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Biomedical subjects

Eugene R Viscusi

Publications and source records attributed to Eugene R Viscusi.

At least 19 recordsLinked to original sources
PubMed2007

Extended-duration agents for perioperative pain management.

Perioperative pain management has drastically evolved over the years to satisfy current unmet needs. Intermittent delivery of drugs has been replaced by continuous delivery systems involving oral, neuraxial, and peripheral nerve block routes of administration. One current standard of perioperative pain management is an epidural injection of an opioid such as morphine, fentanyl, or hydromorphone, with or without the addition of a local anesthetic, such as bupivacaine. Although this method is extremely effective in controlling pain during the most critical 48-hour period postoperatively, it also has its disadvantages. Risks associated with indwelling epidural catheters include infection, adverse effects, and spinal hematoma. The development of extended- and controlled-release drug delivery systems has revolutionized perioperative pain management. This class of drugs comprises MS Contin (Purdue Pharma LP, Stamford, CT), OxyContin (Purdue Pharma LP), Opana ER (Endo Pharmaceuticals, Chadds Ford, PA), and DepoDur (Endo Pharmaceuticals). There are also phase II trials in progress examining controlled-release formulations of local anesthetics. This review discusses extended- and controlled-release agents administered perioperatively.

Analgesics↗
PubMed2007

Can epidural anesthesia and warfarin be coadministered?

Epidural hypotensive anesthesia can, in addition to imparting numerous intraoperative benefits, provide excellent postoperative pain control for patients having joint arthroplasties. However, because of the risk of epidural hematoma, epidural anesthesia is not coadministered with anticoagulation in some centers. We retrospectively ascertained, by chart review, the incidence of epidural hematoma in 11,235 patients having 12,991 knee arthroplasties at our institution who received oral anticoagulation and epidural anesthesia for their surgery. Warfarin was administered on the day of surgery. With the exception of 212 patients, the epidural catheter was removed within 48 hours of surgery. Based on clinical examinations, we detected no epidural hematomas. For 1030 patients (1038 knees) whose charts were reviewed in detail, the mean international normalized ratio at the time of removal of the epidural catheter was 1.54 (range, 0.93-4.25). We identified no other complications related to the coadministration of epidural anesthesia and warfarin. Although administration of epidural anesthesia in patients with coagulopathy can be detrimental, we recognized no cases of epidural hematoma causing neurologic symptoms in patients receiving controlled oral anticoagulation after total knee arthroplasty.

Anesthesia, Epidural↗
PubMed2006

Patient-controlled analgesia: Finding a balance between cost and comfort.

PURPOSE: Despite the growing movement in acute pain management, acute postoperative pain continues to be undermanaged. Although numerous clinical practice guidelines for pain management have been published throughout the last 12 years, inadequate pain relief remains a significant health care issue. Insufficient dosage of analgesics is a common problem, and therapy for those patients still with pain represents a considerable health care dilemma. SUMMARY: Patient-controlled analgesia (PCA) refers to a process in which patients determine when and how much medication they receive, regardless of analgesic technique. Patient-controlled modalities using intravenous (i.v.) and epidural routes have dramatically improved postoperative pain management. PCA has emerged as an effective way for patients to manage their pain, allowing self-administration of small doses of analgesics to maintain a certain level of pain control. PCA is most commonly delivered via an intravenous or epidural route, and while patient satisfaction is higher with PCA than with conventional methods of analgesic administration, the invasiveness, costs, health care resources, and risk of errors associated with currently available modalities may limit their utility. The overall effectiveness of any analgesic technique depends on both the degree of pain relief and the incidence of side effects or complications. These adverse events of acute pain complicate postoperative recovery and may lead to longer hospital stays, as well as increased health care costs. Several new PCA modalities are being developed to address these limitations. These systems deliver drugs through a variety of routes (for example, transdermal). Most notable is a self-contained, credit card-sized fentanyl transdermal patient-activated system. It provides pain relief therapeutically equivalent to that of standard regimen of morphine i.v. PCA, with pharmacokinetics similar to those of intravenous fentanyl infusion. Fentanyl HCl patient-activated transdermal systems (PATS) may be an effective, noninvasive alternative to currently available i.v. PCA modalities. Whichever drug or device is utilized, the overall success relies on the expert supervision of nurses, pharmacists, and anesthesiologists in an acute pain service. CONCLUSION: Current PCA techniques using i.v. or epidural administration have limitations. Development of new technology offering alternative routes for PCA administration is at the forefronts of PCA research.

