1 Pain Clinic, St Richards Hospital, Chichester PO19 4E, UK. 2 Department of Anaesthesia, St. Georges Hospital, London SW17 0QT, UK. 3 Department of Public Health Sciences, St Georges Hospital Medical School, London SW17 0RE, UK*Corresponding author
Accepted for publication: April 18, 2002
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Abstract |
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Methods. A MEDLINE search of the literature was conducted for publications concerned with the management of postoperative pain. Over 800 original papers and reviews were identified. Of these 212 papers fulfilled the inclusion criteria but only 165 provided usable data on pain intensity and pain relief. Pooled data on pain scores obtained from these studies, which represent the experience of a total of nearly 20 000 patients, form the basis of this review.
Results. Different pain measurement tools provided comparable data. When considering a mixture of three analgesic techniques, the overall mean (95% CI) incidence of moderate-severe pain and of severe pain was 29.7 (26.433.0)% and 10.9 (8.413.4)%, respectively. The overall mean (95% CI) incidence of poor pain relief and of fair-to-poor pain relief was 3.5 (2.44.6)% and 19.4 (16.422.3)%, respectively. For i.m. analgesia the incidence of moderate-severe pain was 67.2 (58.176.2)% and that of severe pain was 29.1 (18.839.4)%. For PCA, the incidence of moderate-severe pain was 35.8 (31.440.2)% and that of severe pain was 10.4 (8.012.8)%. For epidural analgesia the incidence of moderate-severe pain was 20.9 (17.824.0)% and that of severe pain was 7.8 (6.19.5)%. The incidence of premature catheter dislodgement was 5.7 (4.07.4)%. Over the period 19731999 there has been a highly significant (P<0.0001) reduction in the incidence of moderate-severe pain of 1.9 (1.12.7)% per year.
Conclusions. These results suggest that the UK Audit Commission (1997) proposed standards of care might be unachievable using current analgesic techniques. The data may be useful in setting standards of care for Acute Pain Services.
Br J Anaesth 2002; 89: 40923
Keywords: analgesic techniques, intramuscular; analgesia, patient-controlled; anaesthetic techniques, epidural; pain, postoperative
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Introduction |
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There is evidence that pain services affect morbidity and duration of hospital stay.7 However, despite the vast amount published on acute pain there have been few if any attempts to establish standards of care for acute postoperative pain services, although a number of large audits have been published. In a brief reference to postoperative pain in 1997 the Audit Commission (UK) proposed a standard whereby less than 20% of patients should experience severe pain following surgery after 1997, and that this should ideally reduce to less than 5% by 2002.8 It is not clear from the Audit Commission document how these figures have been arrived at, nor how valid this standard might be. In the light of this recommendation we decided to review the published literature on acute pain management in order to establish the validity of the Audit Commissions proposed standard.
In the past, pain relief has been provided mainly by as required intramuscular (i.m.) injections of opioids. More recently, intravenous (i.v.) patient-controlled analgesia (PCA) and epidural analgesia have become popular, as they are perceived as being more effective. However, pain and pain relief are just one aspect of the wide range of outcome variables with which pain services are interest. For a review to be comprehensive it should consider three broad areas of outcome, such as effectiveness, safety, and tolerability. Effectiveness can be inferred from pain scores and pain relief reports. The incidence of respiratory depression and hypotension may be indicative of the safety of the techniques whilst tolerability is reflected by the occurrence of nausea and vomiting, sedation, itching, and the need for urinary catheterization. Psychological effects such as nightmares/hallucinations and panic attacks may also be important.
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Methods |
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All publications identified by the search strategy were categorized according to the level of evidence obtained, based broadly on the criteria of the US Preventive Task Force (Appendix I). Subsequent analysis was not confined to randomized controlled clinical trials but included cohort studies, case control studies, and audit reports; that is level 2 and level 3 evidence. Case reports were not included, nor were authors approached for raw or unpublished data. No attempt was made to grade individual papers according to quality. All of the studies used in the analysis were given equal value. Data extraction was undertaken by one author (S.D.). Figure 1 summarizes the methodology.
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Definitions
We were interested in obtaining, from the published literature, the incidence of analgesic failure after major surgery. Defining analgesic failure would involve making a number of assumptions, and may differ between patients and medical staff. We have simply calculated the overall incidence of pain intensity in two categories: the percentage of patients who experienced moderate-severe pain and the percentage of patients who experienced severe pain at some time during the first 24 h. We calculated these incidences for each of the three analgesic techniques in common practice: i.m. analgesia, PCA, and epidural analgesia.
Information was extracted from published studies, which reported pain scores using any one of three different measures; visual analogue scale (0100 mm), numerical rating scale (010), and verbal rating scales (mild/moderate/severe). The different measurements have been recorded and where studies involved comparison between drugs using the same technique (e.g. epidural opioids vs epidural local anaesthetics) the results have been pooled, to reflect what happens in clinical practice, such as a mixture of drug regimens. Where the study has compared analgesic techniques (PCA vs epidural) results have been recorded separately under each technique.
Studies used either contemporaneous pain assessments and/or retrospective pain assessments. For contemporaneous pain scores the worst score in the first 24 h was used, excluding recovery room. The percentage of patients with moderate-severe pain and with severe pain was recorded from each study and this figure was weighted by the number of patients in the study. Moderate-severe pain was taken as a visual score greater than 30/100 or a numerical score greater than 3/10 in this review, in common with most authors. In many but not all studies it was possible to obtain a separate figure for the percentage of patients experiencing severe pain, which was taken as pain intensity score of greater than 70/100 or 7/10. Only when pain intensity scores were reported as raw data, as percentages with moderate or severe pain, or as histograms were we able to extract incidence data. The commonest reason not to include pain intensity data was when pain scores were presented as mean and standard deviation. As the pain scores were unlikely to be normally distributed it was impossible to obtain the percentage of patients experiencing moderate-severe pain and severe pain. Commonly, a single verbal score was recorded after 24 h, whereas visual scores were often recorded contemporaneously at intervals during the 24 h period.
Several studies reported not only pain but also pain relief. Escape criteria such as the need for additional rescue analgesia was also reported in some studies. Most studies reported pain/pain relief at rest but there are some scales that combine pain at rest and on movement; these have been analysed separately.
A number of studies reported the incidence of premature catheter dislodgement, and as this was relevant to analgesic failure this was included in the study. Occasionally the incidence of missed segments or unilateral blocks was reported, but this was insufficient for formal analysis.
Statistics
The mean percentage reporting a given level of pain was found by the method of weighted mean, weighting by the number of subjects in the group.10 When patients were grouped by analgesic technique, some studies contributed subjects to more than one group. The presence of a few studies in more than one analgesic technique was ignored in the analysis, possibly resulting in a small loss of power. Where appropriate groups were compared using analysis of variance. The percentage of patients reporting pain was weighted by the number as described previously and this figure was used in the analysis rather than any other statistical transformation. This is because our main aim was to estimate the percentage reporting pain for the whole population. All analyses were done using Stata 5.0 (Stata Corp., College Station, TX).
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Results |
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Pain intensity
We initially analysed visual and verbal scales separately. Visual or verbal scales produced similar distributions for the percentage of patients having moderate or greater pain (Fig. 2). The corresponding distributions for severe pain are shown in Figure 3. Visual and verbal pain scales were compared using analysis of variance and there were no significant differences between the distributions.
