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N Rawal

Publications and source records attributed to N Rawal.

At least 19 recordsLinked to original sources
PubMed2006

Current practices for postoperative pain management in Europe and the potential role of the fentanyl HCl iontophoretic transdermal system.

Survey results continue to reveal that postoperative pain is insufficiently managed throughout Europe and the rest of the world. However, the efficient use of existing resources, as well as the introduction of novel technologies, may aid in its improvement. Use of an acute pain service has the potential to improve pain management through specialized patient care and utilization of effective analgesic techniques. Multimodal analgesic techniques, which include adjuvant non-opioids and/or regional analgesic techniques, can provide effective analgesia and reduce the amount of systemic opioids (or obviate the need) for postoperative pain management. Patient-controlled analgesia modalities may also offer improvements to pain management, as in practice they provide pain relief superior to the intermittent administration of bolus doses of opioids. A novel patient-controlled analgesia modality that has been approved by the European Medicines Evaluation Agency (EMEA) for the treatment of acute, moderate-to-severe pain is the needle-free, pre-programmed fentanyl HCl iontophoretic transdermal system. This system was shown in a recent US clinical trial to be comparable in efficacy to a standard regimen of morphine intravenous patient-controlled analgesia. Adverse events associated with the use of the fentanyl iontophoretic transdermal system are generally similar to those experienced by patients using intravenous morphine patient-controlled analgesia. Considerations regarding the selection of patients for treatment with the fentanyl iontophoretic transdermal system are similar to those with other patient-controlled analgesia modalities; sufficient upper limb mobility and alertness are required to operate the system. Utilization of the fentanyl iontophoretic transdermal system, together with the guidance of an effective acute pain service, may lead to improvements in postoperative pain management.

Administration, Cutaneous↗
PubMed2006

Umbilical cord plasma concentrations of free morphine following single-dose diamorphine analgesia and their relationship to dose-delivery time interval, Apgar scores and neonatal respiration.

OBJECTIVE: To find the effect of dose-delivery interval on cord-blood levels of diamorphine metabolites and its effect on Apgar sores and neonatal respiration. STUDY DESIGN: Pilot study conducted in labour ward of a district general hospital. One hundred women who had normal delivery and received single dose of 7.5mg of intramuscular injection of diamorphine in labour were recruited in the study. A 2.0 ml sample of umbilical venous blood was collected from the placenta after delivery of the baby. The sample was analysed using RIA method to measure free morphine. Details about the labour and baby's condition at birth were recorded. RESULTS: The concentration of free morphine in the umbilical venous blood was significantly associated with the dose-delivery interval (coefficient (95% CI)=1.08(0.99-1.18), p<0.001). Twenty neonates had low Apgar score (< or =7) at 1 min. The odds of such a low score were raised with higher log free morphine in the cord venous plasma, but not statistically significantly (OR (95% CI)=5.3 (0.84-34), p=0.08). Fourteen neonates required resuscitation. The odds of requiring resuscitation were significantly raised with higher log free morphine: OR (95% CI)=9.3 (1.0-86), p=0.05. CONCLUSION: Concentration of free morphine in the umbilical venous blood after delivery was significantly associated with the dose-delivery interval and this had significant effect on the need for resuscitation.

Analgesics, Opioid↗
PubMed2006

Pain relief following breast augmentation surgery: a comparison between incisional patient-controlled regional analgesia and traditional oral analgesia.

BACKGROUND AND OBJECTIVES: Postoperative pain is a common problem following ambulatory breast augmentation surgery. This study was performed to compare standard of care (oral analgesics) with patient-controlled incisional regional analgesia (PCRA) for postoperative pain management at home for 48 h. A second aim was to compare the analgesic efficacy of ropivacaine 0.25% vs. 0.5%. METHODS: Surgery was performed under local anaesthesia and monitored anesthesia care. Sixty adults (ASA 1-2) were randomized to one of two groups. Patients in Group PCRA could self-administer ropivacaine 0.25% 10 mL in the left breast and ropivacaine 0.5% in the right breast. Patients in Group T (tablets) received our standard of care treatment, i.e. oral paracetamol 1 g four times a day and oral ibuprofen 500 mg three times a day. Parameters measured included: analgesic requirements (in post-anesthesia care unit, PACU and post-discharge), pain intensity (visual analogue scale), patient satisfaction, global analgesia, side-effects, and quality of recovery. RESULTS: Pain scores were significantly lower in Group PCRA compared to Group T at all time periods (P < 0.05). No differences were found in pain scores between the right and left breasts. Significantly more patients in Group T requested analgesics in the recovery unit (27 vs. 7; P = 0.001) and also at home (20 vs. 11; P < 0.02). More patients in the tablet group had nausea and vomiting (10 vs. 3; P < 0.05). Global analgesia on day 2 was significantly better in PCRA group; however, patient satisfaction was similar in both groups. More patients in the tablet group had sleep disturbance and woke up at night due to pain. CONCLUSIONS: Pain relief after ambulatory breast augmentation is superior with incisional PCRA when compared to oral analgesic combination of paracetamol and ibuprofen. Incisional PCRA was associated with minimal side-effects and less sleep disturbance. There was no difference in the analgesic efficacy between ropivacaine 0.25% and 0.5%.

