A single blind RCT to evaluate the effect of intraoperative bupivacaine infilteration fro post operative pain relief was conducted. Observations based on the VAS and mean duration for requirement of 1st analgesic dose post operatively. Results compared with other similar studies and found that the there is significant reduction in the VAS of post operative pain and increase in the duration for requirement for the 1st dose of the analgesic postoperatively
“A Comparative Study of Bupivacaine with Dexamethasone and Bupivacaine with C...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
A single blind RCT to evaluate the effect of intraoperative bupivacaine infilteration fro post operative pain relief was conducted. Observations based on the VAS and mean duration for requirement of 1st analgesic dose post operatively. Results compared with other similar studies and found that the there is significant reduction in the VAS of post operative pain and increase in the duration for requirement for the 1st dose of the analgesic postoperatively
“A Comparative Study of Bupivacaine with Dexamethasone and Bupivacaine with C...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Le degré de relâchement musculaire en chirurgie coelioscopique de la vésicule biliaire fait partie du quotidien des discussions entre anesthésistes et chirurgiens au bloc opératoire. Au fond tous sont convaincus de l'efficacité du curare : le chirurgien qui le demande et l'anesthésiste qui pense lui à sa décurarisation.
Cette étude teste curarisation profonde versus curarisation de routine dans la chirurgie coelioscopique de la vésicule biliaire. Avec comme première question "est-ce qu'une curarisation profonde permet de travaillert avec une pression abdominable moindre?", pression dont on sait qu'elle est pourvoyeuse de douleur post-opératoire.
La réponse est que le degré de curarisation participe de façon marginale au confort du chirurgien... et ne permet pas plus fréquemment de travailler à pression abdominale basse.
Le degré de relâchement musculaire en chirurgie coelioscopique de la vésicule biliaire fait partie du quotidien des discussions entre anesthésistes et chirurgiens au bloc opératoire. Au fond tous sont convaincus de l'efficacité du curare : le chirurgien qui le demande et l'anesthésiste qui pense lui à sa décurarisation.
Cette étude teste curarisation profonde versus curarisation de routine dans la chirurgie coelioscopique de la vésicule biliaire. Avec comme première question "est-ce qu'une curarisation profonde permet de travaillert avec une pression abdominable moindre?", pression dont on sait qu'elle est pourvoyeuse de douleur post-opératoire.
La réponse est que le degré de curarisation participe de façon marginale au confort du chirurgien... et ne permet pas plus fréquemment de travailler à pression abdominale basse.
Evaluation of Effect of Low Dose Fentanyl, Dexmedetomidine and Clonidine in S...iosrjce
In the present study effect of intrathecal hyperbaric Bupivacaine 0.5% with low doses of Clonidine
or Fentanyl or Dexmedetomidine were compared in elective lower abdominal surgeries. This was a prospective
randomized control trial. 90 patients belonging to ASA 1 &II, aged between 20-50 years were allocated into
three groups. Group-C: Clonidine 30µg, Group-D: Dexmedetomidine 5 µg, Group-F: Fentanyl 25 µg. The
onset of sensory blockade was comparable in all the three groups. The onset of motor blockade was earlier by
about 1.3 mins in Dexmedetomidine group when compared to Clonidine and Fentanyl group. Duration of
sensory blockade was prolonged in Dexmedetomidine group (346mins) when compared to Clonidine (300mins)
and Fentanyl (302mins) group. Time duration of motor blockade was prolonged in Dexmedetomidine group
(269mins) when compared to Clonidine (223mins) and Fentanyl (220mins) group. The haemodynamic
parameters were clinically and statistically insignificant The time of first request for analgesics by the patients
was more in Dexmedetomidine group (250mins) when compared to Clonidine (194mins) and Fentanyl
(189mins) group. The use of intrathecal Dexmedetomidine as an adjuvant to Bupivacaine is an attractive
alternative to Fentanyl or Clonidine for long duration surgical procedures due to its profound intrathecal
anesthetic and analgesic properties combined with minimal side effects.
