced, thereby making it cost ef13. Albert, J. M., and Talbott, T. M. Patient-controlled analgesia vs fective in comparison to non-PCA approaches to postconventional intramuscular analgesia following colon surgery. Dis. operative analgesia. Further studies are now needed to Colon Rectum 31, 83-86 (1988). evaluate the cost effectiveness of this device as com- 14. Nimmo, W. S., and Duthie, D. J. Pain relief after surgery, Anaesth. Intensive Care 15, 68-71 (1987). oared to other means of delivering PCA.
38, 55-58 (1990)
Simplified Postoperative Patient-Controlled Analgesia on a Gynecologic Oncology Service MICHAEL L. BERMAN, M.D.,’ GERALD G. BRIGGS, PHARM D.,* PAT BOGH, PHARM D.,* ROBERT MANNEL, ALBERTO MANETTA, M.D., AND PHILIP J. DISAIA, M.D.
M.D.,
Division qf Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine Medical Center, 101 City Drive, Orange, California 92668, and *Long Beach Memorial Medical Center, 2801 Atlantic Avenue. Long Beach, California 90801 Received
July 19, 1989
Many different PCA devices exist for pain management. In general their disadvantages include bulky size and weight, which impede early ambulation, and relatively complex programmable modules, which must be understood by the patient for their proper operation. The purpose of this study was to evaluate the usefulness of a lightweight disposable PCA device, the Travenol Infusor with Patient Control Module, which involves no programming by the patient or hospital personnel.
Twenty-nine women who underwent various abdominal operations for gynecologic malignancies self-administered postoperative analgesia by means of disposable Travenol Infusors with Patient Control Modules. Administration of morphine sulfate at a rate of 1 mg per injection and a maximum of 10 mg per hour via patient-controlled analgesia was judged satisfactory by all 29 patients. The mean dose rate administered ranged from 1.2 to 1.5 mg per hour per day during the first 3 days postoperatively. No respiratory depression occurred and excessive sedation was reported by only 2 patients after the first 24 hr postoperatively. If further surgeries were required, more than 90% of these patients would prefer patient-controlled analgesia to intramuscular injections. Q 1990AcademicPress,Inc.
MATERIALS
For this investigation, S-ml Travenol Infusors (Code 2C1073) and Patient Control Modules (Code 2C1079) were provided by Baxter Healthcare Corporation, Deerfield, Illinois. Together these form a lightweight unit which is secured to the patient’s wrist with a strap (Fig. 1). On patient demand, the infusor delivers a OS-ml bolus intravenously from an internal bladder through a filter (Fig. 2). The infusor takes 6 min to refill the bladder and if the button is pressed during this cycle the patient will receive a proportionate partial dose. This establishes a lockout interval of 6 min. Because the refill rate is constant, the dose administered per injection can be altered only by changing the concentration of narcotic being infused. Each patient was instructed in the use of the infusor 1 week preoperatively on enrollment and again just prior to surgery. Initial instruction included the use of a sample device to deliver a dose of sterile water into a receptacle. A patient information brochure was given preoperatively to further ensure postoperative understanding and compliance. Thirty-three patients were enrolled prior to abdominal operations on the Gynecologic Oncology service at Women’s Hospital of Memorial Medical Center, Long
INTRODUCTION
On many surgical services postoperative pain control has been undergoing major changes [ 1,2]. The standard approach of a decade ago, intermittent intramuscular narcotic injections either on schedule or on demand, has been replaced in many centers by patient-controlled analgesia (PCA), wherein relatively small doses of narcotic injections are self-administered intravenously by the patient when needed. The physician determines the maximum drug dose to be delivered over a reference time frame, thereby preventing narcotic overdosage. The advantages of PCA over nurse-administered intramuscular injections (im) include smoother, more steady-state pain control, less frequent patient oversedation, and reduced use of pharmacy and nursing personnel for preparation and administration of drugs [l-14]. In addition, the patient is permitted to take an active role in her own postoperative care, thereby accepting a certain measure of responsibility for her recovery. ’ To whom reprint
AND METHODS
requests should be addressed.