Administration, Oral↗
PubMed2006

Incisional and epidural analgesia after caesarean delivery: a prospective, placebo-controlled, randomised clinical study.

BACKGROUND: This study evaluated efficacy, safety and patient satisfaction with incisional analgesia with a subfascial catheter compared to epidural analgesia for pain relief following caesarean section. METHODS: Forty patients were randomised after elective caesarean section to receive either intermittent 10-mL boluses of 0.125% levobupivacaine into the epidural space and physiologic saline into the surgical wound or intermittent 10-mL boluses of 0.25% levobupivacaine into the wound and epidural saline with a repeated 10-dose regimen. Analgesic efficacy was evaluated by numerical pain scores (0-10, 0=no pain, 10=worst pain) and based on the consumption of supplemental opioid. Side effects, patient satisfaction and plasma concentrations of levobupivacaine were recorded. RESULTS: In the epidural group average pain scores were lower (1.8 vs. 3, P=0.006) and the consumption of local anaesthetic (29 mL vs. 38 mL, P=0.01) was smaller during the first four postoperative hours, after which both groups had pain scores of 3 or less at rest. All parturients were able to walk after the 24-h study period. The total consumption of rescue opioid oxycodone (32 vs. 37 mg, P=0.6) during the whole 72-h study period was low in both study groups. Side effects were mild and rare. Satisfaction scores were equally high in the two groups. Peak plasma concentrations of levobupivacaine were below the toxic range. CONCLUSION: Incisional local analgesia via a subfascial catheter provided satisfactory pain relief with patient satisfaction comparable to that seen with epidural analgesia. This technique may be a good alternative to the more invasive epidural technique following caesarean section as a component of multimodal pain management.

Adult↗
PubMed2005

A procedure-specific systematic review and consensus recommendations for postoperative analgesia following laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy has advantages over the open procedure for postoperative pain. However, a systematic review of postoperative pain management in this procedure has not been conducted. METHODS: A systematic review was conducted according to the guidelines of the Cochrane Collaboration. Randomized studies examining the effect of medical or surgical interventions on linear pain scores in patients undergoing laparoscopic cholecystectomy were included. Qualitative and quantitative analyses were performed. Recommendations for patient care were derived from review of these data, evidence from other relevant procedures, and clinical practice observations collated by the Delphi method among the authors. RESULTS: Sixty-nine randomized trials were included and 77 reports were excluded. Recommendations are provided for preoperative analgesia, anesthetic and operative techniques, and intraoperative and postoperative analgesia. CONCLUSIONS: A step-up approach to the management of postoperative pain following laparoscopic cholecystectomy is recommended. This approach has been designed to provide adequate analgesia while minimizing exposure to adverse events.

Analgesia↗
PubMed2005

Predicting postoperative analgesia outcomes: NNT league tables or procedure-specific evidence?

Number needed to treat (NNT) values have been recommended and used to assess efficacy of analgesics for acute pain management. However, the data analysed come from a variety of procedures, which may potentially hinder the interpretation of the NNT value for specific procedures. We reanalysed available NNT data with acetaminophen in relation to the magnitude of surgical injury. Acetaminophen was less effective for pain relief after orthopaedic procedures than after dental procedures. The relative risk ratio for more than 50% pain relief, compared with placebo, was only 1.87 compared with 3.77 (P<0.05). Although NNT can give a valuable overview of efficacy, this concept is not necessarily applicable to all types of surgery. We suggest that estimates of NNT should be related to specific surgical procedures.

Acetaminophen↗
PubMed2005

Stress reduction and analgesia in patients exposed to calming music postoperatively: a randomized controlled trial.