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Over the period 19721998 significantly fewer patients reported poor pain relief (P<0.04), a decrease of 0.4 (95% CI 0.10.6) percentage points per year. When adjusted for analgesic technique the relationship was no longer significant. However, the proportion reporting fair-to-poor pain relief was unchanged over time.
Premature epidural catheter dislodgement
We have confined our analysis to the incidence of catheter loss as we felt that unilateral block and missed segment represented technical difficulties with instigating the block. The overall mean (95% CI) incidence of premature epidural catheter dislodgement based on 13 629 patients from 32 studies was 5.7 (4.07.4)%.
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Discussion |
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This review differs from a formal systematic review with meta-analysis in a number of respects. We did not confine ourselves to randomized controlled trials and no attempt was made to grade individual papers according to quality. All of the studies used in the analysis were given equal value as we were not concerned with the conclusion of the individual study merely the incidences of pain intensity. We feel that this approach is justified as we were not considering the results of published studies but were concerned with extracting the data from them. However, we did confine our search to English language publication because of the necessity to read in detail both the methods and results sections of each paper. This might be considered as a flaw although the large number of publications included will tend to reduce any tendency to bias. The hand search performed on four anaesthetic journals was designed to cross check the completion of the electronic search. As few new papers were picked up by this search method it was not extended to other journals. Data extraction was undertaken by one author, because we did not need to confer over quality of each study, simply extract reported incidence. A degree of heterogeneity is inevitable in a review of this type. However, we feel that the large numbers of studies included and the small number of differences sought will reduce the likelihood of statistical heterogeneity. Also, we were mindful of the dangers of over interpretation inherent in searching for causes of heterogeneity. Indeed, it has been suggested that over investigating heterogeneity may be likened to subgroup analysis in individual trials.13 Nevertheless, we have simply reported incidences of pain intensity, and refrained from formal statistical comparisons between analgesic techniques. With respect to clinical heterogeneity we found that the surgical case mix of the studies used was not only very similar between the three analgesic techniques but was also similar to that reported by Moriarty and colleagues14 and to the case mix of the Acute Pain Service in one of the authors hospitals (Table 6). We feel confident therefore that these findings mirror clinical practice.
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Analgesic failure has been described in various terms in different studies depending on which pain scale was used. Many studies using verbal rating scales regarded moderate or severe pain in the postoperative period as representing inadequate analgesia. In studies that have used visual scales, scores more than 30/100 or 3/10, respectively, were the most frequently used scores indicative of inadequate analgesia.17 18 Rarely lower scores (more than 20/100)19 or higher scores (more than 50/100)20 were used as endpoints to define inadequate analgesia. A visual score more than 70/100 was the most common endpoint to define severe pain, although more than 50 has been used.21 Another group has proposed that moderate pain on verbal score equates to a mean visual score of 49 mm, whilst severe pain equates to a mean visual score of 75 mm.16 Nevertheless, by analysing both visual and verbal scales separately we were able to demonstrate that, used in this way, these two scoring systems give broadly similar results, and can be used interchangeably.
A number of studies recorded pain both at rest and on movement. It is unclear whether patients distinguish between pain at rest and pain on movement. This may be influenced by such factors as presence of persistent cough, need for physiotherapy, dressing changes, etc. It is probable that, when patients are asked to rate pain over the previous 4 h or at the end of 24 h, they may not distinguish between pain at rest and pain on movement, but may give an overall assessment. It was interesting to note that measurement of pain on movement occurred mostly in studies involving epidural analgesia and seemed of less concern to authors reporting results for other techniques. There were sufficient data to calculate an overall incidence only for pain on movement for moderate-severe pain, but not for severe pain alone. It seems from the literature that pain on movement was reported relatively infrequently and the calculated incidence of pain was associated with wide confidence intervals. For this reason we have limited conclusions and recommendations to pain at rest, which was available for both moderate-severe pain and severe pain, and was associated with narrower confidence intervals.
A number of studies report not only pain intensity but also pain relief. Escape criteria such as the need for additional rescue analgesia have also been reported in some studies. The literature on pain relief after major surgery reports a wide range of effectiveness of analgesic techniques. It was unclear how to interpret the incidence of pain relief, as opposed to pain intensity. There were sufficient studies to calculate incidence of fair-to-poor pain relief and poor pain relief but confidence intervals were relatively wide. The incidences of pain relief do not match the incidences of pain intensity, either overall or for each analgesic technique. It is possible that the incidence of pain intensity is a more direct measure, as pain relief will presumably vary with initial pain intensity.
Our findings that i.m. analgesia was associated with the highest percentage of patients experiencing inadequate analgesia support the general view that it is the least effective of the three techniques studied. Although using strict criteria for administration, i.m. analgesia can be an effective technique,22 23 the literature suggests this does not occur in clinical practice. The rate of analgesia failure after i.m. analgesia has received relatively scant attention in the literature; there were only 45 published articles (many acting as control groups for other techniques) with no large prospective studies as exist for both PCA and epidural analgesia. Epidural analgesia is generally considered more effective than PCA. Large prospective studies of epidural analgesia such as Scott report 17.4% analgesic failure22 and Stenseth reported 2437% of patients after laparotomy experienced analgesic failure by their criteria.25 Our review indicates a lower incidence of moderate-severe pain and severe pain when epidural was used (20.9 and 7.8%, respectively) compared with PCA (35.8 and 10.4%, respectively). The epidural figures are undoubtedly confounded by technical failures such as premature epidural catheter displacement, which we found to have an incidence of 5.7%. Epidural analgesia does present some particular challenges to pain services. The rate of technical failure has been reported as high as 18.7% in the first 72 h.25 In addition to premature catheter dislodgement, problems include unsuccessful placement, unilateral block, and missed segments. When these problems occur on postoperative wards there may be no back-up analgesia provided, and it may take time for the problem to be recognized and an appropriate response initiated.
We avoided any measures of patient satisfaction in this review, although some studies did report satisfaction rates. Satisfaction is complex and probably has contributions from many aspects of postoperative care, including effectiveness of analgesia, and perceived safety of analgesic technique and side-effects of treatment. While a number of studies have assessed patient satisfaction and measuring postoperative pain intensity, there was generally a poor correlation between the two. Patient satisfaction remains high even in the presence of moderate to severe pain.17 26 27 The reasons for this are complex. Patients appear to expect some pain after surgery. Furthermore, in the presence of pain, patients are apparently satisfied by the fact that their health carers are attempting to provide pain relief even if the results are not always successful, as judged by postoperative pain scores. Satisfaction does not actually measure what happened after surgery, but only how satisfied the patient was about what happened. If patients are not aware that excellent postoperative pain relief is achievable then they may well be satisfied with less. Patients may not seek complete pain relief and so self-administer PCA to only moderate levels of pain relief.28 In addition patients may report higher satisfaction for fear of offending those providing their postoperative care. Measuring patient satisfaction will, it seems, nearly always show high levels of satisfaction for pain relief after surgery, and it is not a particularly discriminating measure of success of a pain service.
