Complications with patient controled analgesia (PCA) - Forum

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Complications with patient controled analgesia (PCA) - Ärzteforum

Post#1 »

One of our orthopaedic surgeons has returned from a conference with anecdotal evidence of an increased incidence of ileus, Ogilvie's syndrome or pseudo-megacolon with perforation of the caecum in orthopedic patients using patient controled analgesia (PCA) after orthopaedic surgery. Has anyone noted this complication with PCA?


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Surgeon

Re: Complications with patient controled analgesia (PCA) - Ärzteforum

Post#2 »

I have had 3 or 4 pseudo obstructions in the past 2 years, but all de-novo in elderly or institutionalised patients on multiple medications; not post op. All responded well to colonoscopic decompression.

Almost all our patients having major ops get either PCA or epidural. Haven't seen pseudo-obstruction in any except one elderly woman with Parkinson's who had had laparotomy for sigmoid volvulus but probably had underlying motility disorder as well. However, I do think we get more rapid return to normal gut activity with epidurals.

Our anaesthetists run a close audit of their post op pain management, so I'll ask them to check it out and will post again if this is something that's showing up more in other disciplines (like orthopaedics), but not in general surgery.

Poland

Re: Complications with patient controled analgesia (PCA) - Ärzteforum

Post#3 »

There was a recent article in one of the major journals which, unfortunately, I do not have at my immediate disposal as I respond, demonstrating a statistically significant increase in post-op ileus in bowel cases with the use of morphine PCA. This has likwise been my anecdotal experience. I attempt to discontinue the continuous MS infusion within 24-36 hours and supplement most patients with Toradol q6h during the first 24 hours. This has seemed to work well, most patients beginning oral alimentation in 2-3 days. There will always be the occasional patient destined to get the "bloats". They are usually the ones who require foley catheter reinsertion as well. I find that postop ileus is the single most frequent factor contributing to lenghtened hospital stays. I'll try to ferret out the reference and forward it to you.

Myorelaxant

Re: Complications with patient controled analgesia (PCA) - Ärzteforum

Post#4 »

Toradol can be dangerous in the elderly or poor risk patient (a large proportion of the people I operate on) even in lower doses, because it can cause renal failure.

I had one 70 year old otherwise healthy female patient who underwent elective laparotomy (chole plus repair of paraesophageal hiatal hernia) who the Anesthetist (without asking me) gave 60 mg Toradol to intra-op--she had no urine for the next 24 hours. Central pressures were okay and her oliguria resolved spontaneously the next day.

Another patient at our hospital had a total knee replacement by our Orthopedist. A week later he still had an ileus (uncertain why) and was not doing well. The Orthopedist consulted an internist who among other things started Toradol--his urine dropped to almost nothing and his BUN, Cr and K went way up (K over 7)--luckily everything improved after the Toradol was stopped.

I have also heard anecdotal reports of patients on dialysis from Toradol.

Conversely, Toradol works well in young people--20's through 40's-- including some in whom maximal dose PCA MS (30 mg q4hours on the PCA pumps that our hospital uses) did not work for.

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Schom

Re: Complications with patient controled analgesia (PCA) - Ärzteforum

Post#5 »

I, too, have seen renal failure develop in a patient (3 days post AAA) in whom the anesthesiologist removed the epidural catheter and gave 60 mgm Toradol iv.

Current recommendations include no loading dose. Just begin with 30 mg iv q 6 hours; 15 mg iv q 6 hours if over 50 years of age. It is a highly effective drug.

One of my colleagues has had bad experience with increased post-op bleeding in modified radical mastectomy patients and does not use it in those patients. I have not seen problems of increased post-op bleeding personally.

Sojer

Re: Complications with patient controled analgesia (PCA) - Ärzteforum

Post#6 »

No question about it, Toradol must be used in recommended doses and for brief periods (e.g., 4 doses IV q. 6h immediately post -op). Used in conjunction with PCA, MS use can be considerably decreased while maintaining patient comfort.

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