Analgesia, Patient-Controlled↗
PubMed2006

Postoperative upper and lower gastrointestinal recovery and gastrointestinal morbidity in patients undergoing bowel resection: pooled analysis of placebo data from 3 randomized controlled trials.

BACKGROUND: This analysis examines gastrointestinal recovery in patients who underwent bowel resection (BR) in 3 recent trials. METHODS: Patients who underwent BR in the placebo groups of 3 randomized, double-blind, phase III, parallel-group, multicenter alvimopan efficacy trials were analyzed. RESULTS: Most patients tolerated solid food and had a bowel movement by postoperative day 4. The majority of patients were discharged from the hospital by day 6, but 24.4% required a prolonged hospital stay or readmission. The incidence of nausea was highest on the day of surgery and decreased thereafter, whereas vomiting was uncommon on the day of surgery but increased slightly on postoperative days 1 to 6. The incidence of postoperative nasogastric tube insertion was highest (12%) on day 2. CONCLUSIONS: This analysis provides valuable clinical insight into gastrointestinal recovery after BR in a large homogenous patient population receiving multimodal care.

Aged↗
PubMed2006

An iontophoretic fentanyl patient-activated analgesic delivery system for postoperative pain: a double-blind, placebo-controlled trial.

An iontophoretic fentanyl HCl patient-activated transdermal system (fentanyl HCl PATS) is under development for the treatment of acute postoperative pain. The fentanyl HCl PATS is a needle-free, credit card-sized, preprogrammed system that is applied to the patient's upper outer arm or chest. The fentanyl HCl PATS was demonstrated to be superior to placebo in a previous trial; however, the randomization scheme used and the lack of control of entry pain level may have contributed to the lack of robust findings. We compared the fentanyl HCl PATS with placebo for acute postoperative pain management in a larger trial that addressed the limitations of the previous study. Adult patients admitted to the postanesthesia care unit after major surgery were titrated to comfort with opioids and randomized 1:1 to receive the fentanyl HCl PATS 40 microg or placebo for 24 hours. Supplemental IV fentanyl was available to patients upon request in both treatment groups for the first 3 hours after enrollment. The primary efficacy end-point was the percentage of patients who discontinued participation in the study because of inadequate analgesia. Pain intensity scores, patient global assessments (PGA), and investigator global assessments (IGA) were collected. Four-hundred-eighty-four patients (PATS, n = 244; placebo, n = 240) were enrolled. Fewer patients receiving the fentanyl HCl PATS discontinued because of inadequate analgesia compared with placebo (28.7% versus 60.0%; P < 0.0001). Mean last pain intensity scores were 3.5 and 5.4 for the fentanyl HCl PATS and placebo groups, respectively. Patients (73.4%, PGA) and investigators (72.1%, IGA) considered the fentanyl HCl PATS a good or excellent method of pain control. Treatment-related adverse events were similar between groups. This study demonstrated the superiority of the iontophoretic fentanyl HCl PATS over placebo for acute postoperative pain management.

Analgesia, Patient-Controlled↗
PubMed2005

The evolving role of spinal agents in acute pain.

Local anesthetics and opioids were among the earliest pharmacologic agents used for intrathecal injection. Side-effect profiles have limited the use of additional agents and, after a century of clinical use, local anesthetics and opioids remain the most widely used intrathecal or epidural medications.

Anesthetics, Local↗
PubMed2005

Efficacy and safety of single and repeated administration of 1 gram intravenous acetaminophen injection (paracetamol) for pain management after major orthopedic surgery.