In summary, we present a review of published data on the effectiveness of acute postoperative pain management from which it has been possible to calculate the incidence of moderate-severe pain and of severe pain after major surgery for each of the three commonly used analgesic techniques. Assuming a mixture of analgesic techniques the overall incidence of moderate-severe pain was 30% and the overall incidence of severe pain was 11%. For i.m. analgesia the incidence of moderate-severe pain was 67% and that of severe pain was 29%. For PCA, the incidence of moderate-severe pain was 36% and that of severe pain was 10%. For epidural analgesia the incidence of moderate-severe pain was 21% and that of severe pain was 8%. The incidence of premature epidural catheter dislodgement was 6%. These incidences of pain are calculated weighted means and so it is possible to propose reasonable targets. We suggest that individual pain services should aim to achieve figures better than the above mean incidences. However, despite the significant reduction in the incidence of pain over time we would suggest that, based on these data, the UK Audit Commissions standard of less than 5% of patients experiencing severe pain after major surgery by 2002 may not be achievable.
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Appendix I |
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Level 2
Evidence from one or more well-designed randomized clinical trial (RCT).
Level 3
Evidence from well-designed, non-controlled studies (prospective longitudinal study with/without specific intervention) or from well-designed case-controlled studies (retrospective study of a cohort with information pursued backwards in time).
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Appendix II |
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Bennett R, Batenhorst R, Graves DA, Foster TS, Griffen WO, Wright BD. Variation in postoperative analgesic requirements in the morbidly obese following gastric bypass surgery. Pharmacotherapy 1982; 2: 503
Bollish SJ, Collins CL, Kirking DM, Bartlett RH. Efficacy of patient controlled versus conventional analgesia for postoperative pain. Clin Pharm 1985; 4: 4852
Bourke DL, Spatz E, Motara R, Ordia JI, Reed J, Hlavacek JM. Epidural opioids during laminectomy surgery for postoperative pain. J Clin Anaesth 1992; 4: 27781
Brewington K. PCA in gynecological surgery. Alabama Med 1989; Nov: 1517
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Chen PP, Chui PT, Gin T. Comparison of ondansetron and metoclopramide for the prevention of postoperative nausea and vomiting after major gynaecological surgery. Eur J Anaesthesiol 1996; 13: 48591
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Donovan BD. Patient attitudes to postoperative pain relief. Anaesth Intensive Care 1983; 11: 1258
Eisenach JC, Grice SC, Dewan DM. Patient controlled analgesia following cesarean section; a comparison with epidural and intramuscular narcotics. Anesthesiology 1988; 68: 4448
Goudie TA, Allan WB, Lonsdale M, Burrow LM, Macrae WA, Grant IS. Continuous subcutaneous infusion of morphine for postoperative pain relief. Anaesthesia 1985; 40: 108692
Gurel A, Unal N, Elevli M, Eren A. Epidural morphine for postoperative pain relief in anorectal surgery. Anesth Analg 1986; 65: 459502
Harrison DH, Sinatra R, Morgese L, Chung JH. Epidural narcotic and PCA for post cesarean section pain relief. Anesthesiology 1988; 68: 4547
Hasenbos M, van Egmund J, Gielen M, Crul JF. Postoperative analgesia by epidural versus intramuscular nicomorphine after thoracotomy. Part 1. Acta Anaesthesiol Scand 1985; 29: 5726
Hasenbos M, van Egmond J, Gielen M, Crul JF. Postoperative analgesia by epidural versus intramuscular nicomorphine after thoracotomy. Part II. Acta Anaesthesiol Scand 1985; 29: 57782
Hasenbos M, van Egmond J, Gielen M, Crul JR. Postoperative analgesia by high thoracic epidural versus intramuscular nicomorphine after thoracotomy. Acta Anaesthesiol Scand 1987; 31: 60815
Hew E, Foster K, Gordon R, Hew-Sang E. A comparison of nalbuphine and meperidine in treatment of postoperative pain. Can J Anaesth 1987; 34: 4625
Hjortso NC, Neumann P, Frosig F, Andersen T, Lindhard A, Rogon E, Kehlet H. A controlled study on the effect of epidural analgesia with local anaesthetics and morphine on morbidity after abdominal surgery. Acta Anaesthesiol Scand 1985; 29: 7906
Jayr C, Thomas H, Rey A, Farhat F, Lasser P, Bourgain J. Postoperative pulmonary complications: epidural analgesia using bupivacaine and opioids versus parenteral opioids. Anesthesiology 1993; 78: 66676
Kalso E, Pertunnen K, Kaasinen S. Pain after thoracic surgery. Acta Anaesthesiol Scand 1992; 36: 96100
Kenady DE, Wilson JF, Schwartz RW, Bannon CL. A randomised comparison of PCA versus standard analgesic requirements in patients undergoing cholecystetomy. Surg Gynecol Obstet 1992; 174: 2168
Kilbride MJ, Senagore AJ, Mazier WP, Ferguson C, Ufkes T. Epidural analgesia. Surg Gynecol Obstet 1992; 174: 13740
Kuhn S, Cooke K, Collins M, Jones JM, Mucklow JC. Perceptions of pain relief after surgery. BMJ 1990; 300: 168790
Lange MP, Dahn MS, Jacobs LA. PCA versus intermittent analgesia dosing. Heart Lung 1988; 17: 4958
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Logas WG, el-Baz N, el-Ganzouri A, et al. Continuous thoracic epidural analgesia for postoperative pain relief following thoracotomy. Anesthesiology 1987; 67: 78791
Mahoney OM, Noble PC, Davidson J, Tullos HS. The effect of continuous epidural analgesia on postoperative pain, rehabilitation and duration of hospitalisation in total knee arthroplasty. Clin Orthop Related Res 1990; 260: 307
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Owen H, McMillan V, Rogowski D. Postoperative pain therapy: a survey of patients expectations and their experiences. Pain 1990; 41: 3037
Powell H, Smallman JM, Morgan M. Comparison of intramuscular ketorolac and morphine in pain control after laparotomy. Anaesthesia 1990; 45, 53842
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Vijayan R. Subcutaneous morphinea simple technique for postoperative analgesia. Acute Pain 1997; 1: 216
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Appendix III |
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Atwell JR, Flanigan RC, Bennett RL, Allen DC, Lucas BA, McRoberts JW. The efficacy of patient controlled analgesia in patients recovering from flank incisions. J Urol 1984; 132: 7013
Badner NH, Doyle JA, Smith MH, Herrick IA. Effect of varying intravenous PCA dose and lockout interval while maintaining a constant hourly maximum dose. J Clin Anesth 1996; 8: 3825
