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Biomedical subjects

M A Ashburn

Publications and source records attributed to M A Ashburn.

36 records · Page 2Linked to original sources
PubMed1993

Oral transmucosal fentanyl citrate (OTFC) for the treatment of postoperative pain.

Oral transmucosal fentanyl citrate (OTFC) has been used in a variety of clinical situations. This study was designed to determine if OTFC could provide analgesia to patients with acute pain after major surgery. Following written informed consent, 38 ASA Physical Status I-III patients undergoing either a total hip replacement or total knee arthroplasty were studied prospectively. The patients were randomly allocated to receive either OTFC (7-10 micrograms/kg) or a placebo identical in appearance to an OTFC unit. General anesthesia was administered for surgery, and patient-controlled analgesia (PCA) with morphine was initiated in all patients. The PCA interval dose was adjusted to provide adequate analgesia as determined by the patient and physician; the PCA lock-out time was not changed. On the morning after surgery, the most recent 12 h of PCA data (milligrams per hour of morphine and PCA attempts per hour) were recorded. OTFC or placebo units were administered at times 0, 4, and 8 h during a 12-h study, resulting in three identical units being completely consumed. PCA data, as well as incidence and severity of any adverse side effects, were recorded during the study and for the next 12 h. Treatment groups were compared for similarity, and study variables were analyzed. Twenty-eight patients completed the study, 13 in the control group and 15 in the OTFC group. There were no significant differences between the study groups as to patients' age, gender, ASA classification, or surgical procedure. In addition, there were no differences between the groups in the number of PCA attempts or delivered dose of morphine during the prestudy or poststudy periods.(ABSTRACT TRUNCATED AT 250 WORDS)

Administration, Oral↗
PubMed1993

Management of pain in the cancer patient.

The pain experience of the cancer patient is the result of many factors, including nociceptive sources, specific pain syndromes, and behavioral contributions. Careful evaluation of the patient is necessary to identify the contributors to the patient's pain experience and to select treatment modalities which address the underlying causes. For patients who are experiencing poorly controlled pain as a result of cancer, therapy often includes multiple management strategies involving more than one discipline. Therefore, an interdisciplinary approach may be more useful for pain management. Disciplines and specialties. involved in such care commonly include anesthesiologists, oncologists, psychiatrists, psychologists, physical therapists, pharmacists, nurses, and social workers. The locus of control often influences how patients respond to their physicians' advice. Patients with a strong internal locus of control usually want to participate actively in treatment decisions. Such patients often resent having decisions made about their treatment without their participation. A lack of sense of control can exacerbate such patients' pain and limit compliance with recommended treatments. Drug therapy is the mainstay of cancer pain management. The therapy should be individualized to the patient, and medications should be selected for specific indications. The WHO three-step analgesic ladder should be used as a guide in selecting analgesics. Drugs should be administered by mouth unless it is impossible to do so, and drug costs should be considered when selecting analgesic medications. Doses should be titrated to response. Adjuvant drug therapy should be considered early and implemented when indicated. Practitioners should be familiar with the medications prescribed and be alert for the appearance of adverse side effects. Patients should be monitored and reassessed continuously. A thorough diagnostic work-up should be completed for new symptoms when indicated. For patients with specific pain syndromes, or for whom drug therapy has not been successful, local anesthetic and neurolytic block therapy and more invasive drug delivery systems (e.g., epidural catheters) should be considered. Although cure may not be attainable in many cancer patients, the obligations of health professionals to these patients are no less than to patients for whom a cure is achievable. Effective pain management has a profound impact on the quality of life, and may give the patient the opportunity to face death with dignity and reduced suffering.

Humans↗
PubMed1992

Iontophoretic delivery of morphine for postoperative analgesia.