A Prospective comparative study of Local anaesthesia & Spinal anaesthesia for...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
ORIGINAL ARTICLE HIP - ANESTHESIAA randomized controlled.docxgerardkortney
ORIGINAL ARTICLE � HIP - ANESTHESIA
A randomized controlled trial of postoperative analgesia following
total knee replacement: transdermal Fentanyl patches
versus patient controlled analgesia (PCA)
M. J. Hall1 • S. M. Dixon2 • M. Bracey3 • P. MacIntyre4 • R. J. Powell3 •
A. D. Toms3
Received: 13 November 2014 / Accepted: 12 February 2015 / Published online: 11 March 2015
� Springer-Verlag France 2015
Abstract
Background This randomized controlled trial compared a
standard patient controlled analgesic (PCA) regime with a
transdermal and oral Fentanyl regime for post-operative
pain management in patients undergoing total knee
replacement.
Methods One hundred and ninety-six patients undergoing
total knee replacement were recruited. Pre- and post-op-
eratively Visual Analogue Score (VAS), Oxford Knee
Score, Health Anxiety and Depression Score and Brief Pain
Inventory Score were completed. According to the day 1,
VAS score patients were randomly allocated to either a
PCA regime or a Fentanyl transdermal/oral regime. Patient
reported outcomes were measured until the patients were
discharged.
Results The results demonstrate that in terms of analgesic
effect, day of discharge and side effect profile the two
regimes are comparable.
Conclusions We conclude that a Fentanyl transdermal
regime provides adequate analgesic effect comparable to a
standard PCA regime in conjunction with a low side effect
profile. Using a transdermal analgesic system provides ef-
ficient continuous delivery enabling a smooth transition
from hospital to home within the first week. Transdermal
Fentanyl provides an alternative analgesic regime that can
provide an equivalent analgesic effect so as to enable a
satisfactory outcome for the patient in terms of function
and pain.
Level of evidence II.
Keywords Total knee replacement � Post-operative
analgesia � Patient controlled analgesia � Fentanyl patches
Introduction
Knee replacement surgery has proved a successful and
cost-effective method for relieving pain and restoring
function in patients with osteoarthritis [1]. However, pain
management after knee replacement surgery remains a
significant problem, with patients reporting this as a major
concern prior to surgery [2]. Implementing relevant pre-
operative screening methods may facilitate the identifica-
tion of individuals at high risk of experiencing high post-
operative pain [3]. Despite recent advances in the aetiology
of pain, improved pain treatments and the development of
clinical guidelines for pain assessment, the under-treatment
of post-operative pain remains a challenge to both surgeon
and anaesthetist. Recent studies have clearly demonstrated
that patient satisfaction following total knee replacement is
multifactorial with the most significant predictor of dis-
satisfaction being a painful total knee replacement [1].
Providing effective pain relief in the post-operative pe-
riod is essential to enable early mobili.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
How to Give Better Lectures: Some Tips for Doctors
Anestesia 2
1. burns 34 (2008) 929–934
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns
Patient controlled sedation using a standard protocol for
dressing changes in burns: Patients’ preference, procedural
details and a preliminary safety evaluation§
Andreas Nilsson a,*, Ingrid Steinvall b, Zoltan Bak b,c, Folke Sjoberg b,c,d
¨
a
Department of Anesthesiology and Intensive Care, Division of Perioperative Medicine, Linkoping University Hospital,
¨
581 85 Linkoping, Sweden
¨
b
The Burn Unit, Department of Hand and Plastic Surgery, Linkoping University Hospital, 581 85 Linkoping, Sweden
¨ ¨
c
Department of Intensive Care, Linkoping University Hospital, 581 85 Linkoping, Sweden
¨ ¨
d
Faculty of Health Sciences, Department of Biomedicine and Surgery, Linkoping University Hospital, 581 85 Linkoping, Sweden
¨ ¨
article info abstract
Article history: Background: Patient controlled sedation (PCS) enables patients to titrate doses of drugs by
Accepted 10 April 2008 themselves during different procedures involving pain or discomfort.