Bahar M, Rosen M, Vickers MD. Self-administered nalbuphine, morphine and pethidine. Anaesthesia 1985; 40: 52932
Bennett RL, Batenhorst RL, Bivins BA, et al. PCA: a new concept of postoperative pain relief. Ann Surg 1982; 195: 7004
Bennett RL, Batenhorst RL, Graves DA, Foster TS, Griffen WO, Wright BD. Variation in postoperative analgesic requirements in the morbidly obese following gastric bypass surgery. Pharmacotherapy 1982; 2: 503
Black AM, Goodman NW, Bullingham RE, Lloyd J. Intramuscular ketorolac and morphine during PCA after hysterectomy. Eur J Anaesthesiol 1990; 7: 917
Blackburn A, Stevens JD, Wheatley RG, Madej TH, Hunter D. Balanced analgesia with intravenous kerorolac and PCA morphine following abdominal surgery. J Clin Anaesth 1995; 7: 1038
Bollish SJ, Collins CL, Kirking DM, Bartlett RH. Efficacy of patient controlled versus conventional analgesia for postoperative pain. Clin Pharm 1985; 4: 4852
Cepeda MS, Vargas L, Ortegan G, Samnchez MA, Carr DB. Comparative analgesic efficacy of patient controlled analgesia with ketorolac versus morphine after elective intra-abdominal operations. Anesth Analg 1995; 80: 11503
Chauvin M, Hongnat JM, Mourgeon E, Lebrault C, Bellanfant F, Alfonsi P. Equivalence of postoperative analgesia with patient controlled intravenous or epidural alfentanil. Anesth Analg 1993; 76: 12518
Coleman SA, Brooker-Milburn J. Audit of postoperative pain control. Anaesthesia 1996; 51: 10936
Dahl JB, Daugaard JJ, Larsen HV, Nielsen TH, Kristoffersen E. Patient controlled analgesia: a controlled trial. Acta Anaesthesiol Scand 1987; 31: 7447
Dawson PJ, Libreri FC, Jones DJ, Libreri G, Borkstein AR, Royse CF. The efficacy of adding a continuous intravenous morphine infusion to patient controlled analgesia in abdominal surgery. Anaesth Intensive Care 1995; 23: 4538
Dingus DJ, Sherman JC, Rogers DA, DiPiro JT, May R, Bowden TA. Buprenorphine versus morphine for PCA after cholecystectomy. Surg Gynecol Obstet 1993; 177: 16
Eisenach JC, Grice SC, Dewan DM. Patient controlled analgesia following cesarean section; a comparison with epidural and intramuscular narcotics. Anesthesiology 1988; 68: 4448
Etches RC, Warriner CB, Badner N, et al. Continuous intravenous administration of ketorolac reduces pain and morphine consumption after total hip and knee arthroplasty. Anesth Analg 1995; 81: 117580
Gallion HH, Wermeling DP, Foster TS, VanNagell JR, Donaldson ES. PCA in gynaecologic oncology. Gynecol Oncol 1987; 27: 24752
George KA, Wright PM, Chisakuta A, et al. Thoracic epidural analgesia compared with patient controlled intravenous morphine after upper abdominal surgery. Acta Anaesthesiol Scand 1994; 38: 80812
Gilliland HE, Prasad BK, Mirakhur RK, Fee JP. An investigation of the potential morphine sparing effect of midazolam. Anaesthesia 1996; 51: 80811
Hansen LE, Noyes MA, Lehman ME. Evaluation of PCA versus PCA plus continuous infusion in postoperative cancer patients. J Pain Symptom Manage 1991; 6: 414
Harmer M, Slattery P, Rosen M, Vickers MD. Intramuscular on demand analgesia: double blind controlled trial of pethidine, buprenorphine, morphine and meptazinol. Br J Anaesth 1983; 286: 6802
Harrison DM, Sinatra R, Morgese L, Chung JH. Epidural narcotic and PCA for post-cesarean section pain relief. Anesthesiology 1988, 68: 4547
Jayr C, Beaussier M, Gustafsson Y, et al. Continuous epidual infusion of ropivacaine for postoperative analgesia after abdominal surgery. Br J Anaesth 1998; 81: 88792
Kenady DE, Wilson JF, Schwartz RW. Bannon CL. A randomised comparison of PCA versus standard analgesic requirements in patients undergoing cholecystetomy. Surg Gynecol Obstet 1992; 174: 2168
Kilbride MJ, Senagore AJ, Mazier WP, Ferguson C, Ufkes T. Epidural analgesia. Surg Gynecol Obstet 1992; 174: 13740
Klasen JA, Opitz SA, Melzer C, Thiel A, Hempelmann G. Intrarticular, epidural and intravenous analgesia after total knee arthoplasty. Acta Anaesthesiol Scand 1999; 43: 10216
deKock MF, Pinchon GP, Scholtes JL. Intraoperative clonidine enhances postoperative morphine PCA. Can J Anaesth 1992; 39: 53744
van Lancker P, Mortier E, Pieters A, Rolly G. Evaluation of morphine for PCA with the infusorsystem after opiate free locoregional anesthesia for osteotomy of the foot. Acta Anaesthesiol Belgica 1995; 46: 1139
Lange MP, Dahn MS, Jacobs LA. PCA versus intermittent analgesia dosing. Heart Lung 1988; 17: 4958
Lehmann KA, Kratzenberg U, Schroeder-Bark B, Horrichs-Haermeyer G. Postoperative PCA with tramadol: analgesic efficacy and minimum effective concentrations. Clin J Pain 1990; 6: 21220
Lehmann KA, Ribbert N, Horrichs-Haermeyer G. Postoperative PCA with alfentanil: anlgesic efficacy and minimum effective concentrations. J Pain Symptom Manage 1990; 5: 24958
Lehmann KA, Gerhard A, Horrichs-Haermeyer G, Grond S, Zech D. Postoperative PCA with sufentanil: analgesic efficacy and minimum effective concentrations. Acta Anaesthesiol Scand 1991; 35: 2216
de Leon-Casasola O, Lema MJ, Karabella D, Harrison P. Postoperative myocardial ischaemia: epidural v intravenous PCA. Reg Anesth 1995; 20: 10512
Loper KA, Ready LB, Nessly M, Rapp SE. Epidural morphine provides greater pain relief than PCA intravenous morphine following cholecystectomy. Anesth Analg 1989; 69: 8268
Loper KA, Ready LB, Downey M, et al. Epidural and intravenous fentanyl infusions are clinically equivalent after knee surgery. Anesth Analg 1990; 70: 725
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McKenzie R, Rudy T, Ponter-Hammill M. Side effects of morphine PCA and meperidine PCA: a follow-up of 500 patients. J Am Assoc Nurse Anesth 1992; 60: 2827
van den Nieuwenhuyzen MC, Engbers FH, Burm AG, Vletter AA, van Kleef JW, Bovill JG. Computer controlled infusion of alfentanil versus patient controlled administration of morphine for postoperative analgesia: a double blind randomised trial. Anesth Analg 1995; 81: 6719
Notcutt WG, Morgan RJ. Introducing patient-controlled analgesia for postoperative pain control into a district general hospital. Anaesthesia 1990; 45: 4016
Owen H, Plummer JL, Armstrong I, Mather LE, Cousins MJ. Variables of PCA 1: bolus size. Anaesthesia 1989, 44: 710
Owen H, Currie JC, Plummer JL. Variation in the blood concentration/analgesic response relationship during PCA with fentanyl. Anaesth Intensive Care 1991; 19: 55560
Parker RK, Holtmann B, White PF. PCA: does concurrent opioid infusion improve pain management after surgery. JAMA 1991; 266: 194752