Iontophoresis is a method of transdermal administration of ionized drugs in which electrically charged molecules are propelled through the skin by an external electrical field. This was a prospective, randomized, single-blind study to determine the effectiveness of iontophoretically delivered morphine HCl for the control of postoperative pain. Thirty-eight patients who underwent total knee or hip replacement completed this clinical trial. Informed consent was obtained before surgery and patients were instructed on the use of a patient-controlled analgesia (PCA) device. Postoperatively, pain in the recovery room was initially controlled with IV meperidine, and thereafter with PCA therapy using meperidine, 2 mg/cc, with a dose of 10 mg IV and a lock-out period of 15 min. The dose was adjusted as necessary and the lock-out period remained the same. The number of patient requests and the dose (mg) administered was recorded hourly. On the morning following surgery, iontophoresis devices were attached for 6 hr to patients who received either morphine HCl or lactated ringers solution. During this period and for 12 hr following completion of iontophoresis, PCA analgesia remained available to patients. Venous blood samples for determination of morphine levels were obtained every 30 min during iontophoresis, then every 60 min for 2 hr following iontophoresis. Of the 38 patients, 17 received iontophoresed morphine, and 21 received iontophoresed lactated ringers. The morphine group utilized the PCA device more than the control group during the baseline period. However, following the institution of iontophoresis and continuing up to 12 hr following completion of iontophoresis, the morphine group used significantly less PCA meperidine to maintain analgesia than the control group (p = 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1992

Novel delivery systems: oral transmucosal and intranasal transmucosal.

During the past 2 decades, anesthesiologists have been provided with a number of new, potent opioid analgesics and sedative/hypnotics, as well as an increased understanding of the pharmacokinetic and pharmacodynamic principles that govern their action and disposition. These developments have suggested that the skin and the buccal and nasal mucous membranes may have use as alternate routes of analgesic and anesthetic drug delivery. A novel transmucosal delivery system for fentanyl has recently been developed by incorporating the drug into a dissolvable matrix on a stick called an "oralete." Oral transmucosal fentanyl citrate has been evaluated as a premedication in the pediatric population and as an analgesicfor acute postoperative and emergency room pain, procedural pain, and breakthrough cancer pain by using fentanyl. Increases in plasma fentanyl and onset of clinical effect are rapid (20-40 min) with this formulation. A potential advantage is the apparent ease of titration to a sedative or analgesic end point. This system may improve premedication, acute postoperative analgesia, and chronic pain therapy in various clinical settings. Delivery of opioids through the nasal mucosa also has been recently investigated. In one study, sufentanil was administered (1.5, 3.0, or 4.5 mu/kg) to 80 children ranging in age from 6 mo to 7yr. Easy separation from parents was achieved in 86% of the children 10 min following administration of the premedication. Unfortunately, 61% of the children cried after drug administration, and side effects included reduced ventilatory compliance (chest-wall rigidity) with higher doses (3.0 and 4.5 microg/kg). Nevertheless, nasal transmucosal drug delivery may have value, especially in frightened or uncooperative children.

Administration, Intranasal↗
PubMed1991

Oral transmucosal fentanyl citrate for analgesia and sedation in the emergency department.

STUDY OBJECTIVE: To evaluate the safety and efficacy of oral transmucosal fentanyl citrate (OTFC) as a noninvasive method of providing analgesia and sedation for patients in the emergency department. DESIGN: Prospective, nonblinded. SETTING: ED of a tertiary care university hospital. TYPE OF PARTICIPANTS: Ten patients, 6 to 34 years old, with acute painful conditions requiring treatment in the ED. INTERVENTIONS: Premedication with OTFC and local anesthetic prior to incision or wound closure. MEASUREMENTS AND MAIN RESULTS: Pain and activity (sedation) scores, vital signs (including systolic and diastolic arterial blood pressures, heart and respiratory rates, and pulse oximetry-determined oxygen saturation) were measured before and at two- to ten-minute intervals during and after OTFC consumption. All patients accepted OTFC. Patients received an average of 13.7 +/- 2.5 micrograms/kg of fentanyl citrate in 11.8 +/- 6.8 minutes. Decreases in pain were reported in two patients in two minutes and by all patients 14 minutes after beginning OTFC consumption. Sixty percent of patients became drowsy or sedated 12 to 30 minutes after beginning OTFC. Vital signs and oxygen saturation changes were small and not clinically significant. The most important side effects were pruritus (30%), nausea (20%), and dizziness and dry mouth (40%). All were considered mild and not disturbing, although one patient required post-procedure antiemetic therapy for recurrent vomiting. The mean time to discharge from the ED was 139 +/- 54 minutes after receiving OTFC. CONCLUSION: OTFC may be useful in providing rapid, noninvasive analgesia and sedation in the ED and deserves further evaluation.

