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Biomedical subjects

N Rawal

Publications and source records attributed to N Rawal.

105 records · Page 6Linked to original sources
PubMed1985

Epidural and intrathecal morphine in intensive care units.

Analgesia and sedation for patients in intensive care units (ICU) who require mechanical ventilation are most commonly provided by intermittent i.v. injections of opiates and benzodiazepines. However, the technique has a number of disadvantages. Also, in many cases these drugs are inadequate, even in large doses, and muscle relaxants may be necessary for patient respirator coordination. The analgesic effect of epidural and intrathecal morphine was studied in 24 ICU patients requiring controlled ventilation. In spite of large doses of phenoperidine, diazepam and a number of other analgesics and sedatives, all patients were restless, agitated and coordinated poorly with the respirator. Through an indwelling epidural catheter morphine (4 mg) was injected intermittently as required in 11 patients and as a continuous infusion (20-40 mg/day) in five patients. In eight patients morphine (2-4 mg) was injected intrathecally as a single injection. Both epidural and intrathecal morphine gave potent analgesia and good patient respirator coordination. The duration of analgesia was shortest after intermittent injections of epidural morphine and longest after intrathecal morphine. However, continuous infusion of morphine in the epidural catheter appears to be the most practical method. In patients with multiple trauma and in patients where frequent assessment of the level of consciousness is important this technique is superior to parenteral analgesic sedative combinations. Intrathecal morphine may be indicated in patients in a compromised position. The daily analgesic requirement can be reduced by about 10-100 times by the use of epidural and intrathecal morphine respectively.

Adult↗
PubMed1984

Comparison of intramuscular and epidural morphine for postoperative analgesia in the grossly obese: influence on postoperative ambulation and pulmonary function.

In a randomized double-blind study of thirty grossly obese patients undergoing gastroplasty for weight reduction, the effects of intramuscular and epidural morphine were compared as regards analgesia, ambulation, gastrointestinal motility, early and late pulmonary function, duration of hospitalization, and occurrence of deep vein thrombosis in the postoperative period. The patients were operated on under thoracic epidural block combined with light endotracheal anesthesia. A six-grade scale was devised to quantify postoperative mobilization. A radioactive isotope method using 99mTc -plasmin was employed to detect postoperative deep vein thrombosis. For 14 hr after the first analgesic injection, respiratory frequency was noted every 15 min and arterial blood gases were measured hourly. Peak expiratory flow was recorded daily until the patient was discharged from hospital. Spirometry was performed the day before and the day after surgery. Plasma concentrations of morphine were measured after both intramuscular and epidural administration. Both intramuscular and epidural morphine gave effective analgesia, but the average dose of intramuscular morphine was up to seven times greater than that required by the epidural route. A larger number of patients receiving epidural morphine postoperatively were able to sit, stand, or walk unassisted within 6, 12, and 24 hr, respectively. Being alert and more mobile as a result of superior postoperative analgesia from epidural morphine, patients in this group benefited more from vigorous physiotherapy routine, which resulted in fewer pulmonary complications. Furthermore, earlier postoperative recovery of peak expiratory flow and bowel function presumably contributed to a significantly shorter hospitalization in patients receiving epidural morphine. There was no evidence of prolonged respiratory depression in this high-risk category of patients. The 99mTc -plasmin tests revealed no significant difference between the two groups.

Adult↗
PubMed1984

Respiratory depression after epidural morphine--an experimental and clinical study.