Persson K, Sjostrom S, Sigurdartdottir I. Patient controlled analgesia with codeine for postoperative pain relief in ten extensive metabolisers and one poor metaboliser of dextromethorphan. Br J Clin Pharmacol 1995; 39: 1826
Pryle BJ, Vanner RG, Enriquez N, Reynolds F. Can pre-emptive lumbar epidural blockade reduce postoperative pain following lower abdominal surgery. Anaesthesia 1993; 48: 1203
Pueyo FJ, Carrascosa F, Lopez L, Iribarren MJ, Garcia-Pedrajas F, Saez A. Combination of ondasetron and droperidol in the prophylaxis of postoperative nausea and vomiting. Anesth Analg 1996; 83: 11722
Robinson SL, Rowbotham DJ, Mushambi M. Electronic and disposable PCA systems. Anaesthesia 1992; 47: 1613
Rosenberg PH, Heino A, Scheinin B. Comparison of IM analgesia, intercostal block, epidural morphine and on-demand intravenous fentanyl in the control of pain after upper abdominal surgery. Acta Anaesthesiol Scand 1984; 28: 6037
Russell AW, Owen H, Ilsley AH, Kluger MT, Plummer JL. Background infusion with patient controlled analgesia: effect on postoperative oxyhaemoghlobin saturation and pain control. Anaesth Intensive Care 1993; 21: 1749
Sands RP, de Leon-Casasola OA, Harrison P, Velagapudi S, Lema MJ. Randomised double blind comparison of epidural and intravenous fentanyl for postoperative pain. Acute Pain 1997; 1: 714
Sawaki Y, Parker RK, White PF. Patient and nurse evaluation of PCA delivery systems for postoperative pain management. J Pain Symptom Manage 1992; 7: 44353
Schug SA, Fry RA. Continuous regional analgesia in comparison with intravenous opioid administration for routine postoperative pain control. Anaesthesia 1994; 49: 52832
Scott DA, Chamley DM, Mooney PH, Deam RK, Mark AH, Hagglof B. Epidural ropivacaine infusion for postoperative analgesia after major lower abdominal surgerya dose finding study. Anesth Analg 1995; 81: 9826
Searle NR, Roy M, Bergeron G, et al. Hydromorphone PCA after coronary artery bypass surgery. Can J Anaesth 1994; 41: 198205
Sharma SK, Davies MW. Patient controlled analgesia with a mixture of morphine and droperidol. Br J Anaesth 1993; 71: 4356
Shipton EA, Beeton AG, Minkowitz HS. Introducing a PCA based Acute Pain relief service into southern Africathe first 10 months. SAMJ 1993; 83: 50155
Sidebotham D, Dijkhuizen MR, Schug SA. The safety and utilization of patient controlled analgesia. J Pain Symptom Manage 1997; 14: 2029
Smythe M, Loughlin K, Schad RF, Lucarroti RL. PCA versus intramuscular analgesic therapy. Am J Hosp Pharm 1994; 51: 143341
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Tsui SL, Lo RJ, Tong W, et al. A clinical audit for postoperative pain control on 1443 surgical patients. Acta Anaesthesiol Sin 1995; 33: 13748
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Tsui SL, Lee DK, Ng KF, Chan TY, Chan WS, Lo JW. Epidural infusion of bupivacaine plus fentanyl provides better postoperative analgesia than patient controlled analgesia with intravenous morphine after gynaecological laparotomy. Anaesth Intensive Care 1997; 25: 47681
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Wheatley RG, Madej TH, Jackson IJ, Hunter D. The first years experience of an acute pain service. Br J Anaesth 1991; 67: 3539
White WD, Pearce DJ, Norman J. Postoperative analgesia: a comparison of intravenous on-demand fentanyl with epidural bupivacaine. BMJ 1979; 2: 1667
White PF. Subcutaneous PCA: an alternative to intravenous PCA for postoperative pain management. Clin J Pain 1990; 6: 297300
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Zacharias M, Pfeifer MV, Herbison P. Comparison of two methods of intravenous administration of morphine for postoperative pain relief. Anaesth Intensive Care 1990; 18: 2059
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Appendix IV |
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Bailey PW, Smith BE. Continuous epidural infusion of fentanyl for postoperative analgesia. Anaesthesia 1980; 35: 10026
Baker MW, Tullos HS, Bryan WJ, Oxspring H. The use of epidural morphine in patients undergoing total knee arthroplasty. J Arthroplasty 1989; 4: 1579
Banning AM, Schmidt JF, Chraemmer-Jorgensen B, Risbo A. Comparison of oral controlled release morphine and epidural morphine in the management of postoperative pain. Anesth Analg 1986; 65: 3858
el-Baz N, Goldin M. Continuous epidural infusion of morphine for pain relief after cardiac operations. J Thorac Cardiovasc Surg 1987; 93: 87883
Bisgaard C, Mouridsen P, Dahl J. Continuous lumbar epidural bupivacaine plus morphine v. epidural morphine after major abdominal surgery. Eur J Anaesthesiol 1990; 7: 21925
Brodsky JB, Chaplan SR, Brose WG, Mark JB. Continuous epidural hydromorphone for postthoracotomy pain relief. Ann Thor Surg 1990; 50: 88893
Broekema AA, Gielein MJ, Hennis PJ. Postoperative analgesia with continuous epidural sufentanil and bupivacaine. Anesth Analg 1996; 82: 7549
Burstal R, Wegener F, Hayes C, Lantry G. Epidural analgesia: prospective audit of 1062 patients. Anaesth Intensive Care 1998; 26: 16572
Cahill J, Murphy D, OBrien D, Mulhall J, Fitzpatrick G. Epidural buprenorphine for pain relief after major abdominal surgery. Anaesthesia 1983; 38: 7604
Callesen T, Scouenberg L, Nielsen D, Guldager H, Kehlet H. Combined epidural-spinal opioid free anaethesia and analgesia for hysterectomy. Br J Anaesth 1999; 82: 88588
Capdevila X, Barthelet Y, Biboulet P, Ryckwaert Y, Rubenovitch J, dAthis F. Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery. Anesthesiology 1999; 91: 815
Chaplan S, Duncan S, Brodsky J, Brose W. Morphine and hydromorphone epidural analgesia. Anesthesiology 1992; 77: 10904
Chauvin M, Hongnat JM, Mourgeon E, Lebrault C, Bellenfant F, Alfonsi P. Equivalence of postoperative analgesia with patient controlled intravenous or epidural alfentanil. Anesth Analg 1993; 76: 12518
Chisakuta AM, George KA, Hawthorne CT. Postoperative epidural infusion of a mixture of bupivacaine with fentanyl for upper abdominal surgery. Anaesthesia 1995; 50: 725
Chrubasik J, Wiemers K. Continuous plus on demand epidural infusion of morphine for postoperative pain relief by means of a small externally worn infusion device. Anesthesiology 1985; 62: 2637
Coleman SA, Brooker-Milburn J. Audit of postoperative pain control. Anaesthesia 1996; 51: 10936
Conacher I, Paes M, Jacobsen L, Phillips P, Heaviside D. Epidural analgesia following thoracic surgery. Anaesthesia 1983; 38: 54651
Cox CR, Serpell MG, Bannister J, Coventry DM, Williams DR. A comparison of epidural infusions of fentanyl or pethidine with bupivacaine in the management of postoperative pain. Anaesthesia 1996; 51: 6958
