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Biomedical subjects

Narinder Rawal

Publications and source records attributed to Narinder Rawal.

At least 19 recordsLinked to original sources
PubMed2005

Organization, function, and implementation of acute pain service.

Undertreatment of postoperative pain continues to be a major problem internationally. The solution does not seem to be the development of new analgesic drugs or technologies but the development of an appropriate organization that utilizes existing expertise. Evidence suggests that the introduction of an Acute Pain Service (APS) reduces patients' pain intensity, but other outcome benefits are modest. Although the number of hospitals with an APS is increasing, the literature is unclear about the optimal structure, staffing, and function. There is a need for the development of well-defined APS criteria with which to assess performance and compare with national standards.

Hospital Departments↗
PubMed2005

Combined spinal-epidural anaesthesia.

PURPOSE OF REVIEW: The purpose of this review is to present the most important recent studies on the clinical use of the combined spinal-epidural technique. RECENT FINDINGS: The predominant recent literature on the combined spinal-epidural technique involves its use in obstetrics. A 2004 UK survey showed that the use of the technique is increasing. Studies are presented which show the role of intrathecal drug selection for improving the quality of the combined spinal-epidural technique for anaesthesia for Caesarean section. The pros and cons of using the method as opposed to traditional epidural for labour analgesia are still being debated; the results of a meta-analysis show that combined spinal-epidural provides faster onset of analgesia and increased maternal satisfaction but the incidence of pruritus is high. This review also looks at some technical aspects of the technique. SUMMARY: The use of combined spinal-epidural is widespread and increasing particularly in obstetric anaesthesia and analgesia. Recent literature provides new information about the choice of drugs and technical aspects of the technique and also about its advantages and drawbacks in obstetric and non-obstetric patients.

Journal Article↗
PubMed2005

Intraarticular patient-controlled regional anesthesia after arthroscopically assisted anterior cruciate ligament reconstruction: ropivacaine/morphine/ketorolac versus ropivacaine/morphine.

UNLABELLED: Anterior cruciate ligament reconstruction (ACLR) is associated with moderate to severe postoperative pain. We compared the intraarticular analgesic effects of ropivacaine and morphine with or without ketorolac and the need for rescue IV morphine at rest and during movement in patients undergoing anterior cruciate ligament reconstruction during spinal anesthesia. Thirty-nine patients receiving intraarticular patient-controlled regional analgesia with a 10-mL bolus and a 60-min lockout interval were randomized into 3 groups: the RM group received 0.25% ropivacaine and morphine 0.2 mg/mL; the RMK group received 0.25% ropivacaine, morphine 0.2 mg/mL and ketorolac 1 mg/mL; the P group received saline. Analgesic mixtures were prepared in 100-mL bags and coded. If needed, rescue morphine 2 mg was self-administered IV with 10-min lockout intervals. Pain scores and patient satisfaction were assessed at rest and during movement. There were no significant differences among the groups in pain scores and patient satisfaction. Daily morphine consumption was significantly smaller in the RMK group (8 +/- 8 mg) compared with the RM group (23 +/- 20 mg; P = 0.002) and in both groups compared with control (46 +/- 21 mg; P < 0.001). We conclude that intraarticular patient-controlled regional analgesia provides effective pain relief after anterior cruciate ligament reconstruction. The combination of intraarticular ropivacaine, morphine, and ketorolac was superior to control or to a combination of ropivacaine and morphine. IMPLICATIONS: This study showed the feasibility and efficacy of intraarticular patient-controlled regional analgesia technique for pain relief after anterior cruciate ligament reconstruction. The combination of intraarticular ropivacaine, morphine, and ketorolac was superior to control or to a combination of ropivacaine and morphine.

Adolescent↗
PubMed2004

Postoperative pain after abdominal hysterectomy: a double-blind comparison between placebo and local anesthetic infused intraperitoneally.

