Articles: analgesia.
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Review Randomized Controlled Trial Clinical Trial
Randomized trial of postoperative patient-controlled analgesia vs intramuscular narcotics in frail elderly men.
Postoperative use of as-needed intramuscular narcotics is potentially hazardous in frail elderly patients. Patient-controlled analgesia (PCA) allows patients to self-administer small boluses of narcotic, allowing better dose titration, enhanced responsiveness to variability in narcotic requirements, and reduction in serum narcotic level fluctuation. Although theoretically useful, this method has not bee well studied in the elderly or medically ill. ⋯ Patients who had previously received intramuscular injections reported that PCA was easier to use and provided better analgesia. Serum morphine levels showed significantly less variability on postoperative day 1 with PCA, compared with intramuscular injections. We conclude that PCA is an improved method of postoperative analgesia in high-risk elderly men with normal mental status, compared with as-needed intramuscular injections.
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An alternative to parenteral narcotic management is the administration of analgesics into the epidural space. The recognition and prevention of complications or side effects of epidural analgesia are prime concerns in planning nursing care for these patients.
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Forty patients (ASA status I-III) recovering from major orthopedic or gynecological operations were investigated to evaluate analgesic efficacy and threshold concentrations of tramadol and its main metabolite O-demethyltramadol (M1) in serum during the early postoperative period, using patient-controlled analgesia (PCA) by means of the Abbott Lifecare Infuser. Following an individualized intravenous loading dose of 97.5 +/- 42.3 mg (mean, SD), tramadol demand doses were 20 mg with a limit of 500 mg within 4 h; the lockout time was set to 5 min. The duration of PCA was 20.5 +/- 4.8 h. ⋯ Minimum effective tramadol serum concentration (MEC) varied greatly and could be best described by a log-normal distribution (range 20.2-986.3 ng/ml, median 287.7 ng/ml). Intraindividual MEC variability was lower than intersubject variability (38.2 vs 59.1%). Median M1 concentrations were 36.2 ng/ml.
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This retrospective study was undertaken to assess the efficacy and safety of epidural morphine in providing analgesia following Caesarean section under epidural anaesthesia. The morphine was administered as a single bolus, following delivery, in doses ranging from 2 to 5 mg. The charts of 4880 Caesarean sections, performed on 4500 patients, were reviewed. ⋯ Herpes simplex labialis was recorded in 3.5 per cent of patients. Epidural morphine is thus confirmed as an effective analgesic technique post-Caesarean section with 3 mg being the optimal dose. Even in this young healthy patient population, clinically detectable respiratory depression occurs so clinical respiratory monitoring is indicated.
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The effects of epidural analgesia on first labors have been studied by Thorp and colleagues. One study has been published and is the subject of a question-and-answer discussion, presented here. ⋯ For both groups the frequency of cesarean section for fetal distress was similar (p less than 0.20), and the frequency of low Apgar scores at 5 minutes and cord blood gas values showed no significant differences. The authors concluded that "epidural analgesia in labor may increase the incidence of cesarean section for dystocia in nulliparous women".