Methods: We studied it in a prospective crossover design using a fixed protocol without
Keywords: lockout time to examine it as an alternative method of sedation for changing dressings in
Alfentanil burned patients. Eleven patients with >10% total burn surface area (TBSA) had their
Anesthesia dressings changed, starting with sedation by an anaesthetist (ACS). The second dressing
Burns change was done with PCS (propofol/alfentanil) and the third time the patients had to
Propofol choose ACS or PCS. During the procedures, data on cardiopulmonary variables, sedation
Patient controlled sedation (bispectral index), pain intensity (VAS), procedural details, doses of drugs, and patients’
Sedation preferences were collected to compare the two sedation techniques.
Results: The study data indicated that wound care in burned patients is feasible with a
standardized PCS protocol. The patients preferred PCS to ACS on the basis of self-control,
and because they had less discomfort during the recovery period. Wound care was also
considered adequate by the staff during PCS. No respiratory (respiratory rate/transcuta-
neous PCO2) or cardiovascular (heart rate/blood pressure) adverse events were recorded at
any time during any of the PCS procedures. The doses of propofol and alfentanil and BIS
index decrease were less during PCS than ACS. Procedural pain was higher during PCS but
lower after the procedure.
Conclusion: We suggest that PCS using a standard protocol is an interesting alternative to
anaesthetist-provided sedation during dressing changes. It seems effective, saves
resources, is safe, and at same time is preferred by the patients. The strength of these
conclusions is, however, hampered by the small size of this investigation and therefore
further studies are warranted.
# 2008 Elsevier Ltd and ISBI. All rights reserved.
§ ¨
The study was performed at the Burn Unit, Department of Hand and Plastic Surgery, Linkoping University Hospital, Ostergotland
¨ ¨
County Council.
* Corresponding author. Tel.: +46 13 22 1834; fax: +46 13 22 2836.
E-mail address: andreas.nilsson@lio.se (A. Nilsson).
0305-4179/$34.00 # 2008 Elsevier Ltd and ISBI. All rights reserved.
doi:10.1016/j.burns.2008.04.002
2. 930 burns 34 (2008) 929–934
1. Introduction enrolled in a prospective exploratory study at the National
Burn Centre at Linkoping University Hospital, Linkoping,
¨ ¨
Patients with severe burns have severe pain and anxiety, Sweden.
which have both psychological and physical effects for the Inclusion criteria were: need for analgesia and sedation for
recovery process [1]. Pain for these patients is elicited not at least two consecutive dressing changes. Patients with
only from the trauma event, but is also the result of injures of more than 10% or more than 5% full thickness was
repeated procedures, dressing changes and physiotherapy. asked to participate. Exclusion criteria were ASA III–V, burned
These procedures are repeated, and often lead to appreci- hands (because of difficulties in using the PCS device) or
able pain, and they emphasise the need for advanced difficulties in communication or understanding of the proce-
strategies for the treatment of pain [2]. Morphine, fentanyl, dure. Four patients entered the study but did not fulfil the
and alfentanil are commonly used opioids that provide protocol because only one or two dressing changes were
continuous, analgesia during and after the operation and needed that required analgesia and sedation.