Abdominal hysterectomy is associated with moderate to severe postoperative pain. We randomly divided 40 patients (ASA status I-II) undergoing elective abdominal hysterectomy into 2 groups: group P received an infusion of normal saline 5 mL/h via a catheter placed intraperitoneally at the end of surgery, and group L received 0.25% levobupivacaine 12.5 mg/h (5 mL/h). Ketobemidone was administered IV via a patient-controlled analgesia pump as a rescue analgesic in all patients. The catheter was removed after 24 h. Incisional pain, deep pain, and pain on coughing were assessed 1, 2, 3, 4, 8, 16, and 24 h after surgery by using a visual analog scale. Ketobemidone consumption during 0-72 h was recorded. Time to sit, walk, eat, and drink; home discharge; and plasma concentrations of levobupivacaine were also determined. Pain at the incision site, deep pain, and pain on coughing were all significantly less in group L compared with group P at 1-2 h after surgery. After 4 h, the mean visual analog scale pain scores at rest and during coughing remained <3 cm during most time periods. Total ketobemidone consumption during 4-24 h was significantly less in group L compared with group P (mean, 19 versus 31 mg, respectively). A less frequent incidence of postoperative nausea, but not vomiting, was also found during 4-24 h in group L compared with group P (P < 0.025). Total and free plasma concentrations of levobupivacaine were small. We conclude that levobupivacaine used as an infusion intraperitoneally after elective abdominal hysterectomy has significant opioid-sparing effects.

Adult↗
PubMed2003

The combined spinal--epidural technique.

In recent years, the use of regional anaesthesia techniques for surgery, obstetrics and post operative pain management have increased in popularity. The combined spinal-epidural (CSE) technique has attained widespread popularity for patients undergoing major surgery below the umbilicus who may require prolonged and effective postoperative analgesia. The CSE technique is now well established in several institutions. This chapter includes the clinical experience, advantages and potential problems, and discusses future perspectives of the CSE technique.

Ambulatory Surgical Procedures↗
PubMed2002

Incisional self-administration of bupivacaine or ropivacaine provides effective analgesia after inguinal hernia repair.

PURPOSE: To evaluate the safety and applicability of two local anesthetic (LA) solutions self-administered for pain treatment after inguinal hernia repair (IHR) by balloon-pumps via catheters placed in the surgical wound. Effectiveness of analgesia was also compared. METHODS: Two groups of patients for IHR were included in the randomized, double-blind study. An epidural catheter was placed in the surgical wound, tunneled subcutaneously and connected to a balloon-pump containing either 0.25% bupivacaine (B) or 0.25% ropivacaine (R). Postoperatively, the patient self-administered the LA into the wound. Administration could be repeated after 20 min. If moderate to severe pain still persisted, rescue medication (piritramid) was given intravenously. The variables recorded in both groups were: visual analogue scale (VAS), pain scores at rest and with movement, number of applications, wound healing, patients' satisfaction. RESULTS: During the first 24 hr, median number of LA applications in 26 B patients was 4 (range 1-6) and in 25 R patients 3 (range 1-5). Both groups showed low VAS pain scores: less than 2 at rest, less than 4 with movement. Eighty percent of patients of each group would choose this type of analgesia again. Two patients from B Group and three from R Group needed rescue medication. No wound infection was observed. There were no statistically significant differences between the groups. CONCLUSION: Self-administration of the LA solution via a catheter in the surgical wound is an effective method of pain relief after IHR with little side-effects.

Adolescent↗
PubMed2002

Incisional and intra-articular infusions.

Incisional and intra-articular local anaesthetic techniques are simple, safe and inexpensive analgesic methods for the management of post-operative pain following a variety of surgical procedures. These techniques are capable of providing effective analgesia over a limited field and with minimal systemic effects. In the literature single-dose local anaesthetics have been administered in most of the studies; however, the duration of analgesia is short-lived. In recent years catheter techniques have been increasingly used as intermittent bolus or continuous infusion in the surgical wound or intra-articularly for long-lasting post-operative analgesia in both hospitalized and day-case patients. The incisional and intra-articular use of opioids and several non-opioids, either alone or in combination with local anaesthetics, has also been evaluated. This chapter reviews the current status of single dose and infusions of local anaesthetics and adjuvants for incisional and intra-articular analgesic techniques and also looks at future perspectives.