Administration, Oral↗
PubMed1991

Absorption and bioavailability of oral transmucosal fentanyl citrate.

Oral transmucosal fentanyl citrate (OTFC) is a novel, noninvasive dosage form of fentanyl used to provide children and adults with sedation, anxiolysis, and analgesia. In order to determine the bioavailability and absorption of fentanyl from OTFC, 12 volunteers were given intravenous fentanyl citrate or OTFC 15 micrograms/kg on each of two occasions. On a third occasion, the authors assessed oral administration (gastrointestinal absorption) by giving eight of the same volunteers the same dose of a solution of fentanyl citrate to swallow. In each study, arterial blood samples were taken over 24 h for analysis of plasma fentanyl. After intravenous (iv) administration of fentanyl, clearance (mean +/- standard deviation) was 0.67 +/- 0.15 l/min; volume of distribution at steady state was 287 +/- 79 l; and the terminal elimination half-life was 425 +/- 102 min. Peak plasma concentrations of fentanyl were higher (3.0 +/- 1.0 vs. 1.6 +/- 0.6 ng/ml, P = 0.01) and occurred sooner (22 +/- 2.5 vs. 101 +/- 48.8 min, P = 0.003) after OTFC than after oral solution administration. Plasma concentrations of fentanyl after OTFC decreased rapidly, to less than 1.0 ng/ml within 75-135 min after the beginning of administration. Peak absorption rate was greater (11.1 +/- 4.3 vs. 3.6 +/- 2.1 micrograms/min, P = 0.004) and occurred much sooner after OTFC than after oral solution administration (19 +/- 2.6 vs. 87.5 +/- 38.1 min, P = 0.001). Systemic bioavailability was greater after OTFC administration than after the oral solution (0.52 +/- 0.1 vs. 0.32 +/- 0.1, P = 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Administration, Oral↗
PubMed1990

Oral transmucosal fentanyl citrate for premedication in paediatric outpatients.

Two doses (10-15 micrograms.kg-1, Group I, and 15-20 micrograms.kg-1, Group II) of oral transmucosal fentanyl citrate (OTFC) plus a placebo (Group III) were evaluated for premedication in 105 healthy children, aged 2 to 13 yr, undergoing short (less than 1 hr) operations in the hospital short-stay unit. The study was randomized and double-blinded and 91 of the 105 children also received droperidol, 25 micrograms.kg-1 IV, after induction of anaesthesia with halothane and N2O in oxygen. Both doses of OTFC produced significantly greater sedation (first present at 20 min) and anxiolysis (first present in Group I at 40 min) than the placebo. Recovery times were similar in the three groups and analgesic requirements in the recovery room were significantly lower in Group I than Group III. Both OTFC groups took longer to tolerate oral fluids in the postoperative discharge unit than the placebo group and this caused patients in Group I to have a delayed discharge from the hospital compared to Group III. Preoperative pruritus occurred significantly more frequently in Groups I and II (58 and 76 per cent, respectively) than Group III (23 per cent). Although the incidences of nausea and vomiting tended to be slightly higher in the OTFC groups in the preoperative holding and postoperative discharge units, the differences among the groups were not statistically significant. Likewise droperidol did not reduce the incidence of postoperative nausea or vomiting. The data indicate that OTFC may be a safe and effective premedicant in paediatric patients having short operations but delays discharge from the hospital (by 30-50 min) by delaying the time patients tolerate fluids early after operation.

Administration, Oral↗
PubMed1990

Cardiovascular effects of large doses of pentamorphone in the dog.

The cardiovascular effects of large doses of pentamorphone were evaluated in nine mongrel dogs basally anesthetized with sodium thiopental, 25 to 30 mg/kg, intravenously. All dogs were mechanically ventilated with 100% oxygen, and the PaCO2 was maintained between 35 and 40 mm Hg. Mean arterial pressure (MAP), central venous pressure, heart rate (HR), cardiac output (CO), pulmonary artery pressure, and pulmonary artery occluded pressure were measured, and stroke volume and systemic and pulmonary vascular resistances were calculated. Baseline measurements were obtained, then pentamorphone, 10 micrograms/mL, was given as an intravenous infusion at 2.5 micrograms/kg/min. Additional data were obtained after infusion of 25, 50, 75, 100, 125, 150, 200, 250, 300, and 350 micrograms/kg of pentamorphone. The inspired gases were then changed to 50% nitrous oxide in oxygen, and after a 20-minute equilibration period, an additional set of data was collected. Pentamorphone, 25 micrograms/kg, decreased HR 50%, MAP 65%, and CO 54%. No further changes in any measured or calculated variables were observed with additional doses of pentamorphone. The addition of 50% nitrous oxide to the inspired gas mixture had no effect on any measured or calculated hemodynamic variable. The minimal hemodynamic effects of pentamorphone in the dog suggest that further investigation into its use as an anesthetic is warranted.