BACKGROUND AND OBJECTIVES: This randomized controlled trial was designed to evaluate, first, whether intra- or postoperative music therapy could influence stress and immune response during and after general anaesthesia and second, if there was a different response between patients exposed to music intra- or postoperatively. METHOD: Seventy-five patients undergoing open hernia repair as day care surgery were randomly allocated to three groups: intraoperative music, postoperative music and silence (control group). Anaesthesia and postoperative analgesia were standardized and the same surgeon performed all the operations. Stress response was assessed during and after surgery by determining the plasma cortisol and blood glucose levels. Immune function was evaluated by studying immunoglobulin A (IgA) levels. Patients' postoperative pain, anxiety, blood pressure (BP), heart rate (HR) and oxygen saturation were also studied as stress markers. RESULTS: There was a significantly greater decrease in the level of cortisol in the postoperative music group vs. the control group (206 and 72 mmol L(-1) decreases, respectively) after 2 h in the post anaesthesia care unit. The postoperative music group had less anxiety and pain and required less morphine after 1 h compared with the control group. In the postoperative music group the total requirement of morphine was significantly lower than in the control group. The intraoperative music group reported less pain after 1 h in the post anaesthesia care unit. There was no difference in IgA, blood glucose, BP, HR and oxygen saturation between the groups. CONCLUSION: This study suggests that intraoperative music may decrease postoperative pain, and that postoperative music therapy may reduce anxiety, pain and morphine consumption.

Adult↗
PubMed2005

Assessment of contraceptive services in a maternity unit of a district general hospital in the UK.

A survey was undertaken to assess the quality of contraceptive services provided to women delivering in a District General Hospital. Separate questionnaires were given to the women and the midwives giving the contraceptive advice. Response rate of the survey was 87%. Thirty eight per cent of women reported having some discussion on contraception during antenatal period. All the women had received contraceptive advises during the postpartum period. Eighty one per cent of women felt that sufficient information and enough time was given to discuss contraception. However analysis of questionnaires indicated that most received information only on short-term contraceptive methods. Out of 64 midwives surveyed, 52 had attended a family planning course. However 37 of them had attended the course at least 3 years earlier. Thirty eight midwives felt that they have adequate knowledge to give advice but all of them reported that they should receive further training. There should be provision for comprehensive discussion regarding contraceptive options during both antenatal and postpartum periods. Midwives require regular training in family planning.

Contraception↗
PubMed2005

Selective salpingography and fallopian tube recanalisation: experience from a district general hospital.

The Royal College of Obstetricians and Gynaecologists has included selective salpingography and tubal catheterisation (SS-TC) in its evidence-based clinical guideline for the management of infertility in secondary care. In spite of being a cost-effective and minimally invasive treatment option for proximal tubal blockage, SS-TC has been slow to become adopted across the UK. We here describe our initial experience with setting up of tubal recanalisation service in a district general hospital (DGH) in the UK, along with our preliminary results. Tubal patency was achieved in 11 patients out of 14 who underwent SS-TC (78%). Four women achieved spontaneous pregnancy (success rate 28.57%) within 1 year of treatment. The procedure should become a universally accepted, taught and practiced approach in the diagnosis and treatment of the fallopian tube. Especially in infertility units located in a DGH it can be used selectively in the patients with good prognosis and other cases referred to tertiary center for more rapid in-vitro fertilisation (IVF).

Catheterization↗
PubMed2005

Morphine for post-caesarean section analgesia: intrathecal, epidural or intravenous?

INTRODUCTION: Good analgesia is important after a caesarean section but there are no studies to date that compared intrathecal (IT), epidural (EP) and intravenous patient-controlled analgesia (IV PCA) morphine for post-caesarean section analgesia. In this study, we compared the differences in the quality of analgesia and side effects rendered by IT, EP and IV PCA morphine for post-caesarean section analgesia. METHODS: We systematically collected and reviewed the data of 949 women who received IT, EP or IV PCA morphine for post-caesarean analgesia during a six-month period. We reviewed the patients 24 hours after surgery and recorded the type of analgesia, the use of adjuncts, pain scores, side effects and degree of satisfaction with the mode of analgesia. The data was captured in an electronic database and analysed. RESULTS: IT morphine was the predominant method of post-caesarean analgesia, accounting for 89.5 percent of the cases. Non-steroidal anti-inflammatory drugs (NSAIDs) were more commonly used in the IT and EP group (IT 76 percent, EP 80 percent and IV PCA 49 percent, p-value is less than 0.05). IT morphine group had a significantly lower pain score at rest (p-value is less than 0.001) and on movement (p-value is less than 0.05) when compared with IV PCA group. EP morphine also resulted in a lower pain score than IV PCA on movement (p-value is less than 0.05). There was no difference in pain scores between EP and IT morphine. In the subgroup analysis of patients who did not receive NSAIDs, IT and EP morphine group also registered lower pain scores at rest and on movement than IV PCA group (p-value is less than 0.05). There was no difference in the satisfaction scores among the three groups. CONCLUSION: The use of IT and EP morphine was associated with lower pain scores than IV PCA morphine at rest and on movement in the first 24 hours after caesarean section. No severe side effects were found.