Analgesia↗
PubMed2002

Clonidine for treatment of postoperative pain: a dose-finding study.

The aim of this double-blind randomized study was to evaluate the optimal intravenous dose of clonidine administrated during the peri-operative period, after lumbar hemilaminectomy for herniated disk repair. The "optimal intravenous dose" was defined as that providing minimal analgesic request, stable haemodynamic profile and a minimal sedation score during 12h after extubation. Eighty adult patients, ASA physical status I-II, undergoing lumbar hemilaminectomy for herniated disk (L(4)-L(5), L(5)-S(1)) were included in the study. All the patients were randomly assigned to one of four study groups (A, B, C, D), 20 patients each. The same standardized general anaesthesia was performed for each group. Thirty minutes before the end of surgery, group A, B and C patients received three different loading doses of intravenous clonidine (5 microg/kg, 3 microg/kg, 2 microg/kg respectively), followed by the same infusion of intravenous clonidine (0.3 microg/kg per hour). Group D patients received a bolus dose and a continuous infusion of NaCl 0.9%. In the recovery unit, postoperative pain was treated by a patient-controlled analgesia device, containing morphine. Pain relief was evaluated by the total morphine requirement during the postoperative period. Systolic blood pressure (SBP), heart rate and sedation were also noted during the first 12h postoperatively. Intravenous clonidine decreased morphine requirements in a dose-dependent manner. Group A, B, C and D patients requested 5 +/- 2, 11 +/- 3, 19 +/- 4 and 29 +/- 8 doses of morphine respectively. Clonidine also affected SBP in a dose-related manner. Group A, B and C patients had an SBP decrease respectively of 26 +/- 3%, 7 +/- 4% and 2 +/- 2% compared with basic values while, at the same time, in group D patients no SBP variation was registered. In conclusion, this study demonstrates that, when sedation and analgesic effect of clonidine is required, 3 microg/kg bolus dose followed by a continuous infusion of 0.3 microg/kg per hour has to be considered the optimal intravenous dose. The higher dose of intravenous clonidine (5 microg/kg) produced better analgesia but the degree of hypotension and sedation was more severe and longer lasting; it required ephedrine administration and careful monitoring of the patient. On the other hand, the bolus of intravenous clonidine 2 microg/kg (group C) was less effective in terms of pain relief but with similar side-effects to the 3 microg/kg dosage (group B).

Adult↗
PubMed2002

Postoperative pain relief using intermittent injections of 0.5% ropivacaine through a catheter after laparoscopic cholecystectomy.

UNLABELLED: Postoperative pain has been an important limiting factor for ambulatory laparoscopic cholecystectomy. We anesthetized 40 ASA physical status I-II patients using propofol for the induction and sevoflurane in oxygen and air for the maintenance of anesthesia. At the end of the anesthesia, the patients were randomized into one of two groups: Group P (Placebo) and Group R (0.5% Ropivacaine). Twenty milliliters of normal saline or ropivacaine, respectively, were injected intraperitoneally at the end of surgery via a catheter placed in the bed of the gall bladder. Postoperatively, intermittent injections (10 mL) of the study solution were given when required for pain. Ketobemidone 1-2 mg was given IV as rescue medication. Pain was assessed using a visual analog scale at 1, 2, 3, 4, 8, 12, 16, and 20 h after surgery and once each day for 1 wk at rest (deep pain), shoulder and incision sites, and pain during coughing. Recovery was assessed by the time to transfer from Phase 1 to 2, the ability to walk, drink, and eat, and the ability to void. Plasma concentrations of ropivacaine were measured in eight patients. Time to ability to walk, defecation, driving a car, and return to normal activities were also recorded through a questionnaire sent home with the patient. During the first 4 postoperative h, patients in Group R had lower scores for deep pain and during coughing compared with Group P (P < 0.05). No differences were found in the postoperative consumption of ketobemidone. Median times to recovery at home were similar between the groups. By the seventh day, 93% of the patients had returned to normal activities of daily living. We conclude that the early postoperative pain after ambulatory laparoscopic cholecystectomy could be relieved using intermittent injections of ropivacaine 0.5% into the bed of the gall bladder. IMPLICATIONS: Early postoperative pain can be relieved by intermittent injections of ropivacaine 0.5% through a catheter placed in the bed of the gall bladder after ambulatory laparoscopic cholecystectomy.