Analysis of Variance↗
PubMed1990

Frequent hypoxemia and apnea after sedation with midazolam and fentanyl.

More than 80 deaths have occurred after the use of midazolam (Versed), often in combination with opioids, to sedate patients undergoing various medical and surgical procedures. We investigated the respiratory effects of midazolam (0.05 mg.kg-1) and fentanyl (2.0 micrograms.kg-1) in volunteers. The incidence of hypoxemia (oxyhemoglobin saturation less than 90%) and apnea (no spontaneous respiratory effort for 15 s) and the ventilatory response to carbon dioxide were evaluated. Midazolam alone produced no significant respiratory effects. Fentanyl alone produced hypoxemia in half of the subjects and significant depression of the ventilatory response to CO2, but did not produce apnea. Midazolam and fentanyl in combination significantly increased the incidence of hypoxemia (11 of 12 subjects) and apnea (6 of 12 subjects), but did not depress the ventilatory response to CO2 more than did fentanyl alone. Adverse reactions linked to midazolam and reported to the Department of Health and Human Services highlight apnea- and hypoxia-related problems as among the most frequent adverse reactions. Seventy-eight per cent of the deaths associated with midazolam were respiratory in nature, and in 57% an opioid had also been administered. All but three of the deaths associated with the use of midazolam occurred in patients unattended by anesthesia personnel. We conclude that combining midazolam with fentanyl or other opioids produces a potent drug interaction that places patients at a high risk for hypoxemia and apnea. Adequate precautions, including monitoring of patient oxygenation with pulse oximetry, the administration of supplemental oxygen, and the availability of persons skilled in airway management are recommended when benzodiazepines are administered in combination with opioids.

Adolescent↗
PubMed1989

Persistent pain following trauma.

Persistent pain following trauma can lead to long-term disability. This article reviews the pain syndromes most commonly seen following trauma. These include myofascial pain, sympathetically maintained pain, and phantom pain syndromes. Early diagnosis and treatment is emphasized in order to minimize the development of secondary problems of physical dysfunction, emotional deterioration, and substance abuse. Treatment modalities appropriate to these syndromes are reviewed and include medical, anesthesiological, rehabilitative, and behavioral medicine approaches. With prompt diagnosis and referral to a multidisciplinary pain treatment center, most patients will experience significant decreases in their pain, allowing them to return to the workforce and resume a normal life.

Humans↗
PubMed1989

Oral transmucosal fentanyl citrate (lollipop) premedication in human volunteers.

The authors determined whether fentanyl incorporated into a candy lollipop, oral transmucosal fentanyl citrate (OTFC), would cross mucosal tissues of the mouth in sufficient quantities during and after dissolution to produce sedation and/or analgesia. Associated respiratory and circulatory changes, side effects, and plasma concentrations of fentanyl were also measured. The evaluations were done in 28 adult volunteers who received fentanyl citrate in doses of 5, 4, 2, 1, and 0.5 mg in OTFC and rapidly sucked the lollipops (N = 20) or allowed them to passively dissolve (N = 8). Rapid consumption of OTFC resulted in more rapid onset of a pleasant feeling (first subjective sensation) but not more rapid onset of objective sedation or analgesia than passive dissolution. There was a significant correlation between dose of OTFC and magnitude of sedation (P less than 0.001, Spearman rank correlation = -0.82). Higher doses of OTFC produced greater and longer lasting analgesia and respiratory depression and a higher incidence of nausea and vomiting than lower doses, but pruritus (33%-87%) was not related to the dose of OTFC. Heart rate and arterial blood pressures were not changed by any dose of OTFC. The data indicate that low doses of OTFC (0.5 and 1 mg, equivalent to 5-20 micrograms.kg-1 of fentanyl citrate) produce analgesia and sedation with minimal side effects and little respiratory depression in adult volunteers and deserve further evaluation in patients.