This study was comprised of an experimental part (20 volunteers) and a clinical part (10 surgical patients). In the experimental part, the effects of either 2-, 4-, or 10-mg doses of epidural morphine on ventilatory responses to a standardized CO2 challenge were studied in healthy volunteers. In the clinical part, ventilatory responses to CO2 were evaluated in patients receiving 4 mg of epidural morphine for pain relief after gall bladder surgery. Naloxone infusion was given to five volunteers to determine whether ventilatory changes due to epidural morphine could be prevented. Using a nonrebreathing method, end-tidal PCO2 (PETCO2) and minute ventilation (tidal volume X frequency) were measured before and 1, 5, 8, 13, and 22 hr after epidural morphine injection. Ventilation was stimulated by 4% CO2 in 21% O2 and 75% N2. In the experimental study, a dose-related depression of ventilatory drive was seen after epidural morphine. After 2- and 4-mg doses, increases in PETCO2 were present up to 5 hr after injection with a corresponding reduction in minute ventilation. Ten mg of epidural morphine was followed by a significant reduction in minute ventilation and an increase in PETCO2 that started 1 hr after injection, peaked at 5 hr, and then remained almost unchanged for the next 17 hr. PETCO2 was higher and remained elevated longer in surgical patients than in volunteers given the same amount of epidural morphine (4 mg).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1983

An experimental study of urodynamic effects of epidural morphine and of naloxone reversal.

Urinary retention after epidural morphine is a distressing and troublesome complication. This study was undertaken to determine the effects of morphine (epidural, intramuscular, and intravenous) on urinary bladder function and possible reversal by naloxone. Thirty male volunteers (aged 20-28 years) were studied; the doses studied were 2, 4, and 10 mg of epidural morphine, 10 mg intramuscular morphine, and 10 mg intravenous morphine. The urodynamic study consisted of measurements of urine flow rate, strength of detrusor contraction, bladder capacity, and urethral pressure. Irrespective of dose, all subjects receiving epidural morphine showed marked relaxation of the detrusor shortly after injection. There was a corresponding increase in the maximal bladder capacity leading to urinary retention. These effects lasted an average of 14-16 h. Urethral pressures remained unchanged. Urodynamic changes after intramuscular and intravenous morphine were minimal. Treatment using a single intravenous injection of 0.8 mg naloxone promptly reversed the effects of epidural morphine on the bladder. Prevention of urinary retention was achieved with an intravenous infusion of naloxone started before administration of epidural morphine. The possible mechanisms of urinary retention following epidural opiates are discussed.

Adult↗
PubMed1982

Epidural morphine for postoperative pain relief: a comparative study with intramuscular narcotic and intercostal nerve block.

The relatively new technique of epidural morphine analgesia was compared with two well established method of pain relief in 90 patients undergoing gallbladder surgery and divided randomly into three groups of 30 patients each. The first group received intramuscular narcotic analgesic ketobemidone, the second group was given 0.5% bupivacaine-epinephrine intercostal nerve block, and the third group received a single dose of 4 mg of epidural morphine for postoperative pain relief. The mean duration of analgesia after ketobemidone was 5.5 hours, and after intercostal block 11 hours. Of the patients given epidural morphine, 40% did not require further analgesia after the initial injection; the remaining patients in this group were pain free for a mean duration of 19 hours. The mean reduction in postoperative peak expiratory flow was most marked following ketobemidone and least after epidural morphine. Postoperative changes in PaO2 and PaCO2 reflected the changes in peak expiratory flow. Plasma levels of morphine after epidural injection were so low that a regional spinal analgesic action of epidural morphine appeared more likely than a systemic effect. Delayed respiratory depression was not encountered after epidural morphine. It is concluded that a single dose of 4 mg of epidural morphine provides excellent regional analgesia of long duration without drowsiness or circulatory of respiratory depression thus facilitating early ambulation. The technique is superior to more common methods of pain relief after gallbladder surgery, e.g., intercostal nerve block and intramuscular narcotics.

Adult↗
PubMed1981

Postoperative pain relief by epidural morphine.