Aged↗
PubMed2002

Patient-controlled regional analgesia (PCRA) at home: controlled comparison between bupivacaine and ropivacaine brachial plexus analgesia.

BACKGROUND: The aim of this randomized, double-blinded study was to compare the analgesic efficacy of bupivacaine versus ropivacaine brachial plexus analgesia after ambulatory hand surgery. An additional aim was to study the feasibility and safety of patient-controlled regional analgesia (PCRA) outside the hospital. METHODS: Sixty patients scheduled for ambulatory hand surgery underwent surgery with axillary plexus blockade. After surgery, the plexus catheter was connected to an elastomeric, disposable "homepump," containing 100 ml of either 0.125% bupivacaine or 0.125% ropivacaine. When patients experienced pain, they self-administered 10 ml of the study drug. Analgesic efficacy of PCRA was evaluated by self-assessment of pain intensity by visual analog scale (VAS) and verbal scale. Patients recorded adverse effects, technical problems, use of rescue analgesic tablets, and overall satisfaction. A follow-up telephone call was made the day after surgery. RESULTS: Visual analog scale scores decreased after each treatment in both groups, but there were no significant differences between the two drugs. One patient in each group took rescue dextropropoxyphene tablets. In both groups, 87% patients expressed their desire to have the same treatment again. On the day of surgery, significantly more patients were satisfied with ropivacaine PCRA. None of the patients had any signs or symptoms of local anesthetic toxicity or catheter infection. CONCLUSIONS: This double-blinded study has demonstrated the feasibility of self-administration of local anesthetic to manage postoperative pain outside the hospital. Ropivacaine and bupivacaine provided effective analgesia, and patient satisfaction with PCRA was high. Patient selection, follow-up telephone call, and 24-h access to anesthesiology services are prerequisites for PCRA at home.

Adult↗
PubMed1994

Organization of acute pain services: a low-cost model.

It is being increasingly recognized that the solution to the problem of inadequate postoperative pain relief lies not so much in development of new techniques but in development of a formal organization for better use of existing techniques. Acute Pain Services (APS) are being increasingly established to provide good quality postoperative analgesia. In the United States such 24-h services usually consist of anesthesiologists, residents, specially trained nurses and pharmacists. However, less than 30% of US surgical population has access to APS. Furthermore, only patients selected by surgeons receive the benefits of these services. Additionally, the economic costs of such services are high (> or = $200/patient). Less expensive alternatives have to be developed if the aim is to improve the quality of postoperative analgesia for every patient after any type of surgery. Sophisticated analgesia techniques such as epidural and patient-controlled analgesia (PCA) are neither necessary nor realistic for the majority of patients. Our nurse-based anesthesiologist-supervised model is based on the concept that postoperative pain relief can be greatly improved by provision of in-service training for surgical nursing staff, optimal use of systemic opioids and use of regional analgesia techniques and PCA in selected patients. Regular recording of each patient's pain intensity by VAS every 3 h and recording of treatment efficacy on a bedside vital-sign chart are the cornerstones of this model. A VAS greater than 3 is promptly treated. Surgeon and ward nurse participation are crucial in this organization.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗
PubMed1993

Management of terminal cancer pain in Sweden: a nationwide survey.