the intravenous route is often preferred for rapid pain The study was designed as a single-centre, single-case,
control. Self-titration of morphine (patient controlled crossover, controlled study. Patients were their own control
analgesia; PCA) has been suggested as an important group, because they started with dressing changes under
technique to meet the increasing and high requirement sedation by an anaesthetist (ACS, FS or ZB; anesthesiologists
for opioids [3]. Successful pain management requires that with 10 years experience of burn care) using routine sedating
pain is regularly assessed and its intensity evaluated as, for techniques. While the patient breathed oxygen and air,
example by a visual analogical scale (VAS), and adequate sedation and analgesia were accomplished with intermittent,
pain relief must be provided accordingly [4]. Wound care intravenous propofol (Propofol-1Lipuro 10 mg/ml, Braun) and
and dressing changes are associated not only with pain, but fentanyl (Fentanyl1 0.05 mg/ml, Braun). The second dressing
with factors that are also known to affect the experience of change was done using PCS as described below. At the third
pain such as anxiety and loss of self-control. The ther- dressing change the patients were asked to choose one of the
apeutic challenge is to find methods that control pain and two techniques.
relieve anxiety and at the same time avoid over-sedation During the sedation procedures a protocol was used to
and a delayed recovery [1]. collect cardiopulmonary data (heart rate, non-invasive blood
Patient controlled sedation (PCS) has received increasing pressure, saturation, and respiratory rate). Transcutaneous
interest when it has been used to improve the conditions of PCO2 were collected using TCM3—TINA (Radiometer, Copen-
patients having painful or unpleasant procedures such as hagen, Denmark). Intensity of pain was assessed using a 11-
lithotripsy, colonoscopy, or dental procedures [5–7]. It is point visual analogue scale (VAS) when patients were able to
important also to others that the patient controlled sedation answer during the procedure, after finishing the dressing
technique has been used in these settings (lithotripsy, changes, and 10 min later. Complications were recorded,
dental, colonoscopy) without anesthesia-trained personnel. whether it was possible to treat the wounds adequately (yes
Presently, in clinical practice at our hospital, lithotripsy is or no), and the duration of treatment. The bispectral (BIS)
done using a propofol-based PCS technique without index was monitored using the A-2000 BISTM system (Aspect
anesthesia-trained personnel. The procedure is based on Medical Systems, Natick, MA, USA). The recording of all these
European Guidelines for sedation and/or analgesia by non- variables started before the onset of sedation and every 3 min
anaesthesiology doctors [8]. In patients with burns we are during the procedure, and up to 30 min afterwards. If a lower
aware of only one dose-finding study that attempted to use BIS index appeared on the display between measurement
it as an alternative to traditional ways of giving analgesics points, the lowest observed index was recorded. Within 2 h of
and sedatives [9]. completion of the dressing change, each patient was asked
The present study was designed to compare PCS, based on a about how they experienced the sedation and the awakening
standard protocol, with routine sedation provided by anaes- from it.
thetists, to assess the feasibility of PCS for adequate dressing
changes, and also to assess patients’ preferences. Close 2.2. Patient controlled sedation
surveillance of respiratory (respiratory rate/transcutaneously
assessed PCO2) and cardiovascular (heart rate/mean arterial One hour before the dressing change all patients were given
pressure) data were measured as an estimate of safety, as the their regular daytime analgesics. These comprised: acetami-
aim is to, in the future and after further refinement, to nophen (Panodil1 1 g, GlaxoSmithKline Healthcare) and a
implement this strategy in the care of patients with burns long-acting opioid, Oxycodone (Oxycontin1 between 5 and
without using specifically trained anaesthesia personnel. 40 mg). Before the start of the procedure or the anticipated