55 All
0090-X258/90 $ I.50 Copyright 0 1990 by Academic Press, Inc. rights of reproduction in any form reserved.
BERMAN ET AL.
56
FIG. 1. Travenol infusor and patient control module.
Beach, California. At enrollment a complete explanation of the study and PCA device was given and signature of informed consent obtained. Four patients were subsequently excluded: one whose surgery was canceled, one who was transferred to the Intensive Care Unit for an arrhythmia which occurred before initiation of PCA, and two who withdrew because of pain unrelieved by initial bolus injections prior to the use of the Travenol Infusor. Drug preparation was performed in a laminar airflow
hood under sterile conditions within 4 hr of initial patient use. The devices were filled with a 60-ml solution of 2 mg/ml morphine sulfate in 5% dextrose. Thus, a maximum of 1 mg per 6-min interval or 10 mg per hour could be infused by the patient. A replacement device was employed when the solution within the infusor was exhausted or 48 hr, whichever came first. The PCA device was filled and primed under sterile conditions and intravenous access was achieved via a 21-gauge l&in. needle through a running iv line at the port most proximal to the patient. For the study, time “0” began when analgesia was requested in the recovery room by the patient and approved by the anesthesiologist. An initial bolus of morphine sulfate 0.05 mg/kg ideal body weight was given intravenously and repeated as needed at lo-min intervals until satisfactory analgesia was achieved. Instructions in the use of the PCA device were again reviewed and all subsequent morphine injections were patient initiated. Vital signs were monitored at 15min intervals in the recovery room, hourly for 8 hr upon transfer to the ward, and every 4 hr thereafter. Each parameter-volume of drug solution infused, respiratory rate, sedation score (Table l), and pain score (Table 2)-was monitored at 4-hr intervals and evaluated independently by the study pharmacist and the patient’s nurse. The mean value of the two observations was employed in data analysis. The PCA device was continued until the patient required no further intravenous medication and was able to take oral medications. At time of discharge each patient completed a questionnaire to evaluate subjective assessment of pain relief and acceptance of the device. Patients were categorized as oversedated if the mean sedation score was 3 or greater for two consecutive daytime measurements. Patients who reported two consecutive pain rankings of 3 or higher while the infusor demonstrated over 3 mg/hr morphine use were interpreted as having achieved inadequate pain control. Pain and sedation scores less than or equal to 2 were determined to be evidence of satisfactory pain control. Respiratory depression was defined as a respiratory rate of less than 10 breaths per minute.
TABLE 1 Sedation Scores Description
FIG. 2. Patient activating intermittent infusion.
Alert Drowsy Intermittently dozing Asleep more than 50% of time Only awakens when aroused
Numerical score 1 2 3 4 5
SIMPLIFIED
PATIENT-CONTROLLED
Numerical score 24-hr period
I 2 3 4 5
No pain Mild pain Moderate pain Severe pain Very severe pain
57
DEVICE TABLE 4 Mean Daily Morphine
TABLE 2 Pain Scores Description
ANALGESIA
First” Second Third Fourth Fifth Sixth
RESULTS
Mean morphine usage h-w) 34.2 28.9 29.2 16.9 13.3 9.3
f k ik + 5
20.6 21.1 23.0 13.7 9.1 6.4
Use
Mean hourly usage (mg)
Number of patients
1.4 1.2 I.2 0.7 0.6 0.4
29 28 26 20 II 3
’ Excludes initial boluses at time 0 in recovery room.