Cullen M, Staren E, El-Ganzouri, Logas W, Ivankovich A, Economou S. Continuous epidural infusion for analgesia after major abdominal operations. Surgery 1985; 98: 71826
Dahl JB, Hansen BL, Hjortso NC, Erichsen CJ, Moiniche S, Kehlet H. Influence of timing on the effect of continuous extradural analgesia with bupivacaine and morphine after major abdominal surgery. Br J Anaesth 1992; 69: 48
Duncan LA, Fried MJ, Lee A, Wildsmith JA. Comparison of continuous and intermittent adminstration of extradural bupivacaine for analgesia after lower abdominal surgery. Br J Anaesth 1998; 80: 710
Eisenach JC, Grice SC, Dewan DM. Patient controlled analgesia following cesarean section; a comparison with epidural and intramuscular narcotics. Anesthesiology 1988; 68: 4448
Etches RC, Sandler AN, Lawson SL. A comparison of the analgesic and respiratory effects of epidural nalbuphine or morphine in post-thoracotomy patients. Anesthesiology 1991; 75: 914
Fromme GA, Steidl LJ, Danielson DR. Comparison of lumbar and thoracic morphine for relief of postthoracotomy pain. Anesth Analg 1985; 64: 4545
George KA, Wright PM, Chisakuta A. Continuous epidural fentanyl for post-thoracotomy pain relief. Anaesthesia 1991; 46: 7326
George KA, Chisakuta AM, Gamble JA, Browne GA. Thoracic epidural infusion for postoperative pain relief following abdominal aortic surgery. Anaesthesia 1992; 47: 38894
George KA, Wright PM, Chisakuta AM, Rao NV. Thoracic epidural analgesia compared with patient controlled intravenous morphine after upper abdominal surgery. Acta Anaesthesiol Scand 1994; 38: 80812
Griffiths DP, Diamond AW, Cameron JD. Postoperative extradural analgesia following thoracic surgery: a feasibility study. Br J Anaesth 1975; 47: 4854
Gundersen RY, Andersen R, Narverud G. Postoperative pain relief with high dose epidural buprenorphine: a double blind study. Acta Anaesthesiol Scand 1986; 30: 6647
Hansdottir V, Bake B, Nordberg G. The analgesic efficacy and adverse effects of continuous epidural sufentanil and bupivacaine infusion after thoracotomy. Anesth Analg 1996; 83: 394400
Harbers JB, Hasenbos MA, Gort C, Folgering H, Dirksen R, Gielen MJ. Ventilatory function and continuous high thoracic epidural administration of bupivacaine with sufentanil intravenously or epidurally: a double blind comparison. Reg Anesth 1991; 16: 6571
Harrison DM, Sinatra R, Morgese L, Chung JH. Epidural narcotic and PCA for post-cesarean section pain relief. Anesthesiology 1988; 68: 4547
Hasenbos M, Van Egmond J, Gielen M, Crul JF. Postoperative analgesia by epidural versus intramuscular nicomorphine after thoracotomy. Part II. Acta Anaesthesiol Scand 1985; 29: 57782
Hasenbos M, van Egmond J, Gielen M, Crul JF. Postoperative analgesia by high thoracic epidural versus intramuscular nicomorphine after thoracotomy. Acta Anaesthesiol Scand 1987; 31: 60815
Hjortso NC, Neumann P, Frosig F, et al. A controlled study on the effect of epidural analgesia with local anaesthetics and morphine on morbidity after abdominal surgery. Acta Anaesthesiol Scand 1985; 29: 7906
Hjortso NC, Lund C, Mogensen T, Bigler D, Kehlet H. Epidural morphine improves pain relief and maintains sensory analgesia during continuous epidural bupivacaine after abdominal surgery. Anesth Analg 1986; 65: 10336
Hobbs GJ, Roberts FL. Epidural infusion of bupivacaine and diamorphine for postoperative analgesia: use on general surgical wards. Anaesthesia 1992; 47: 5862
Holmdahl MH, Sjogren S, Strom G, Wright B. Clinical aspects of continuous epidural blockade for postoperative pain relief. Upsala Med J 1972; 77: 4756
Hurford WE, Dutton RP, Alfille PH, Clement D, Wilson RS. Comparison of thoracic and lumbar epidural infusions of bupivacaine and fentanyl for postthoracotomy analgesia. J Cardiothorac Vasc Anaesth 1993; 7: 5215
Jayr C, Thomas H, Rey A, Farhat F, Lasser P, Bourgain JL. Postoperative pulmonary complications: epidural analgesia using bupivacaine and opioids v. parenteral opioids. Anesthesiology 1993; 78: 66676
Jayr C, Beaussier M, Gustafsson Y, et al. Continuous epidual infusion of ropivacaine for postoperative analgesia after abdominal surgery. Br J Anaesth 1998; 81: 88792
Kilbride MJ, Senagore AJ, Mazier WP, Ferguson C, Ufkes T. Epidural analgesia. Surg Gynecol Obstet 1992; 174: 13740
Klasen JA, Opitz SA, Melzer C, Thiel A, Hempelmann G. Intrarticular, epidural and intravenous analgesia after total knee arthroplasty. Acta Anaesthesiol Scand 1999; 43: 10216
de Kock M, Gautier P, Pavlopolou A, Jonniaux M, Lavandhomme P. Epidural clonidine or bupivacaine as the sole analgesic agent during and after abdominal clonidine. Anesthesiology 1999; 90: 135462
Larsen VH, Iversen AD, Christensen P, Andersen PK. Postoperative pain treatments after upper abdominal surgery with epidural morphine at thoracic or lumbar level. Acta Anaesthesiol Scand 1985; 29: 56671
Laveaux MM, Hasenbos MA, Harbers JB, Liem T. Thoracic epidural bupivacaine plus sufentanil: high concentration/low volume versus low concentration/high volume. Reg Anaesth 1993; 18: 3943
Lee A, Simpson D, Whifield A, Scott D. Postoperative analgesia by continuous extradural infusion of bupivacaine and diamorphine. Br J Anaesth 1988; 60: 84550
Leith S, Wheatley RG, Jackson IJ, Madej TH, Hunter D. Extradural infusion analgesia for postoperative pain relief. Br J Anaesth 1994; 73: 5528
de Leon-Casasola OA, Lema MJ, Karabella D, Harrison P. Postoperative myocardial ischaemia: epidural versus intravenous PCA. Reg Anesth 1995; 20: 10512
Logas WG, el-Baz N, el-Ganzouri A, et al. Continuous thoracic epidural analgesia for postoperative pain relief following thoracotomy. Anesthesiology 1987; 67: 78791
Loper KA, Ready LB. Epidural morphine after anterior cruciate ligament repair: a comparison with patient-controlled intravenous morphine. Anesth Analg 1989; 68: 3502
Loper KA, Ready LB, Nessly M, Rapp SE. Epidural morphine provides greater pain relief than PCA intravenous following cholecystectomy. Anesth Analg 1989; 69: 8268
Loper KA, Ready LB, Downey M, et al. Epidural and intravenous fentanyl infusions are clinically equivalent after knee surgery. Anesth Analg 1990; 70: 725
Lubenow TR, Faber LP, McCarthy RJ, Hopkins EM, Warren WH, Ivankovitch AD. Post-thoracotomy pain management using continuous epidural analgesia in 1324 patients. Ann Thorac Surg 1994; 58: 92430
Lubenow TR, Tanck EN, Hopkins EM, et al. Comparison of patient assisted epidural analgesia with continuous epidural analgesia for postoperative patients. Reg Anesthesia 1994; 19: 20611