The aim of this nationwide survey was to evaluate the extent of pain problems, the principles of pain management and the use of newer drug delivery techniques in terminal cancer patients. 'Terminal period' was defined as an expected life span of about 2 weeks. Another aim was to evaluate the level of knowledge of physicians and nurses and to assess their educational needs regarding management of cancer pain. A total of 456 questionnaires were sent to chairmen and head nurses of 6 major specialties (228 departments) that treat cancer patients in Sweden. Depending on the specialty, each questionnaire consisted of 50-60 questions. The response rate was high, ranging from 79% (surgeons) to 100% (gynecological oncologists). During a 1-year period 3767 patients (about 10% of total cancer population) were admitted to hospitals due to severe cancer pain. The results show that almost all physicians follow the analgesic 'ladder' principle recommended by WHO, prefer the oral route for morphine administration, prescribe opioid analgesics on a regular 'by-the-clock' basis and in unrestricted doses. However, about 30% of physicians believe that all patients have moderate to severe pain at the time of their death. Up to 78% of physicians and nurses believe that periodic severe pain is common in terminal cancer patients. In general physicians do not evaluate different pain types nor do they use any instruments for measurement of pain intensity. Surprisingly intermittent subcutaneous (s.c.) or intramuscular (i.m.) injections of morphine are preferred to continuous s.c., intravenous (i.v.) infusions or to intermittent s.c. administration through an indwelling butterfly needle. Few physicians routinely prescribe prophylactic laxatives. Antidepressive medication is rarely used. Neuropathic and bone metastasis pain appear to be poorly managed. More than 50% of physicians and nurses admit that they have inadequate knowledge about pain evaluation techniques, newer analgesics and newer drug delivery systems. More aggressive use of opioids administered by more humane routes and better use of adjuvant therapy can be expected to improve pain management for the terminal patient. There is also a need for better physician and nurse education.

Antidepressive Agents↗
PubMed1992

Intrathecal somatostatin in the guinea pig: effects on spinal cord blood flow, histopathology and motor function.

In the present investigation, the vasoconstrictive, motor and neurodegenerative effects of intrathecal somatostatin (SST) were assessed in guinea pigs implanted with lumbar intrathecal catheters. Five consecutive dose increments of SST (5, 10, 15, 30 and 60 micrograms) to a total of 120 micrograms during the period of 16 +/- 3 min, resulted in a moderate (< 20%), gradual decrease of the spinal blood flow monitored with the laser-doppler method. A subsequent injection of clonidine (50 micrograms) or norepinephrine (10 micrograms) resulted in a more pronounced decrease of spinal blood flow (35% and 79%, respectively). Three consecutive, daily intrathecal injections of 30 or 60 micrograms SST did not cause any loss of weight support or paralysis of the hind limbs. There were no histopathological changes in the white or gray matter of the thoracic and lumbar sections of the spinal cords. It is concluded that SST, in the doses studied, is not neurodegenerative in guinea pigs. These findings are in contrast to those previously seen in rats. The implication of this study may be the necessity to use several alternate animal species in order to evaluate the antinociceptive and neurodegenerative properties of the peptides administered by the intrathecal route and the choice of dose to be compared across species.

Animals↗
PubMed1990

Intrathecal and epidural somatostatin in rats: can antinociception, motor effects and neurotoxicity be separated?

In the present investigation, the antinociceptive, motor blocking and neurotoxic effects of intrathecal and epidural somatostatin (SST) were assessed in rats implanted with lumbar intrathecal and epidural catheters. The doses studied were 5, 7.5, 10, 12.5 and 15 micrograms intrathecally and 100, 250, 400 and 500 micrograms epidurally. It appears that if the intrathecal doses of SST are kept below 15 micrograms and the epidural doses below 250 micrograms, the prolonged tail-flick latency can be separated from the transient motor blockade. The antinociception appears not to be attributable to neurotoxicity by the histological evidence available.

Animals↗
PubMed1988

Antinociceptive and 'neurotoxic' actions of somatostatin in rat spinal cord after intrathecal administration.

In the present investigation, the antinociceptive effect of somatostatin (SST) was assessed after intrathecal injection in rats. It was found that the peptide caused antinociception, hind limb paralysis and neuronal damage of the spinal cord in a dose-dependent manner. The threshold dose for antinociception was lower (approximately 10 micrograms) than that (approximately 30 micrograms) giving rise to chronic motor impairment associated with necrotic changes and loss of an immunohistochemical marker for motoneurons in the spinal cord. It is concluded that the 'neurotoxic' potential of SST should be considered in further clinical trials.

Analgesics↗