The 29 evaluable patients ranged in age from 26 to 6.5, with a median of 47 years. Median weight was 149.6 pounds (range, 96-318) and median height 63.5 in. (range, 5.9-71.5). Racial distribution included 21 caucasians, 4 Orientals, and 4 Hispanics. Operations performed are summarized in Table 3. The mean daily morphine use varied little during the first 72 postoperative hr. from 1.4 mg/hr for the first 24 hr to 1.2 mg/hr on Days 2 and 3 (Table 4). Mean total morphine use, excluding initial boluses in the recovery room, was 106.6 mg (range, 18-375). The mean hours of PCA usage was 91.0 (range, 24-143). Ninety percent of patients (N = 26) remained on PCA for at least 72 hr. Pain control was evaluated by a simple scoring scheme (Table 2). Pain was most severe during the initial 4 hr of the study, with a mean value of 2.8. Subsequently, the mean score never exceeded 2.0. Pain scores plateaued after a progressive fall for each 24-hr interval of the first 3 days (Table 5). The declining numbers of patients on the fourth and subsequent days reflect cessation of all parenteral narcotics. All 29 patients who completed the study had satisfactory pain control as defined under Materials and Methods. Despite the relatively low hourly and daily doses of self-administered morphine, patients experienced varying degrees of narcosis. As expected, the highest mean
sedation scores occurred during the first 16 hr postoperatively, ranging from 3.4 to 2.2 for the four different observation periods. Twenty-eight percent of patients were highly sedated (score 4 or 5, Table 1) during this time. Subsequently, the highest sedation scores occurred at 2400 and 0400 hr daily. Excluding those hours during which highest sedation was expected, mean sedation scores were consistently less than 2.0. Only two patients had isolated instances of excess sedation during daytime hours after the first 16 hr postoperatively. No patients had respiratory depression as defined previously. Patient response at the poststudy exit interview revealed a high degree of satisfaction. Only 14% (N = 4) reported severe pain in the postoperative period while 93% (N = 26) said they preferred the PCA over im injections. The four patients who reported severe pain also reported relief after use of the PCA device, and indicated that they utilized the infusor less frequently than permitted. Seventy-one percent of patients (N = 20) stated that they slept well and only 18% (N = 5) indicated insomnia secondary to pain. On further questioning, 60% (N = 17) did not remember waking to give themselves a bolus of medication. Only one patient felt it was inconvenient to self-medicate during sleeping hours. Overall, 82% (N = 23) felt no redesign of the device was necessary in an effort to avoid the need for self-medication while trying to sleep.
TABLE 3 Operations Performed Procedure Radical hysterectomy with nodes Ovarian tumor debulking Abdominal hysterectomy with nodes Abdominal hysterectomy without nodes Exploratory laparotomy Colostomy Incisional hernia repair/vulvar laser Total
Number of patients 6 I 3 7 4 1 I 29
TABLE 5 Pain Score at End of Each 24-hr Interval Interval
(hr)
Mean pain score
24 48 72 96 120 144
1.7 1.5 1.2 I .3 1.4 1.0
+ 0.9 k 0.6 + 0.4 -+ 0.5 + 0.5 k 0.0
following
Surgery Number of patients 29 28 26 18 IO 2
58
BERMAN ET AL.
DISCUSSION
ACKNOWLEDGMENT
The authors thank Lanie M. Adamson, M.S., for editorial support Postoperative patient-controlled analgesia (PCA) has in the preparation of the manuscript. been evaluated in a number of studies [l-14]. Several advantages have been seen with this form of pain control over nurse-administered intramuscular or intravenous bolus medication, including reduced total drug use and REFERENCES smoother pain control with less oversedation. There are no delays in administration of analgesia, which reduces 1. Bennett, R. L., Batenhorst, R. L., Bivins, B. A., Bell, R. M., anxiety. Travenol Infusors with Patient Control ModGraves, D. A., Foster, T. S., Wright, B. D., and Griffen, W. 0. ules, unlike many other patient-controlled analgesic dePatient-controlled analgesia: A new concept of postoperative pain relief, Ann. Surg. 195(6), 700-705 (1982). vices, are lightweight and simple to use, requiring no 2. Bennett, R. L., Batenhorst, R. L., Graves, D. A., Foster, T. S., patient or hospital personnel programming. The current Baumann, T., Griffen, W. O., and Wright, B. D. Morphine titration study evaluated this device for effectiveness, patient acin postoperative laparotomy patients using PCA, Curr. Ther. Res. ceptance, and complications. 