Adult↗
PubMed2004

Nitric oxide is involved in nicotine-induced burst firing of rat ventral tegmental area dopamine neurons.

In the present study, using single cell recordings in vivo and intracellular recordings in vitro from midbrain slices, the role of N-methyl-d-aspartate (NMDA) receptor signaling on firing activity in ventral tegmental area dopamine neurons elicited by nicotine was investigated in the rat. In accordance with previous studies, systemic nicotine (0.5 mg/kg s.c.) increased both firing rate and burst firing of dopamine neurons in vivo, and bath-applied nicotine (10 microM) increased firing rate in vitro. The competitive NMDA receptor antagonist CGP39551 (2.5 mg/kg i.p.) inhibited nicotine's effects on burst firing and also attenuated the nicotine-induced increase in firing rate. Moreover, although the nitric oxide (NO)-synthase inhibitor N-nitro-l-arginine-methyl-ester (l-NAME; 5.0 mg/kg i.p.) had no effect on cell firing by itself, it prevented the response to nicotine in vivo. In contrast, l-NAME (100 microM) did not influence nicotine's effect on dopamine cell firing in vitro, suggesting that the effect of l-NAME seen in vivo is dependent on presynaptic afferent input. The present study confirms previous results suggesting that the effect of systemically administered nicotine is in part presynaptic and mediated via NMDA receptors. The data also indicate that NO plays an important role in the previously demonstrated, indirect, glutamate-mediated excitation of these neurons by nicotine. By inference, our results provide additional support for the involvement of NO in nicotine dependence.

2-Amino-5-phosphonovalerate↗
PubMed2004

Continuous popliteal sciatic nerve block for outpatient foot surgery--a randomized, controlled trial.

BACKGROUND: A major problem in outpatient foot surgery is severe postoperative pain that is not sufficiently treated by peroral analgesics. METHODS: Sixty-three patients underwent foot surgery under spinal anesthesia. Immediately on conclusion of the operation, sciatic and saphenous nerve blocks were performed. The sciatic nerve was blocked in the popliteal fossa with 30 ml of ropivacaine 5 mg ml(-1) and a perineural catheter was passed through the cannula. The patients were randomized to receive either ropivacaine 2 mg ml(-1) (n=30) or saline (n=30) in the catheter through a disposable elastomeric pump with a fixed infusion rate of 5 ml h(-1) for 55 h. RESULTS: Analgesia was excellent until 23 h 44 min (14 h 34 min) in the treatment group and 18 h 16 min (7 h) in the placebo group [mean (SD), P=0.07]. Thereafter, pain was significantly less in the treatment group on the first and second postoperative days (P=0.001). Sleep disturbances because of the pain in the foot were experienced by 25% of the treatment group on the first night at home and by 50% of the control group (P=0.29). There were no differences between the groups in their need for rescue opioid medication. None of the patients had any major problem with the catheter or pump, and none had any toxic effect referable to the technique. CONCLUSION: This randomized, double-blind study shows that continuous blockade of the sciatic nerve in the popliteal fossa reduces postoperative pain and has no untoward effects in a patient group known to experience severe pain after ambulatory surgery.

Ambulatory Surgical Procedures↗
PubMed2003

New parkin mutations and atypical phenotypes in families with autosomal recessive parkinsonism.

The frequency of parkin mutations was evaluated in 30 families of highly diverse geographic origin with early-onset autosomal recessive parkinsonism. Twelve different mutations, six of which were new, were found in 10 families from Europe and Brazil. Patients with parkin mutations had significantly longer disease duration than patients without the mutation but with similar severity of disease, suggesting a slower disease course. Two patients with parkin mutations had atypical clinical presentation at onset, with predominant tremor when standing.

Adult↗
PubMed2003

Analgesia following music and therapeutic suggestions in the PACU in ambulatory surgery; a randomized controlled trial.

