BackgroundThoracic surgery often results in severe postoperative pain. Regional analgesia via surgically placed extrapleural local anaesthetic (LA) and continuous infusion (CI) is an effective technique, however usually requires supplemental opioid to achieve satisfactory patient analgesia. We hypothesized that high frequency, low background rate extrapleural programmed intermittent boluses (PIB) of LA by could achieve superior patient analgesia and reduced oral morphine equivalent daily dosage (OMEDD) requirements for up to 3 days after thoracic surgery vs. CI.MethodsWe retrospectively analysed data from 84 adult patients receiving extrapleural analgesia after thoracic surgery in a single tertiary teaching hospital. The primary outcome measure was the effect of PIB vs. CI on maximum daily 11-point numerical rating scale (NRS-11) ratings as determined by multivariate linear regression analysis, corrected for OMEDD use, total daily LA dose, surgery type, age, opioid type, and use of ketamine analgesia. Secondary outcome measures were the effect on OMEDD use, the effect of total ‘rescue’ LA boluses, and univariate analyses of the above outcomes and variables.ResultsPIB on day 0, and a higher proportion of LA given as rescue boluses on day 1 were associated with reduced maximum NRS-11 ratings [standardized/ [unstandardized] beta coefficient -0.34/ [-0.92 NRS-11 if PIB] (P = 0.007); and -0.26/ [-0.029 NRS-11 per mg/kg extrapleural ropivacaine] (P = 0.03)], respectively. Only patient age was associated with reduced OMEDD use [day 0: -0.58/ [-4.4 OMEDDs per year of age] (P ≤ 0.005); day 1: -0.49/ [-3.56 OMEDDs per year of age] (P ≤ 0.005); day 2: -0.32/ [-1.9 OMEDDs per year of age] (P = 0.04)]. OMEDD use on day 2, however, was associated with slightly higher maximum NRS-11 ratings [+0.28/ +0.006 NRS-11 per mg OMEDD (P = 0.036)]. On univariate analysis, PIB patients achieved the largest difference in OMEDD use [-98 mg (95% CI -73 to -123 mg)] and NRS-11 ratings [-1.1 (-0.4 to -1.8)] against CI patients on day 3.ConclusionsUse of high frequency, low background rate PIB extrapleural LA after thoracic surgery appears to have a modest beneficial effect on acute pain, but not OMEDD use, over CI when adjusted for patient, surgical and other analgesic factors after thoracic surgery. Further work is required to elucidate the potential magnitude of effect that extrapleural LA given by PIB over CI can achieve.
protection for interhospital transfers, refractory seizures, cardiac arrests and unplanned extubations requiring re-intubations. Approximately 29% of intubations were performed after-hours (8pm-8am). Airway adjuncts were employed in 33% of intubations. The C-MAC video laryngoscope was used in 31% of intubations. A bougie was used in 18% of cases. In-hospital survival of patients requiring intubation in ICU was 80.6%. Peri-intubation complications were present for 29.3%, the most common (18.8%) being desaturation (SpO2 <88%) and hypotension (SBP<80mmHg) 13.9%. Comorbidities that were positively associated with mortality included: age, APACHE-II scores and chronic illness (e.g. renal failure, ischaemic heart disease etc).
Conclusion:Our study provided descriptive data on intubation and complication rates in a regional Australian ICU. This data can be used to focus education and training around improving outcomes in ICU intubations.
Background: Extrapleural paravertebral local anaesthetic catheters are an effective method of post-operative analgesia. We investigated if delivery of ropivacaine via programmed intermittent boluses provided superior analgesia to continuous infusion alone in patients after thoracic surgery.
Methods: A single-centre, retrospective study of 84 adult patients who received an extrapleural paravertebral catheter following thoracic surgery was performed. Patients were stratified into two groups based on the percentage of the total daily ropivacaine dose delivered as a bolus: continuous infusion (< 10%; n = 29) and programmed intermittent bolus (> 10%; n = 55). Outcomes included opioid consumption, pain scores, and ketamine use.
Results: Both groups were comparable. Mean (standard deviation) oral morphine equivalent daily dose consumption on day one, the primary outcome, was 173.4mg (139.7mg) for the continuous infusion group compared to 129.2mg (100.4mg) for the programmed intermittent bolus group, p = 0.10. On day two, the mean (standard deviation) was 149.8mg (130.2mg) and 102.5mg (94.6mg) respectively, p = 0.08. On day three this reached significance with 178.1mg (150.6mg) for the continuous infusion group compared to 80.1mg (74.6mg) for the programmed intermittent bolus group, p = 0.001. There was also a reduction in the number of patients requiring ketamine in the programmed intermittent bolus group on day two (p = 0.02) and day three (p = 0.04). There was no difference in pain scores.
Conclusion: In patients receiving extrapleural paravertebral catheters after thoracic surgery, the delivery of ropivacaine via programmed intermittent boluses may provide superior analgesia compared to continuous infusion alone.
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