pain the patients were asked to give sedation or analgesia by
the PCS device whenever they felt pain or anxiety. Anticipated
2. Patients and methods painful events were predicted during the procedure and
conveyed to the patients so that they could prepare them-
2.1. Study overview selves by giving analgesia and sedation.
Propofol, 20 mg/ml (Propofol-1Lipuro 20 mg/ml, Braun,
After approval from the local ethics committee and informed Sweden) and alfentanil 0.5 mg/ml (Rapifen1 0.05 mg/ml,
consent of the patients, 11 patients with ASA I or II scores with Janssen-Cilag, Sweden) were mixed to 14.8 mg/ml of propofol
burns exceeding 10% total burn surface area (TBSA) were and 0.13 mg/ml of alfentanil in the final solution. A bag
3. burns 34 (2008) 929–934 931
Table 1 – Details of the patients
Patient TBSA Age ACS PCS
Time Propofol Morphine Time Propofol Morphine
1 15 74 64 325 10 74 153 10
2 35 32 69 500 40 85 282 18
3 12 51 91 480 20 52 140 9
4 12 82 33 170 10 50 89 5
5 15 67 81 234 10 62 195 12
6 18 23 130 632 25 60 271 17
7 16 77 82 320 15 113 191 12
8 10 68 65 395 15 50 164 10
9 8 62 44 412 15 56 102 6
10 19 59 56 490 20 78 173 11
11 20 38 47 385 25 63 369 23
Mean 16.4 57.5 69.3* 394.8** 18.6*** 67.5* 193.5** 12.1***
S.D. 7.2 19.3 26.7 130.7 9.0 19.0 83.5 5.3
ACS = anaesthetist controlled sedation; PCS = patient controlled sedation.
The doses of propofol and alfentanil were given during ACS and the first PCS.
Values as mean and standard deviation (S.D.). Doses in milligrams and time in min. Total burned surface area (TBSA).
*P = 0.859 (NS); **P = 0.003; ***P = 0.007. Statistical differences are shown between propofol and morphine.
containing the mixture was connected to an electromecha- 3. Results
nical pump (Graseby 9300 PCS, Graseby Medical Ltd., Watford,
UK). Each time the button was pushed, the patient received 3.1. Details of patients (Table 1)
0.3 ml of the mixture, equivalent to 4.44 mg propofol and
0.039 mg alfentanil. No lockout period was used, which All the patients started the study with ACS followed by at least
resulted in a quantity of 22.2 mg propofol and 0.20 mg two PCS. Ten of the 11 patients preferred to continue dressing
alfentanil possible to give in 1 min. changes using PCS after the first ACS and PCS. One patient was
For comparison and calculations the analgesic doses that of indifferent to the techniques but finally chose PCS.
alfentanil was multiplied by a factor of 7, resulting in
equipotent doses of morphine. Doses of fentanyl were multi- 3.2. Cardiopulmonary and surveillance data
plied by the factor of 100 [10]. (Fig. 1 and Table 2)
2.3. Data analysis and statistics Differences were found for SpO2, BIS, and transcutaneous
PCO2, between ACS and PCS. PCS gave higher mean SpO2
Data are presented as either mean (S.D.) or median (inter- concentrations, but lower PCO2, and less sedation according to
quartile range). For the statistical analysis we used Statis- BIS monitoring.
tica1 Version 6.1 (Stat Soft, Inc., Tulsa, USA). To assess During ACS there was a slight decrease in saturation (<90%)
differences between groups we used the Wilcoxon Matched in two cases, the lowest respiratory rate was 8, and a lowest
Pairs Test. Changes over time in surveillance data between BIS index was 48. Blood pressure (MAP) was reduced during
ACS and all PCS procedures were evaluated by repeated both techniques, the lowest values being between 50 and 68%
measures ANOVA. Values of P < 0.05 were accepted as of baseline. Equivalent data during PCS showed no saturation
significant. value lower than 94% and no respiratory rate less than 10. The
Table 2 – Cardiopulmonary data and sedation data during ACS and PCS
ACS PCS Statistical differences (P)
Mean (S.D.) Min–Max Mean (S.D.) Min–Max
SpO2, % 98 (3) 84–100 99 (2) 94–100 0.032
RR 14 (2) 8–17 16 (5) 10–30 0.707
PtcCO2 (kPa) 5.3 (0.4) 4.5–6.2 5.2 (0.5) 4.0–6.2 0.004
BIS index 84 (11) 48–99 93 (5) 67–99 0.027
HR 80 (11) 56–118 80 (11) 65–102 0.686
MAP (mmHg) 70 (15) 33–110 83 (11) 58–115 0.663
ACS = anaesthetist controlled sedation; PCS = patient controlled sedation.