BACKGROUND: This study was designed to determine whether music (M), or music in combination with therapeutic suggestions (M/TS) could improve the postoperative recovery in the immediate postoperative in daycare surgery. METHODS: One-hundred and eighty-two unpremedicated patients who underwent varicose vein or open inguinal hernia repair surgery under general anaesthesia were randomly assigned to (a). listening to music (b). music in combination with therapeutic suggestions or (c). blank tape in the immediate postoperative period. The surgical technique, anaesthesia and postoperative analgesia were standardized. Analgesia, the total requirement of morphine, nausea, fatigue, well-being, anxiety, headache, urinary problems, heart rate and oxygen saturation were studied as outcome variables. RESULTS: Pain intensity (VAS) was significantly lower (P = 0.002) in the M (2.1), and the M/TS (1.9) group compared with the control group (2.9) and a higher oxygen saturation in M (99.2%) and M/TS (99.2%) group compared with the control (98.0%), P < 0.001, were found. No differences were noted in the other outcome variables. CONCLUSION: This controlled study has demonstrated that music with or without therapeutic suggestions in the early postoperative period has a beneficial effect on patients' experience of analgesia. Although statistically significant, the improvement in analgesia is modest in this group of patients with low overall pain levels.

Ambulatory Surgical Procedures↗
PubMed2003

Patient-controlled regional analgesia (PCRA) with ropivacaine after arthroscopic subacromial decompression.

BACKGROUND: The aim of the study was to evaluate postoperative analgesia and safety of wound instillation of ropivacaine either by a single dose or a patient-controlled regional anaesthesia (PCRA) technique. METHODS: In 40 patients undergoing arthroscopic subacromial decompression the surgeon placed a catheter into the subacromial space at the end of the operation. In Phase I (10 patients), ropivacaine 250 mg was injected twice within 1 h. In Phase II, 30 patients were randomised into three groups: group prilocaine-ropivacaine (PR) = 20 ml of 1% prilocaine-epinephrine injected preoperatively into the subacromial bursa + 20 ml of 0.5% ropivacaine infused in the catheter postoperatively; group saline-ropivacaine (SR) = saline-epinephrine (20 ml) preoperatively + 0.5% ropivacaine as in group PR; group saline-saline (SS) = saline-epinephrine (20 ml) preoperatively + saline postoperatively. The PCRA pump was filled with local anaesthetic or saline to allow boluses of 10-ml each, maximum one bolus/h, via the catheter. Pain relief, side-effects and venous plasma concentration of ropivacaine were evaluated during a 24-h-test period. RESULTS: The free plasma concentration of ropivacaine was 0.12 + 0.041 mg l-1 in Phase I. No adverse effects were seen. In Phase II pain at rest and on movement was lower in group PR than in group SS during the first 30 min postoperatively (P < 0.05). Group PR had the lowest morphine consumption (P < 0.05). Five to seven boluses were administered via the PCRA-pump, and 20 min after administration of the study solution, pain was lower in groups PR and SR compared with group SS (P < 0.001). CONCLUSIONS: Preoperative intrabursal prilocaine with epinephrine + postoperative subacromial administration of ropivacaine by PCRA-technique provided the most effective analgesia with no major side-effects. The free plasma concentrations of ropivacaine were far below toxic concentrations.

Adult↗
PubMed2003

A comparison of intra-operative or postoperative exposure to music--a controlled trial of the effects on postoperative pain.

The effect of intra-operative compared to postoperative music on postoperative pain was evaluated in a controlled trial. In all, 151 patients undergoing day case surgery for inguinal hernia repair or varicose vein surgery under general anaesthesia were randomly allocated to three groups: group 1 listened to music intra-operatively, group 2 listened to music postoperatively and group 3, the control group, listened to 'white noise'. The anaesthetic and postoperative analgesic techniques were standardised. Pain was assessed using a numeric rating scale (0-10) and patients requirements for postoperative morphine, paracetamol and ibuprofen was recorded. The effect of music on nausea, fatigue and anxiety was also investigated. The results showed that patients exposed to music intra-operatively or postoperatively reported significantly lower pain intensity at 1 and 2 h postoperatively and patients in the postoperative music group required less morphine at 1 h compared to the control group. No differences were noted in the other variables. This study demonstrates that there is a short-term pain-reducing effect of music therapy however, the beneficial effects do not differ if the patient is exposed to music intra-operatively or postoperatively.

Adult↗