Epidural catheter analgesia for the management of postoperative pain.
ABSTRACT Since its introduction to North America in 1942, the use of epidural catheter analgesia has increased dramatically. Improved equipment, methods and medications have broadened its application to include among others, surgical anesthesia, chronic pain relief and the management of postoperative pain. Numerous techniques for epidural puncture and insertion of the catheter have been described. Although complications have been associated with placement of an epidural catheter, these are rare when performed by an experienced anesthesiologist. Epidural analgesia was first accomplished by blockade with local anesthetics. Bupivacaine has been called the local anesthetic of choice for epidural infusion. Bolus administration of epidural local anesthetics gives effective analgesia; however, its use is limited by brief duration and occasionally severe hypotension. Epidural local anesthetics have been administered by continuous infusion in an attempt to minimize side effects. Nevertheless, hypotension, as well as motor block, numbness, nausea and urinary retention have occurred. Epidural analgesia with local anesthetics is effective in relieving postoperative pain, but its safety and feasibility have been questioned because of the frequent, potentially serious side effects. These problems led to trials of epidural narcotics for postoperative pain management. The exact site of action of epidural narcotic analgesics is debatable; however, the bulk of evidence supports a direct spinal action. Epidural narcotics appear to specifically inhibit nociceptive stimuli. The prolonged and profound analgesia that occurs with epidural narcotics relative to parenteral administration is due to a higher concentration of drug reaching the CSF through the epidural route. Since nervous transmission is not completely blocked this technique cannot provide anesthesia during operation. Morphine has been the most frequently used narcotic for epidural analgesia. Results of several recent, randomized double-blind studies have shown that epidural narcotics give adequate analgesia comparable with that observed with epidural bupivacaine. Epidural morphine provides a greater duration of analgesia and may cause fewer side effects. Improved analgesia has been reported when epidural narcotics are used in combination with local anesthetics. Continuous administration of low dosage epidural narcotics has been shown to have less frequent side effects than bolus administration. Nevertheless, pruritus, urinary retention, hypotension and severe respiratory depression have been reported with both methods.(ABSTRACT TRUNCATED AT 400 WORDS)
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ABSTRACT: The influences of premedication, anaesthetic agents, and postoperative sedation and pain treatment regimens on the experiences of postoperative respirator treatment of surgical patients (n= 107) have been assessed. Of the patients, 55% recalled the respirator treatment. Administration of anticholinergic drugs and halogenated anaesthetic agents was found to impair the memory process and reduce the number of recallers, and sedation in the ICU with benzodiazepines was found to decrease the number of discomforts experienced by the recalling patients. Most of the patients who received treatment postoperatively for pain, mainly by epidural administration of local anaesthetic agents and/or morphine, recalled the respirator treatment period (85%), as compared to only 50% of the patients receiving intravenous opioids. The number and type of complaints experienced by patients receiving epidural pain treatment did not, however, differ from those reported by intravenously treated patients, and no significant adverse psychological reactions seemed to occur. It is concluded that the use of mainly regional techniques, when appropriate, for pain treatment of surgical patients needing postoperative ventilatory support seems advantageous. The primary aim of relieving pain from the wound area is achieved, allowing such light intravenous sedation and pain treatment that the possibility of communication and giving comforting reassurance is maintained. Such nursing care may be more efficient in helping the patient to cope with the stressful respirator treatment situation then heavy intravenous sedation and pain treatment regimens.Acta Anaesthesiologica Scandinavica 12/2008; 34(7):557 - 562. DOI:10.1111/j.1399-6576.1990.tb03145.x · 2.31 Impact Factor
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ABSTRACT: The postoperative care of seriously injured trauma patients can be challenging and frustrating, yet very satisfying. Recent advances in critical care have been spurred on by improvements in technology, as well as by refinements of our understanding of the basic sciences such as physiology, microbiology, pharmacology, and molecular biology. As the prehospital and initial hospital care of injured patients improves, the role of postoperative care in reducing postinjury mortality is expected to expand. Improved care in intensive care units (ICUs) may contribute to decreases in preventable trauma death rates, particularly in regionalized trauma centers.12, 13 and 75 Because postoperative complications are the rule rather than the exception in severely injured patients, anesthesiologists and surgeons caring for critically ill trauma victims in the postoperative period must be vigilant and prepared to diagnose and treat problems as they arise.This article reviews current concepts in the “routine” postoperative care of the trauma patient and in the management of some of the more common postoperative complications. The reader is encouraged to consult other sources for more thorough discussions of this topic, including trauma in elderly, pregnant, or pediatric patients.42, 49, 67, 68 and 71Anesthesiology Clinics of North America 03/1996; 14(1):239-256. DOI:10.1016/S0889-8537(05)70397-7