Magora F, Olshwang D, Eimerl D, et al. Observations on extradural morphine analgesia in various pain conditions. Br J Anaesth 1980; 52: 24752
Mahoney OM, Noble PC, Davidson J, Tullos HS. The effect of continuous epidural analgesia on postoperative pain, rehabilitation and duration of hospitalisation in total knee arthroplasty. Clin Orthopaed Related Res 1990; 260: 307
Marlowe S, Engstrom R, White PF. Epidural PCA: an alternative to continuous epidural infusions. Pain 1989; 37: 97101
Mehnert JH, Dupont TJ, Rose DH. Intermittent epidural morphine instillation for control of postoperative pain. Am J Surg 1983; 146: 14551
Mehta Y, Juneja R, Madhok H, Trehan N. Lumbar versus thoracic epidural buprenorphine for postoperative analgesia following coronary artery bypass graft surgery. Acta Anaesthesiol Scand 1999; 43: 38893
Mogensen T, Hjortso NC, Bigler D, Lund C, Kehlet H. Unpredictability of regression of analgesia during the continuous postoperative extradural infusion of bupivacaine. Br J Anaesth 1988; 60: 5159
Mourisse J, Hasenbos MA, Gielen MJ, Moll JE, Cromheecke GJ. Epidural bupivacaine, sufentanil or the combination for post-thoracotomy pain. Acta Anaesthesiol Scand 1992; 36: 704
Muldoon T, Milligan K, Quinn P, Connolly DC, Nilsson K. Comparison between extradural infusion of ropivacaine or bupivacaine for the prevention of postoperative pain after total knee replacement. Br J Anaesth 1998; 80: 6801
Nolan J, Dow A, Parr M, et al. Patient controlled epidural analgesia following post-traumatic pelvic reconstruction. Anaesthesia 1992; 47: 103741
Owen H, Kluger MT, Ilsley AH, Baldwin AM, Fronsko RR, Plummer JL. The effect of fentanyl administered epidurally by patient controlled analgesia, continuous infusion, or a combined technique of oxyhaemoglobin saturation after abdominal surgery. Anaesthesia 1993; 48: 205
Raj PP, Knarr DC, Vigdorth E, et al. Comparison of continuous infusion of a local anaesthetic and administration of systemic narcotics in the management of pain after total knee replacement surgery. Anesth Analg 1987; 66: 4016
Rawal N, Sjostrand U, Dahlstrom B. Postoperative pain relief by epidural morphine. Anesth Analg 1981; 60: 72631
Rawal N, Sjostrand U, Christoffersson E, Dahlstrom B, Arvill A, Rydman H. Comparison of intramuscular and epidural morphine for postoperative analgesia in the grossly obese. Anesth Analg 1984; 63: 58392
Rawal N, Schott U, Dahlstrom B, et al. Influence of naloxone infusion of analgesia and respiratory depression following epidural morphine. Anesthesiology 1986; 64: 194201
Renaud B, Brichant JF, Clergue F, Chauvin M, Levron JC, Viars P. Ventilatory effects of continuous epidural infusion of fentanyl. Anesth Analg 1988; 67: 9715
Rosenberg PH, Heino A, Scheinin B. Comparison of intramuscular analgesia, intercostal block, epidural morphine and on-demand intravenous fentanyl in the control of pain after upper abdominal surgery. Acta Anaesthesiol Scand 1984; 28: 6037
Ross R, Clarke J, Armitage E. Postoperative pain prevention by continuous epidural infusion. Anaesthesia 1980; 35: 6638
Rosseel PM, van den Broek WG, Boer EC, Prakash O. Epidural sufentanil for intra and postoperative analgesia in thoracic surgery: a comparative study with intravenous sufentanil. Acta Anaesthesiol Scand 1988; 32: 1938
Rygnestad T, Borchgrevink P, Eide E. Postoperative epidural infusion of morphine and bupivacaine is safe on surgical wards. Acta Anaesthesiol Scand 1997; 41: 86879
Rygnestad T, Zahlsen K, Bergslien O, et al. Focus on mobilisation after lower abdominal surgery. A double blind randomised comparison of epidural bupivacaine with morphine versus lidocaine with morphine postoperative analgesia. Acta Anaesthesiol Scand 1999; 43: 3807
Salomaki TE, Laitinen JO, Nuutinen LS. A randomized double blind comparison of epidural versus intravenous fentanyl infusion for analgesia after thoracotomy. Anesthesiology 1991; 75: 7905
Salomaki TE, Laitinen JO, Vainionpaa V, Nuutinen LS. 0.1% bupivacaine does not reduce the requirement for epidural fentanyl infusion after major abdominal surgery. Reg Anesth 1995; 20: 43543
Salomaki T, Kokki H, Turunen M. Havukainen U, Nuutinen L. Introducing epidural fentanyl for on-ward pain relief after major surgery. Acta Anaesthesiol Scand 1996; 40: 7049
Sandler AN, Stringer D, Panos L, et al. A randomized double-blind comparison of lumbar epidural and iv fentanyl infusions for post-thoracotomy pain relief. Anesthesiology 1992; 77: 62634
Sands RP, de Leon-Casasola OA, Harrison P, Velagapudi S, Lema MJ. Randomised double blind comparison of epidural and intravenous fentanyl for postoperative pain. Acute Pain 1997; 1: 714
Sawchuck CW, Ong B, Unruh HW, Horan TA, Greengrass R. Thoracic versus lumbar epidural fentanyl for post-thoracotomy pain. Ann Thorac Surg 1993; 55: 14726
Schug SA, Fry RA. Continuous regional analgesia in comparison with intravenous opioid administration for routine postoperative pain control. Anaesthesia 1994; 49: 52832
Schultz A-M, Werba A, Ulbing S, Gollmann G, Lehofer F. Perioperative thoracic epidural analgesia for thoracotomy. Eur J Anaesthesiol 1997; 14: 6003
Scheinin B, Asantila R, Orko R. The effect of bupivacaine and morphine on pain and bowel function after colonic surgery. Acta Anaesthesiol Scand 1987; 31: 1614
Schwartz BR, Gregg RV, Kessler DL, Bracken RB. Continuous postoperative epidural analgesia in management of postoperative surgical pain. Urology 1989; 34: 34952
Scott DA, Beilby DS, McClymont C. Postoperative analgesia using epidural infusions of fentanyl with bupivacaine. Anesthesiology 1995; 82: 72737
Scott DA, Chamley DM, Mooney PH, Deam R, Mark AH, Hagglof B. Epidural ropivacaine infusion for postoperative analgesia after major lower abdominal surgerya dose finding study. Anesth Analg 1995; 81: 9826
Scott NB, James K, Murphy M, Kehlet H. Continuous thoracic epidural analgesia versus combined spinal/thoracic epidural analgesia on pain, pulmonary function and metabolic response following colonic surgery. Acta Anaesthesiol Scand 1996; 40: 6916
Shir Y, Raja SN, Frank SM. The effect of epidural versus general anesthesia on postoperative pain and analgesic requirements in patients undergoing radical prostatectomy. Anesthesiology 1994; 80: 4956
Sidebotham DA, Russell K, Dijkhuizen M, Tester P, Schug SA. Low dose fentanyl improves continuous bupivacaine epidural analgesia following orthopaedic, urological or general surgery. Acute Pain 1997; 1: 2732
Singh H, Bossard R, White P, Yeatts R. Effects of ketorolac v. bupivacaine coadministration during patient controlled hydromorphone epidural analgesia after thoracotomy procedures. Anesth Analg 1997; 84: 5649