32(l), 45-52 (1982). Utilizing the previously outlined criteria, pain control 3. Rayburn, W. F., Geranis, B. J., Ramadei, C. A., Woods, R. E., was successful in all 29 patients who completed the and Patil, K. D. Patient-controlled analgesia for post-cesarean section pain, Obstet. Gynecol. 72, 136-139 (1988). study. This was accomplished with a dose rate of 1.2 to 4. Dahl, J. B., Daugaard, J. J., Larson, H. V., Mouridsen, P., Niel1.5 mg/hr, which falls within the range established by sen, T. H., and Kristoffersen, E. Patient-controlled analgesia: A previous PCA studies [9-l 11.The two patients who withcontrolled trial, Acta Anaesthesiol. Stand. 31, 744-747 (1987). drew from the study within the initial 12 hr because of 5. Gallion, H. H., Wermeling, D. P., Foster, T. S., van Nagell, J. R., poor pain control did so because good analgesia was not and Donaldson, E. S. Patient-controlled analgesia in gynecologic achieved with the initial bolus injections of the drug prior oncology, Gynecol. Oncol. 27, 247-253 (1987). to use of the infusor. 6. Graves, D. A., Foster, T. S., Batenhorst, R. L., Bennett, R. L., Analysis of sedation data reveals that 30% (N = 10) and Baumann, T. J. Patient-controlled analgesia, Ann. Intern. Med. 99, 360-366 (1983). of the patients were oversedated at some time in their I. Urquhart, M. L., Klapp, K., and White, P. F. Patient-controlled postoperative course. After excluding the first 12 hr after analgesia: A comparison of intravenous versus subcutaneous hysurgery, which may be complicated by the carryover dromorphone, Anesthesiology 69, 428-432 (1988). effect of general anesthesia, only two patients met the 8. Reedy, M. E., Morris, L. E., Brown, D. L., Snow, D., Koehl, criteria for excess daytime sedation. This translates into M., and Stone, C. K. Double-blind comparison of butorphanol and effective pain control without excessive sedation over morphine in patient-controlled analgesia, Acute Care lZ,(Suppl. 90% of the time, comparable to that for other PCA deI), 40-46 (1988). vices [12-141. The poststudy questionnaire substantiates 9 Bollish, S. J., Collins, C. L., Kirking, D. M., and Bartlett, R. H. Efficacy of patient-controlled versus conventional analgesia for this objective assessment, with 90% subjective reports postoperative pain, C/in. Pharmacol. 4, 48-52 (1985). of preference for this mode of pain control to nurse10 Graves, D. A., Batenhorst, R. L., Bennett, R. L., Wettstein, administered im or iv injections. J. G., Griffen, W. O., Wright, B. D., and Foster, T. S. Morphine This study confirms that the Travenol PCA device is requirements using patient-controlled analgesia: Influence of diurcomparable to other PCA devices with regard to pain nal variation and morbid obesity, C/in. Pharmacol. 2,49-53 (1983). control, side effects, and patient acceptance. Its use was 11. Wermeling, D. P., Foster, T. S., Rapp, R. P., and Kenady, D. E. easily taught to all patients. In addition, it represents an Evaluation of a disposable, nonelectronic, patient-controlled-analgesia device for postoperative pain, C/in. Pharmacol. 6, 307-314 inexpensive disposable system which separates it from (1987). other more complex, expensive and bulky PCA systems. Lange, M. P., Dahn, M. S., and Jacobs, L. A. Patient-controlled 12. Because the patient assumes an active role in the mananalgesia versus intermittent analgesia dosing, Heart Lung 17,495agement of postoperative pain, nursing and pharmacy 498 (1988). personnel labor is reduced, thereby making it cost ef13. Albert, J. M., and Talbott, T. M. Patient-controlled analgesia vs fective in comparison to non-PCA approaches to postconventional intramuscular analgesia following colon surgery. Dis. operative analgesia. Further studies are now needed to Colon Rectum 31, 83-86 (1988). evaluate the cost effectiveness of this device as com- 14. Nimmo, W. S., and Duthie, D. J. Pain relief after surgery, Anaesth. Intensive Care 15, 68-71 (1987). oared to other means of delivering PCA.