Postoperative pain relief was studied in 280 patients undergoing various kinds of surgery, e.g., thoracic, upper and lower abdominal, perineal, obstetric, and orthopedic. Morphine, 2 or 4 mg, was given after surgery through an indwelling epidural catheter. Excellent analgesia was noted in 87% of patients; only 3.5% of patients were dissatisfied. A single injection gave complete pain relief for the entire postoperative period in 30% of cases; in the remaining patients the mean duration of analgesia was 10.7 hours (SD +/- 4.3). Plasma morphine concentrations recorded after 2-mg doses suggest a regional spinal action as the basis for the long duration of analgesia, although the initial effect after 4-mg doses might well include systemic responses due to rapid vascular uptake of morphine from the epidural space. Peak expiratory flow (PEF) measurements and arterial blood gas analyses showed no significant early postoperative respiratory depression. Absence of sedation, orthostatic hypotension, respiratory depression, and motor paralysis facilitated early ambulation with less risk for postoperative respiratory complications. It is concluded that 2-mg doses of epidural morphine give good analgesia of long duration despite low plasma levels. After upper abdominal and thoracic surgery higher doses (4 mg) may be necessary in healthy patients. Elderly and frail patients appear to be sensitive to epidural morphine and doses in excess of 2 mg should be avoided regardless of the type of surgery. With this dose schedule we have not encountered delayed respiratory depression.

Adolescent↗
PubMedDate not supplied

Combined spinal-epidural technique.

BACKGROUND: For the past 16 years the combined spinal-epidural (CSE) technique has been extensively researched and developed to the point where it is now in widespread use. Along with the use of low-dose mixtures of local anesthetics and opioids, and the introduction of fine-gauge pencil-point needles, CSE is being increasingly recognized as another important addition to the armamentarium of the anesthesiologist. METHOD: One hundred and forty-two publications focusing on the CSE technique, or on questions concerning CSE-related issues, were reviewed. Out of 33 double-blind or controlled studies, 23 directly investigated the CSE technique. Fifty-four prospective studies and letters made directly relevant points on advantages or problems with CSE. Twenty-one book chapters, reviews and editorials were included, 11 of them concerning the use of CSE technique. RESULTS: All CSE techniques which may be used for surgical anesthesia, for analgesia in labor or for postoperative pain management are described. Indications, advantages, disadvantages, and the various methods for performing CSE procedures, including sequential CSE block, are described and reviewed, along with the equipment currently available for their administration. CONCLUSION: The CSE technique offers many potential advantages over continuous epidural or subarachnoid methods alone, including a reduction in drug dosage, the ability to eliminate motor blockade and to achieve highly selective sensory blockade and optimize analgesia. These features hold great promise for minimizing the hazards and side effects of traditional epidural and subarachnoid techniques. Controversial fears, risks, and pitfalls of the CSE technique and of continuous epidural and subarachnoid methods are debated and discussed.

Anesthesia, Epidural↗
PubMedDate not supplied

Postoperative pain following knee arthroscopy: the effects of intra-articular ketorolac and/or morphine.

BACKGROUND AND OBJECTIVES: Morphine and nonsteroidal antiinflammatory drugs (NSAID) have been found to be effective in relieving postoperative pain. The goal of this study was to determine whether ketorolac alone or in combination with morphine provides superior pain relief following arthroscopy performed with local anesthesia (LA). METHODS: This was a randomized, double-blind, prospective, study in 100 healthy patients from 15 to 60 years of age. Knee arthroscopy was performed with LA using 40 mL prilocaine (5 mg/mL) with adrenaline (4 microg/mL). At the end of the operation, a catheter was inserted intra-articularly, and one of the following solutions diluted to a total volume of 40 mL was injected: group P (40 mL normal saline), group M (3 mg morphine), group K30 (30 mg ketorolac), group K60 (60 mg ketorolac), and group KM (3 mg morphine + 30 mg ketorolac). Visual analog scale (VAS) pain scores (0-100 mm) were measured preoperative and at 30, 60, 90, 120 minutes postoperative and thereafter 4, 8, 24, and 48 hours at rest and on movement of the knee. The total number of distalgesic tablets (325 mg paracetamol + 32.5 mg dextropropoxyphene) consumed during the 48 hours postoperative was recorded. RESULTS: Significant differences in VAS pain scores were seen between group P and group KM at 4, 8, and 24 hours (P < .05) and between group M and group KM at 4, 8, 24, and 48 hours (P < .01) after the operation at rest. During mobilization of the knee, a significant difference in VAS pain score was found between group P and group KM at 8, 24, and 48 hours (P < .05) and between group P and group K60 at 24 and 48 hours (P < .05). The total consumption of distalgesic tablets did not differ among the groups. CONCLUSIONS: The combination of 3 mg morphine plus 30 mg ketorolac provided significantly better analgesia than either placebo alone or morphine alone. This result could be a synergistic effect.