BACKGROUND: Intravenous acetaminophen injection (paracetamol) is marketed in Europe for the management of acute pain. A repeated-dose, randomized, double-blind, placebo-controlled, three-parallel group study was performed to evaluate the analgesic efficacy and safety of intravenous acetaminophen as compared with its prodrug (propacetamol) and placebo. Propacetamol has been available in many European countries for more than 20 yr. METHODS: After orthopedic surgery, patients reporting moderate to severe pain received either 1 g intravenous acetaminophen, 2 g propacetamol, or placebo at 6-h intervals over 24 h. Patients were allowed "rescue" intravenous patient-controlled analgesia morphine. Pain intensity, pain relief, and morphine use were measured at selected intervals. Safety was monitored through adverse event reporting, clinical examination, and laboratory testing. RESULTS: One hundred fifty-one patients (intravenous acetaminophen: 49; propacetamol: 50; placebo: 52) received at least one dose of study medication. The intravenous acetaminophen and propacetamol groups differed significantly from the placebo group regarding pain relief from 15 min to 6 h (P < 0.05) and median time to morphine rescue (intravenous acetaminophen: 3 h; propacetamol: 2.6 h; placebo: 0.8 h). Intravenous acetaminophen and propacetamol significantly reduced morphine consumption over the 24-h period: The total morphine doses received over 24 h were 38.3 +/- 35.1 mg for intravenous acetaminophen, 40.8 +/- 30.2 mg for propacetamol, and 57. 4 +/- 52.3 mg for placebo, corresponding to decreases of -33% (19 mg) and -29% (17 mg) for intravenous acetaminophen and propacetamol, respectively. Drug-related adverse events were reported in 8.2%, 50% (most of them local), and 17.3% of patients treated with intravenous acetaminophen, propacetamol, and placebo, respectively. CONCLUSION: Intravenous acetaminophen, 1 g, administered over a 24-h period in patients with moderate to severe pain after orthopedic surgery provided rapid and effective analgesia and was well tolerated.

Acetaminophen↗
PubMed2005

Forty-eight hours of postoperative pain relief after total hip arthroplasty with a novel, extended-release epidural morphine formulation.

BACKGROUND: Epidural morphine has proven analgesic efficacy in the postoperative period and is widely used. This study evaluated the efficacy of extended-release epidural morphine (EREM; DepoDur; Endo Pharmaceuticals Inc., Chadds Ford, PA; SkyePharma, Inc., San Diego, CA) in providing pain relief for 48 h after surgery. METHODS: Patients (n = 200) scheduled to undergo total hip arthroplasty were randomized to receive a single dose of 15, 20, or 25 mg EREM or placebo. After surgery and after asking for pain medication, patients had access to intravenous patient-controlled analgesia fentanyl for breakthrough pain as needed. Postoperative intravenous patient-controlled analgesia fentanyl use, time to first postoperative fentanyl use, pain intensity at rest and with activity, patient and surgeon ratings of pain control, and adverse events were recorded. RESULTS: All EREM dosages reduced the mean (+/- SD) fentanyl use versus placebo (510 +/- 708 vs. 2,091 +/- 1,803 microg; P < 0.0001) and delayed the median time to first dose of fentanyl (21.3 vs. 3.6 h; P < 0.0001). All EREM groups had significantly improved pain control at rest through 48 h postdose (area under the curve [0-48 h]) compared with placebo (P < 0.0005). More EREM-treated patients rated their pain control as good or very good compared with placebo (at 24 h: 90 vs. 65%, P < 0.0001; at 48 h: 83 vs. 67%, P < 0.05). No supplemental analgesia was needed in 25% of EREM-treated patients and 2% of placebo-treated patients at 48 h (P < 0.05). The safety profile of EREM was consistent with that of other epidurally administered opioid analgesics. CONCLUSIONS: EREM provided significant postoperative pain relief over a 48-h period after hip surgery, without the need for indwelling epidural catheters.

Adult↗
PubMed2005

Emerging techniques in the management of acute pain: epidural analgesia.