Values as mean and standard deviation (S.D.).
Lowest and highest values recorded are presented as Min and Max.
RR = respiratory rate, PtcCO2 = transcutaneous carbon dioxide, BIS index = bispectral index, HR = heart rate and MAP = mean arterial pressure.
4. 932 burns 34 (2008) 929–934
Fig. 3 – Capacity of the pump in comparison with the
patients with the highest demands. The doses are
presented accumulated from start to the last received
dose. Time (min) is from start.
Fig. 1 – BIS index during ACS (sedation controlled by
anaesthetist) and patient controlled sedation (PCS).
given the doses. The capacity of the pump in relation to the
patients with high dose demands is shown in Fig. 3.
lowest MAP recordings were within 60 and 96% of baseline. 3.4. Procedure rating by personnel
Reduction in the BIS index also occurred during PCS with six
recordings less than 80. After dressing changes, wound care personnel said that in all
cases, during ACS and PCS, sedation was adequate and, wound
3.3. Amount of drug given (Table 1 and Fig. 2) care conditions was good. Two surgeons indicated, however,
that cleansing of the wounds could have been better on two
During PCS all patient requested lower doses of propofol and occasions during PCS.
morphine (193.5 (83.5) and 12.1 (5.3) mg mean (S.D.)) than they
were given by the anaesthetist during ACS (394.8 (130.7) and 3.5. Pain ratings (Table 3)
18.6 (9.0) mg). There was no difference in duration of
procedure between PCS (67.5 (19.0) min) and ACS (69.3 The highest mean (S.D.) pain ratings recorded, during wound
(26.7) min). treatment were greater for PCS (4.9 (2.4)) than for ACS (1.5
During PCS procedures, four patients had a third or less of (1,0)). Immediately and 10 min after dressing changes there
the required doses. The remaining seven patients had more were no differences.
than 40% of required doses. Two of the four patients given less
than a third of the doses given were not satisfied with the
capacity of the pump, although PCS overall was preferred. The 4. Discussion
nine remaining patients were satisfied with how they were
The new finding of this study is that PCS, using a standard
technique with a fixed protocol comprising the drugs propofol
and alfentanil, can be used successfully as an alternative to
ACS for wound care in burned patients. When patients chose
between PCS and ACS, they chose PCS and truly preferred
being in charge of their sedation instead of relying on
somebody else. Although comparable data are lacking for
burns, previous studies indicated a preference for PCS during
other painful or unpleasant procedures [6,7]. A sense of
control, together with a more rapid and less unpleasant
recovery, together with the remaining possibility of deeper
sedation if necessary were reasons given for the choice of PCS
in the present study.
4.1. The procedure and pain
With a patient who can communicate, those who are caring
Fig. 2 – Doses of propofol given by anaesthetist (ACS) for the wounds informed them if unpleasant or painful
compared with the doses requested by the patients (PCS) moments were to be expected, which gives them time to give
during the first PCS. the sedation and analgesia properly as described previously
5. burns 34 (2008) 929–934 933
Table 3 – Intensity of pain evaluated with visual analogue scale (VAS)
Patient ACS PCS
VAS max VAS min 0 VAS min 10 VAS max VAS min 0 VAS min 10
1 2 4 4 5 3 0
2 0 7 3 8 5 3
3 0 4 1 4 1 1
4 0 0 0 1 0 0
5 2 0 0 3 0 0
6 2 3 1 6 1 1
7 2 0 0 3 0 0
8 2 6 3 8 4 2
9 3 2 2 5 4 2
10 2 2 2 3 3 1
11 1 1 0 8 2 0
Mean 1.45* 2.64** 1.45*** 4.91* 2.09** 0.91***
S.D. 1.04 2.42 1.44 2.39 1.81 1.04
ACS = anaesthetist controlled sedation; PCS = patient controlled sedation.