Adolescent↗
PubMedDate not supplied

10 years of acute pain services--achievements and challenges.

Despite unprecedented interest in understanding pain mechanisms and pain management, a significant number of patients continue to experience unacceptable pain after surgery. Recent surveys show that there has been no apparent improvement since an early study in 1952 (15). It is increasingly clear that the solution to the problems of postoperative pain management lies not so much in the development of new techniques but in developing an organization to exploit existing expertise. The most obvious components of an acute pain team include anesthesiologists, surgeons, nurses, and physiotherapists. Protocols encourage consistent standards of safe and effective care and should be used as a framework to individualize treatment. The concept of skilled pain therapists collaborating to provide improved postoperative analgesia within the framework of an organized APS appears to be universally applicable. Acute pain service models have been described from the United States, the United Kingdom, Germany, Switzerland, and Sweden. The U.S. model, which consists of anesthesiologist-based comprehensive pain management teams, is quite effective but is more expensive, and it is not transferable to Europe. A recent United Kingdom survey showed that there is a large degree of variation in what is thought to constitute an APS in the U.K. (16). A nurse-based anesthesiologist-supervised APS in which pain is evaluated in every patient who undergoes surgery has been developed in Sweden. Pain above 3 on the 10-grade VAS is promptly treated. Clearly, neither the anesthesiologist nor the APN guarantees good pain management on wards. In this low-cost model, the role of the anesthesiologist is to teach and train ward nurses, to supervise the APN, and to select patients for special pain therapies such as epidural, PCA, and peripheral nerve blocks. All senior anesthesiologists (section chiefs) working in the operating room are part of this APS. The means of providing satisfactory analgesia are already present in most hospitals. Careful planning and a multidisciplinary approach to pain management will ensure that resources are optimally utilized, and the quality of pain management is consistently maintained.

Acute Disease↗
PubMedDate not supplied

The addition of 0.2 mg subarachnoid morphine to hyperbaric bupivacaine for cesarean delivery: a prospective study of 856 cases.

In an effort to determine the incidence of respiratory depression and other side effects of subarachnoid morphine, we conducted the following prospective study in a large number (856) of young female patients undergoing cesarean delivery in one hospital. During the period from July 1987 to January 1989, patients receiving subarachnoid hyperbaric bupivacaine combined with 0.2 mg preservative-free morphine were included. They were continuously monitored for 24 hours using a pulse oximeter. For 24 hours, the vital signs, including respiratory rate every hour, and the side effects, including pruritus, nausea, and vomiting, were recorded. The need for analgesia and the total dose of opioids during the first 24 hours were documented. Our results showed that respiratory depression (SaO2 less than or equal to 85% and/or respiratory rate ten breaths per minute or less) occurred in eight patients, all of whom were markedly obese. Fifty-eight percent of the patients did not require analgesics for 24 hours. In those requiring an added opioid, the dose was (9.1 +/- 0.5 mg morphine, mean +/- SEM). Eighty-five percent of the patients were satisfied with the postoperative analgesia. Six percent were dissatisfied due to the side effects, i.e., pruritus, nausea and/or vomiting. Nine percent were dissatisfied with the pulse oximeter because it caused false alarms and limited their mobility.

Anesthesia, Obstetrical↗