Epidural analgesia, often using opioids intraoperatively and postoperatively, is widely accepted as a valuable modality for perioperative pain management. In this review I present data from meta-analyses and recently published trials that evaluate the perioperative use of opioids administered epidurally or parenterally (as-needed or by patient-controlled analgesia) and their effect on outcome. Published effects of perioperative epidural techniques on cardiac and pulmonary function are reviewed. Clinical and practical issues associated with epidural anesthesia and analgesia include the existence of analgesic gaps (often related to technical difficulties with the pump or use of an indwelling catheter), the occurrence of hypotension, and compatibility with anticoagulation therapy. A new treatment option, a single epidural injection of morphine for continuous perioperative analgesia (DepoDur; Endo Pharmaceuticals Inc, Chadds Ford, PA), may reduce some of these problems. Data from recent clinical studies are presented.

Acute Disease↗
PubMed2004

Patient-controlled transdermal fentanyl hydrochloride vs intravenous morphine pump for postoperative pain: a randomized controlled trial.

CONTEXT: Patient-controlled analgesia (PCA) with morphine is commonly used to provide acute postoperative pain control after major surgery. The fentanyl hydrochloride patient-controlled transdermal system eliminates the need for venous access and complicated programming of pumps. OBJECTIVE: To assess the efficacy and safety of an investigational patient-controlled iontophoretic transdermal system using fentanyl hydrochloride compared with a standard intravenous morphine patient-controlled pump. DESIGN, SETTING, AND PATIENTS: Prospective randomized controlled parallel-group trial conducted between September 2000 and March 2001 at 33 North American hospitals, enrolling 636 adult patients who had just undergone major surgery. INTERVENTIONS: In surgical recovery rooms, patients were randomly assigned to intravenous morphine (1-mg bolus every 5 minutes; maximum of 10 mg/h) by a patient-controlled analgesia pump (n = 320) or iontophoretic fentanyl hydrochloride (40- microg infusion over 10 minutes) by a patient-controlled transdermal system (n = 316). Supplemental analgesia (morphine or fentanyl intravenous boluses) was administered as needed before and for the first 3 hours after activation of the PCA treatments. Patients then used the PCA treatments without additional analgesics for up to 72 hours. MAIN OUTCOME MEASURES: The primary efficacy variable was patient global assessment of the method of pain control during the first 24 hours. Additional efficacy measures were the proportion of patients discontinuing the study because of inadequate analgesia for any reason, patient-reported pain intensity scores on a 100-mm visual analog scale (VAS), and patient global assessments at 48 and 72 hours. Adverse effects were also recorded. RESULTS: Ratings of good or excellent after 24 hours of treatment for the method of pain control were given by 73.7% of patients (233/316) who used transdermal fentanyl PCA and 76.9% of patients (246/320) who used intravenous morphine PCA; treatment difference was -3.2% (95% confidence interval, -9.9% to 3.5%; P =.36). Early patient discontinuations (25.9% fentanyl vs 25.0% morphine; P =.78) and last pain intensity scores (32.7 fentanyl vs 31.1 morphine on the VAS; P =.45) were not different between the 2 treatments. With continued treatment for up to 48 or 72 hours, more than 80% of patient assessments in each treatment group were good or excellent. The incidence of opioid-related adverse events was similar between the groups. CONCLUSION: An investigational PCA transdermal system using iontophoresis to deliver fentanyl provided postsurgical pain control equivalent to that of a standard intravenous morphine regimen delivered by a PCA pump.

Administration, Cutaneous↗
PubMed2004

Management of acute chest wall sickle cell pain with nebulized morphine.

This paper describes, for the first time, the utilization of nebulized morphine in the management of severe chest pain in two young adult African-American patients who suffered from generalized acute sickle cell painful episodes. While hospitalized, both patients developed new sharp chest wall pain, and were treated with nebulized morphine started at 20 mg MOSO4 in 3.0- to 5.0-mL physiologic buffered saline solution. Within minutes, both patients reported significant relief of chest wall pain. Patient 1 achieved 90% pain relief as well as a significant decrease in the pain intensity score. Patient 2 reported 40% pain relief, and the pain intensity score decreased to a mean of 5.6/10. Hence, treatment every 6 hr was continued for 10 days, after which the chest wall pain subsided. These findings indicate that nebulized morphine may prove effective in the management of acute chest pain in patients with sickle cell anemia. This is a desirable alternative in patients with difficult venous access and may more specifically target chest pain.