Sjostrom S, Hartvig D, Tamsen A. Patient controlled analgesia with extradural morphine or pethidine. Br J Anaesth 1988; 60: 35866
Snijdelaar DG, Hasenbos MA, van Egmond J, Wolff AP, Liem TH. High thoracic epidural sufentanil with bupivacaine: continuous infusion of high volume versus low volume. Anesth Analg 1994; 78: 4904
Stenseth R, Sellevold O, Breivik H. Epidural morphine for postoperative pain: experience with 1085 patients. Acta Anaesthesiol Scand 1985; 29: 14856
Stuart-Taylor ME, Billingham IS, Barrett RF, Church JJ. Extradural diamorphine for postoperative analgesia: audit of a nurse-administered service to 800 patients in a district general hospital. Br J Anaesth 1992; 68: 42932
Torda TA, Pybus DA. Clinical experience with epidural morphine. Anaesth Intensive Care 1981; 9: 12934
Tsui SL, Chan CS, Chan AS, Wong SJ, Lam CS, Jones RD. Postoperative analgesia for oesophageal surgery: a comparison of three analgesic regimens. Anaesth Intensive Care 1991; 19: 32937
Tsui SL, Lo RJ, Tong W, et al. A clinical audit for postoperative pain control on 1443 surgical patients. Acta Anaesthesiol Sin 1995; 33: 13748
Tsui SL, Lee DK, Ng KF, Chan TY, Chan WS, Lo JW. Epidural infusion of bupivacaine plus fentanyl provides better postoperative analgesia than patient controlled analgesia with intravenous morphine after gynaecological laparotomy. Anaesth Intensive Care 1997; 25: 47681
Vandermeersch E. Epidural PCA with bupivacaine and sufentanil. Acta Anaesthesiol Belgica 1992; 43: 714
Wheatley RG, Madej TH, Jackson IJ, Hunter D. The first years experience of an Acute Pain service. Br J Anaesth 1991; 67: 3539
White WD, Pearce DJ, Norman J. Postoperative analgesia: a comparison of intravenous on-demand fentanyl with epidural bupivacaine. BMJ 1979; 2: 1667
Wong LT, Koh LH, Kaur K, Boey SK. A two-year experience of an Acute Pain service in Singapore. Singapore Med J 1997; 38: 20913
Writer WD, Hurtig JB, Evans D, Needs RE, Hope CE, Forrest JB. Epidural morphine prophylaxis of postoperative pain: report of a double blind multicentre study. Can Anaesth Soc J 1985; 32: 3308
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Appendix V |
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Badner NH, Komar WE. Bupivacaine 0.1% does not improve postoperative epidural fentanyl analgesia after abdominal or thoracic surgery. Can J Anaesth 1992; 39: 3306
Baron CM, Kowalski SE, Greengrass R, Horan TA, Unruh HW, Baron CL. Epinephrine decreases postoperative requirements for continuous thoracic epidural fentanyl infusions. Anesth Analg 1996; 82: 7605
Bredtmann RD, Herden HN, Teichmann W, et al. Epidural analgesia in colonic surgery: results of a randomised prospective study. Br J Surg 1990; 77: 63842
Brodsky JB, Chaplan SR, Brose WG, Mark JB. Continuous epidural hydromorphone for postthoracotomy pain relief. Ann Thorac Surg 1990; 50: 88893
Broekema AA, Gielein MJ, Hennis PJ. Postoperative analgesia with continuous epidural sufentanil and bupivacaine. Anesth Analg 1996; 82: 7549
Burstal R, Wegener F, Hayes C, Lantry G. Epidural analgesia: prospective audit of 1062 patients. Anaesth Intensive Care 1998; 26: 16572
Dahl JB, Hansen BL, Hjortso NC, Erichsen CJ, Moiniche S, Kehlet H. Influence of timing on the effect of continuous extradural analgesia with bupivacaine and morphine after major abdominal surgery. Br J Anaesth 1992; 69: 48
Etches RC, Gammer T-L, Cornish R. Patient controlled epidural analgesia after thoracotomy: a comparison of meperidine with and wihout bupivacaine. Anesth Analg 1996; 83: 816
Grant G, Boyd A, Zakowski M, et al. Thoracic versus lumbar administration of epidural morphine for postoperative analgesia after thoracotomy. Reg Anesth 1993; 18: 3515
Griffiths DP, Diamond AW, Cameron JD. Postoperative extradural analgesia following thoracic surgery: a feasibility study. Br J Anaesth 1975; 47: 4854
Ilahi OA, Davidson JP, Tullos HS. Continuous epidural analgesia using fentanyl and bupivacaine after total knee arthroplasty. Clin Orthop Related Res 1994; 299: 4452
Jayr C, Beaussier M, Gustafsson Y, et al. Continuous epidual infusion of ropivacaine for postoperative analgesia after abdominal surgery. Br J Anaesth 1998; 81: 88792
Johnson RG, Miller M, Murphy M. Intraspinal narcotic analgesia: a comparison of two methods of postoperative pain relief. Spine 1989; 14: 3636
Lee A, Simpson D, Whifield A, Scott DB. Postoperative analgesia by continuous extradural infusion of bupivacaine and diamorphine. Br J Anaesth 1988; 60: 84550
de Leon-Casasola OA, Parker B, Lema M, Harrison P, Massey J. Postoperative epidural bupivacainemorphine therapy. Anesthesiology 1994; 81: 36875
Liu SS, Allen HW, Olsson GL. Patient controlled epidural analgesia with bupivacaine and fentanyl on hospital wards. Anesthesiology 1998; 88: 68895
Lubenow TR, Faber LP, McCarthy RJ, Hopkins EM, Warren WH, Ivankovitch AD. Post-thoracotomy pain management using continuous epidural analgesia in 1324 patients. Ann Thorac Surg 1994; 58: 92430
Mahoney OM, Noble PC, Davidson J, Tillos HS. The effect of continuous epidural analgesia on postoperative pain, rehabilitation and duration of hospitalisation in total knee arthroplasty. Clin Orthop Related Res 1990; 260: 307
Mehnert JH, Dupont TJ, Rose DH. Intermittent epidural morphine instillation for control of postoperative pain. Am J Surg 1983; 146: 14551
Melendez JA, Cirella VN, Delphin ES. Lumbar epidural fentanyl analgesia after thoracic surgery. J Cardiothor Anesth 1989; 3: 1503
Paech MJ, Pavy TJ, Evans SF. Single-dose prophylaxis for postoperative nausea and vomiting after major abdominal surgery: ondanseteron versus droperidol. Anaesth Intensive Care 1995; 23: 54854
Paech MJ, Pavy TJ, Orlikowski CE, Lim W, Evans SF. Postoperative epidural infusion: a randomised double blind dose finding trial of clonidine in combination with bupivacaine and fentanyl. Anesth Analg 1997; 84: 13238
Rapp SE, Ready LB, Greer BE. Postoperative pain management in gynecologic oncology patients utilizing epidural opiate analgesia and PCA. Gynecol Oncol 1989; 35: 3414
Ready LB, Loper KA, Nessly M, Wild L. Postoperative epidural morphine is safe on surgical wards. Anesthesiology 1991; 75: 4526
Salomaki TE, Kokki H, Turunen M, Havukainen U, Nuutinen LS. Introducing epidural fentanyl for on-ward pain relief after major surgery. Acta Anaesthesiol Scand 1996; 40: 7049
Sawchuck CW, Ong B, Unruh HW, Horan TA, Greengrass R. Thoracic versus lumbar epidural fentanyl for post-thoracotomy pain. Ann Thorac Surg 1993; 55: 14726
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