Values as mean and standard deviation (S.D.).
Maximum pain score (VAS max in table) represent highest pain experienced during changing dressings and VAS min 0 is the pain intensity
immediate after treatment. 10 min after dressing change pain intensity was again asked for (VAS min 10).
*P = 0.003; **P = 0.234; ***P = 0.109.
[6]. As this was the first series of PCS in this unit, the procedure present sedation. PCS itself is a factor in the satisfaction
might be refined further as personnel get more acquainted among patients having cataract surgery, whether they did use
with the technique. We noticed that although special the pump with propofol or not [11] which in some way may
emphasis was placed on preparing the patients and predicting contribute to acceptance of the pain recorded in our study.
painful events, this was at times missed and may together
with the sometimes impatient behaviour of the personnel 4.2. Safety
explain the intermittently high VAS scores recorded during
care of the wound and PCS. Astonishingly, despite the high Despite the fact that this study used propofol and alfentanil in
VAS reported, it did not seem to affect the patients overall concentrations higher than evaluated previously [6,7,11,12]
judgement of the technique. To optimise the procedure, and a device without a lock out time, PCS was accomplished
therefore, further training may lead to less pain without the without extreme values in cardiopulmonary or BIS data. The
need to change the doses of any drugs. The finding that the patients were monitored closely and were given supplemen-
length of the procedures done by ACS and PCS did not differ tary oxygen and it is therefore unlikely that any adverse
also suggests that PCS was adequate. reaction has been overlooked. In all, we recorded no single
We made an interesting, new discovery during this trial. In value that indicated compromise of breathing or circulation.
all patients verbal complaints of pain (with corresponding The fact that the corresponding decrease in the BIS index was
higher VAS scores) were not always accompanied by pressure also minor supports this further. One must, however, be
on the button to release the drug. There seemed to be cautious about the strength of this conclusion, as the number
cognitive dysfunction with the present drugs and protocol of patients was small.
where, despite patients verbally complaining of pain, they The smaller amounts of analgesic and sedative used in the
were unable to process that into the action of providing study is probably the explanation for there being fewer
themselves with more of the drug. No extra doses were given symptoms of sedation after the procedure, which also
by any bystander. explains the lack of effects on circulation and breathing.
The high scores for pain recorded, and which seem
unreasonably high, argues for more analgesic. This could 4.3. Sedation effects
theoretically be accomplished either by increasing the dose of
alfentanil given by PCS or by the supplementation of a longer- BIS monitoring was used to acquire objective data about the
acting analgesic at the start of the procedure. This must to be state of sedation, instead of using sedation scales, which often
examined further. We must point out that not a single patient involve some interactivity with the patient [7]. BIS indexes
reached the maximum capacity of the pump; however, at the were collected during the procedure with no major distur-
same time it is difficult to give the maximum dose as there is a bances. The position of the patient’s head must be still and
hidden lockout time during which the pump delivers a dose controlled as the BIS monitor detects muscular movement,
already requested. An alternative is to increase the volume of and the signal quality may then be affected. We had few such
alfentanil, but that will only be achieved with less propofol, problems. BIS monitoring has been evaluated with propofol
which will result in reduced sedation (given that the Graseby sedation and is a good predictor of the level of sedation [13].
pump as presently sold commercially delivers only a fixed However, there is a lag time between decreasing values and
maximum volume). As far as we know patients appreciate the the outcome of an observer’s assessment [14]. As the purpose
6. 934 burns 34 (2008) 929–934
was not to delineate minor changes but rather to establish work. This study is performed on clinical basis of the Burn
sedation levels, mainly for the group using PCS, we do not Unit, with no external influence.
think that this has an impact on the interpretation of our
results. As for PCS, few values were recorded below 80%,
references
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lowest values were present during ACS, which has been a
common finding by other authors who compared ASC and PCS
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