Administration, Inhalation↗
PubMed2004

Spinal agents for acute pain management.

This article describes the current and investigational agents for use in the treatment of acute pain. The use of spinal and epidural routes also are discussed.

Analgesia, Epidural↗
PubMed2004

Emerging techniques in the treatment of postoperative pain.

PURPOSE: Causes of inadequate postoperative pain control, challenges with currently available analgesic therapies, characteristics of optimal postoperative analgesic therapy, a liposome-encapsulated, sustained-release dosage form of morphine, and other investigational analgesic therapies are described. SUMMARY: Technical difficulties in analgesic drug administration, inappropriate prescribing, unfounded patient fears or expectations, and the lack of availability of parenteral dosage forms of certain analgesic agents can potentially contribute to inadequate postoperative pain control. The use of epidural catheters for analgesic therapy is limited by the use of prophylactic anticoagulation, the tendency for catheters to migrate and fail, and the need for nursing staff time to monitor the catheter site and infusion pump. Continuous peripheral blocks are not always effective, the devices used are bulky, and the technology is prone to failure. Multimodal therapies are labor-intensive, and some components must be given orally because they are not available in parenteral dosage forms. Optimal postoperative analgesic drug therapy would therefore be noninvasive, easy to administer, require no cumbersome equipment, cause no or minimal adverse effects, and be safe to use in patients receiving prophylactic anticoagulation. A new morphine sulfate sustained-release liposome injection has several of these characteristics, including ease of administration and compatibility with anticoagulation. Single-dose epidural administration of morphine sulfate sustained-release liposome injection in patients undergoing hip arthroplasty provided better pain control than i.v. opioid analgesics given by PCA, with similar adverse effects. CONCLUSION: Opioid analgesics remain the mainstay of postoperative analgesic therapy, but the development of infusion pumps with improved reliability; needle-free technologies, parenteral dosage forms of acetaminophen, selective cyclooxygenase-2 inhibitors, and other non-opioid therapies; and new opioid analgesic agents that provide analgesia without the adverse effects of currently available opioid analgesics may substantially improve postoperative analgesia and health-related quality of life in the postoperative pain patient in the future.

Analgesics↗
PubMed2004

Effective treatment of laparoscopic cholecystectomy pain with intravenous followed by oral COX-2 specific inhibitor.

UNLABELLED: In this multicenter, double-blinded, randomized, placebo-controlled study we evaluated the analgesic and opioid-sparing efficacy of a preoperative dose of i.v. parecoxib followed by oral valdecoxib in treating pain associated with elective laparoscopic cholecystectomy. Patients were randomized to receive a single i.v. dose of parecoxib 40 mg (n = 134) or placebo (n = 129) 30-45 min before induction of anesthesia. Six to 12 h after the i.v. dose, the parecoxib group received a single oral dose of valdecoxib 40 mg, followed by valdecoxib 40 mg qd on postoperative days 1-4, then 40 mg qd prn days 5-7. The placebo i.v. group received oral placebo on an identical schedule. All patients were allowed supplemental i.v. fentanyl as needed during the first 4 h postoperatively (T0-240 min) followed by hydrocodone 5 mg/acetaminophen 500 mg (Vicodin(R); 1-2 tablets orally every 4-6 h as needed). Patients taking parecoxib used 21% less fentanyl than those receiving placebo (P = 0.011). The mean area under the curve of pain intensity (PI) scores over time from T0-240 min was 55.2 for parecoxib and 61.2 for placebo (P = 0.083). At T180 and T240 min, mean PI score was 7.0 and 7.6 points lower in the parecoxib group, respectively (P < 0.02). Fewer patients on valdecoxib required supplemental analgesics (P < 0.05) after discharge. At T240 min and at day 7, Patient's and Physician's/Nurse's Global Evaluations were significantly better in the parecoxib/valdecoxib group (P < 0.05). Incidences of adverse events, adverse events causing withdrawal, and serious adverse events were less for parecoxib/valdecoxib than for placebo. The authors conclude that preoperative parecoxib is a valuable opioid-sparing adjunct to the standard of care for treating pain after laparoscopic cholecystectomy, and subsequent treatment with oral valdecoxib extends this clinical benefit. IMPLICATIONS: Parecoxib 40 mg i.v., 30-45 min preoperatively followed by oral valdecoxib 40 mg qd reduced opioid requirements and provided superior pain relief as well as improved patient global evaluation after laparoscopic cholecystectomy.