Absorption↗
PubMed1988

Anesthesiology update: the preanesthetic evaluation.

Ideal anesthetic management consists of the preanesthetic attainment of a state in which a diagnostic or therapeutic procedure or surgical operation can be performed with as little physiologic and psychologic trauma as possible, and the likelihood of a speedy and uneventful postoperative course is enhanced. Significant impairment of cardiovascular, respiratory, renal and other organ system functions is common in patients facing surgery. Thus, it is imperative that preoperative evaluation be complete. Signs of congestive heart failure, myocardial ischemia or infarction or both, hypertension, electrolyte abnormalities, and cardiac arrhythmias should be aggressively sought and treated before surgery. In addition, before the induction of anesthesia, information must be obtained about the specific associated pathologies (cardiac and otherwise), drugs being used to treat these conditions, and the adequacy of the current therapies. The preoperative evaluation does not begin with the anesthesiologist's visit, but with the evaluation and care given by the primary physician. A team approach is advisable in complex cases. Appropriate consultations, including that of the anesthesiologist, should be made in a timely fashion. Except in emergency situations, the temptation to send incompletely evaluated and treated patients to the operating room should be resisted. Good preoperative preparation will improve the chances for a successful outcome.

Cardiovascular Diseases↗
PubMed1985

The power spectrum analyser as an indicator of cerebral ischaemia during carotid endarterectomy.

Stroke is a potential major complication of carotid endarterectomy and may be caused by cerebral ischaemia or embolisation from the operative site. Conventional EEG monitoring has been used intraoperatively to identify periods of cerebral ischaemia, but this monitoring technique can be difficult to operate and interpret in the operating room. This study reports the use of a new signal analyser, the power spectrum analyser (PSA-1, Neurologics, Inc., Nashville, Tennessee), and its impact on active patient management. Thirty-six patients undergoing carotid endarterectomies were monitored with the PSA-1 in conjunction with routine EEG. Eight patients (22%) showed evidence of ischaemia 22 times on both PSA-1 and routine EEG. At no time did the routine EEG show evidence of ischaemia when the PSA-1 did not. The PSA-1 has proven to be a reliable neurophysiologic monitor for the identification of periods of cerebral ischaemia. Use of this small, easily operated and interpreted machine could enhance safety in operating rooms lacking sufficient resources to use conventional EEG machines.

Aged↗
PubMedDate not supplied

Burn pain: the management of procedure-related pain.

Burn-related pain is often severe and intermittently excruciating for months after the initial injury as the result of the multiple procedures these patients must undergo. Procedure-related pain is often undertreated, especially in children. Pain management should be integrated into the patient's overall care plan. Frequent pain assessment with valid patient self-report measures should be the basis for documenting pain treatment efficacy. Pharmacologic methods of pain management, including the use of opioids and nonopioid analgesics, are the mainstay of pain management. The patient with burns often has altered pharmacokinetics and pharmacodynamics to drugs, and these changes must be integrated into the use of these agents. In addition, individual patient response varies widely, necessitating a highly individualized pain management plan. Sedatives, such as benzodiazepines, are often very helpful adjuncts to opioids in anxious patients but should not be substituted for analgesics. Psychological techniques have proved to be very helpful adjuncts to analgesics but should also not be sued as a substitute for analgesics. General anesthesia should be considered, especially in children, when patients are to undergo extremely painful procedures. Patients need not experience severe pain after burn injury. Pain management, especially during very painful procedures, should be an integrated part of patients care and high-quality pain management to improve patient outcome.

Adult↗
PubMedDate not supplied

Iontophoresis: noninvasive drug delivery.

Iontophoresis allows for the transdermal delivery of charged drugs under the influence of a low-level electric current. Recently iontophoretic technology has been used to deliver lidocaine to provide rapid, noninvasive local anesthesia. Studies have also demonstrated the ability to obtain systemic opiate levels using this technology. In this article we review the history and principles of iontophoresis as well as the literature supporting its use for both local anesthesia and systemic analgesia.

Dexamethasone↗