Administration, Oral↗
PubMed2004

Emerging techniques for postoperative analgesia in orthopedic surgery.

The current use of multimodal analgesia for the management of postoperative pain has resulted in reduced side effects and improved pain relief. Limitations of the technology associated with current pump- or catheter-based systems have prompted the development of continuous delivery systems and extended-duration techniques for pain relief. Among these are morphine sulfate sustained-release liposome injection (Morphine SR, DepoMorphine) and the patient-controlled transdermal system (PCTS, E-TRANS). Morphine SR utilizes the novel DepoFoam technology, a novel delivery system that allows the drug to be gradually released into the surrounding epidural space. Morphine SR is compatible with anticoagulation therapy and eliminates interference from pump and intravenous (IV) equipment. Administration of Morphine SR during hip arthroplasty significantly reduced patients' postoperative consumption of fentanyl. E-TRANS fentanyl PCTS is a transdermal system attached to the patient's arm or upper chest; a button on the device is controlled by the patient to deliver doses of fentanyl. In a study comparing fentanyl HCl PCTS with conventional IV-patient-controlled analgesia (PCA) morphine, PCTS was found to be as safe and effective as PCA for the treatment of postoperative pain. Novel delivery systems that are less invasive, that are compatible with anticoagulation regimens, and that provide continuous delivery, thus preventing analgesic gaps, will facilitate rehabilitation and recovery and ultimately improve patient outcomes.

Analgesia, Epidural↗
PubMed2002

Safety and efficacy of the popliteal fossa nerve block when utilized for foot and ankle surgery.

The popliteal fossa nerve block (PFNB) offers numerous advantages that make it a suitable anesthetic technique for foot and ankle surgery. In this retrospective study, we investigated the acute and long-term safety and efficacy of this relatively underutilized anesthetic technique for foot and ankle surgery. A review of 834 patients who underwent foot and/or ankle surgery by the coauthor (NAA) was conducted. Four hundred sixty-seven patients received a PFNB with the aid of a peripheral nerve stimulator. Variables assessed included the quality of surgical anesthesia, postoperative analgesia and the acute and long-term incidence of postoperative neuralgia and neuropraxia. The PFNBs were performed by anesthesiologists with various levels of training at a tertiary care hospital and all were supplemented with a saphenous nerve block. The PFNB was successful as the sole anesthetic technique in 79% of the cases; 18% were converted to general anesthesia and 3% required augmentation with local anesthetic. There were no complications associated with the PFNB. There were no incidents of postoperative neuralgia or neuropraxia. Only 12% of patients with a successful block required analgesics in the PACU, while 60% of patients with a failed block required systemic analgesics for surgical site pain (p<0.01). These results suggest that the performance of the PFNB with the guidance of a peripheral nerve stimulator is a safe and effective anesthetic technique for foot and ankle surgery.

Ankle↗
PubMedDate not supplied

Development of a standardized peripheral nerve block procedure note form.

OBJECTIVES: Despite the tremendous growth of peripheral nerve blocks, no standard format exists to document their performance. Our objective was to create a peripheral nerve block form based on key elements of literature evidence and on our own group consensus. RESULTS: We describe the process and results of our multi-institutional effort to construct a standardized peripheral nerve block procedure form. CONCLUSION: A form was developed to help meet the medical, legal, and billing requirements of documentation consistent with the performance of peripheral nerve block.

Humans↗