published_or_final_version / Medicine / Master / Doctor of Medicine

Thesis (M.D.)--University of Hong Kong, 2004. / Also available in print.

Orientador: Lino Lemonica / Resumo: Com o rápido avanço que foi observado nos últimos anos nas técnicas cirúrgicas e anestésicas, os procedimentos se tornaram cada vez mais invasivos. Como houve progressivo envelhecimento da população, o período mais delicado de recuperação, ou seja, o pós-operatório, passou a receber maior atenção. O surgimento de novas técnicas de analgesia, como a Analgesia Controlada pelo Paciente (PCA), vem preencher as necessidades da comunidade médica, cada vez mais atenta à qualidade dos serviços prestados. O Hospital de Clínicas da Faculdade de Medicina da UNESP, Botucatu, atento a essa nova realidade constituiu o Serviço de Dor Aguda (SEDA) para que esta lacuna fosse também preenchida em nosso meio. No intuito de identificar a atuação do SEDA, realizou-se levantamento, de fevereiro de 1995 a dezembro de 1997, com a pesquisa das evoluções de 679 pacientes seguidos pelo SEDA e que fizeram uso do método PCA de analgesia. Observou-se que os resultados obtidos pelo Serviço estavam acima da média relatada pela literatura internacional, com excelentes níveis de analgesia atingidos, baixa ocorrência de efeitos colaterais, e nenhuma complicação fatal no período do estudo. / Abstract: In the past years a fast developing has been observed in the surgery and anesthetic technique, with more invasive procedures being performed. As the general population has becoming older, the critical recovery period, it means the post surgery period, became focus of attention. The developing of new analgesia techniques, such as Patient Controlled Analgesia (PCA), has the intention of fulfill the needs of the medical community, day by day more aware about the quality of the services. The Hospital of the Sao Paulo State Medical School, Botucatu, aware of this new reality had decided to form the Acute Pain Management Service (SEDA). With the goal of identify the way the SEDA acts this research was realized in period between February, 1995, to December, 1997. Data of 679 patients who used the PCA device were evaluated. The results in this study were as good as the international literature shows, with high quality analgesia, low side effects and no fatal complications on the period observed. / Mestre

Abstracts: The purpose of the study was to compare the efficacy and cost between intravenous patient-controlled analgesia (PCA) with intramuscular (IM) analgesics for women in the first two days after surgery. The study included 200 patients who were assigned to receive PCA or intramuscular injections opioid during a period of 2 days after surgery. The PCA group included 124 patients and IM group had 76 patients. The data were collected using a structured questionnaires, patient chart review and hospital charge data. The several findings were observed in this study. 1. The pain level in the PCA group was significantly lower than in the IM group (P< 0.01). The PCA group had significantly greater satisfaction with pain control than those in IM group (p< 0.01). The influence of activity by pain in the IM group had significantly greater than those in PCA group (p< 0.05). 2. The incidence of skin itching in PCA group was significantly higher than in the IM group ¡]P< 0.01¡^.3. Cost per patient was higher for PCA group¡]NT$ 420.9¡Ó22.6¡^than IM group¡]NT$228.4¡Ó60.1¡^. In conclusion, PCA produced better pain relief, get better patient¡¦s satisfaction than conventional on-demand IM opioid injections but it was more expensive.

Made available in DSpace on 2014-06-11T19:22:21Z (GMT). No. of bitstreams: 0 Previous issue date: 2001Bitstream added on 2014-06-13T20:28:37Z : No. of bitstreams: 1 barros_gam_me_botfm.pdf: 228323 bytes, checksum: 6466d10f0d4eb9a3ff79e8f785fea941 (MD5) / Com o rápido avanço que foi observado nos últimos anos nas técnicas cirúrgicas e anestésicas, os procedimentos se tornaram cada vez mais invasivos. Como houve progressivo envelhecimento da população, o período mais delicado de recuperação, ou seja, o pós-operatório, passou a receber maior atenção. O surgimento de novas técnicas de analgesia, como a Analgesia Controlada pelo Paciente (PCA), vem preencher as necessidades da comunidade médica, cada vez mais atenta à qualidade dos serviços prestados. O Hospital de Clínicas da Faculdade de Medicina da UNESP, Botucatu, atento a essa nova realidade constituiu o Serviço de Dor Aguda (SEDA) para que esta lacuna fosse também preenchida em nosso meio. No intuito de identificar a atuação do SEDA, realizou-se levantamento, de fevereiro de 1995 a dezembro de 1997, com a pesquisa das evoluções de 679 pacientes seguidos pelo SEDA e que fizeram uso do método PCA de analgesia. Observou-se que os resultados obtidos pelo Serviço estavam acima da média relatada pela literatura internacional, com excelentes níveis de analgesia atingidos, baixa ocorrência de efeitos colaterais, e nenhuma complicação fatal no período do estudo. / In the past years a fast developing has been observed in the surgery and anesthetic technique, with more invasive procedures being performed. As the general population has becoming older, the critical recovery period, it means the post surgery period, became focus of attention. The developing of new analgesia techniques, such as Patient Controlled Analgesia (PCA), has the intention of fulfill the needs of the medical community, day by day more aware about the quality of the services. The Hospital of the Sao Paulo State Medical School, Botucatu, aware of this new reality had decided to form the Acute Pain Management Service (SEDA). With the goal of identify the way the SEDA acts this research was realized in period between February, 1995, to December, 1997. Data of 679 patients who used the PCA device were evaluated. The results in this study were as good as the international literature shows, with high quality analgesia, low side effects and no fatal complications on the period observed.

The aim of this research was to compare the pain experience of cardiac surgical patients who attended the Acute Pain Service (APS) education program with cardiac surgical patients who did not attend the APS. The participants of both groups, pain levels, consumption of total analgesia, anxiety levels, satisfaction with pain management, ratios of self-administered bolus doses and failed attempts on Patient Controlled Analgesia (PCA) device and their length of hospital stay were compared. The findings indicated no statistical significant differences between the two groups being investigated in relation to pain levels, total analgesia consumed, anxiety levels, satisfaction with pain management, total demands and delivery attempts on the PCA and their length of hospital stay. The clinical mplications are significant. The preoperative pain management education program provided by APS clinical nurses for cardiac surgical patients does not have the positive outcomes expected.

Abstract In four prospective clinical trials, 114 parturients used intravenous patient-controlled remifentanil analgesia during the 1st stage of labour. The median effective dose per bolus was ascertained to be 0.4 μg/kg and the pain scores were reduced with this by a median of 2 on a numerical scale (0–10). Compared with nitrous oxide, 15 parturients included in a cross-over study reported a larger reduction in pain scores during remifentanil analgesia (1.5 vs. 0.5, p =  0.001) and better pain relief scores (2.5 vs. 0.5 on a ranked five point scale 0–4, p  &lt;  0.001). In a parallel study including 45 parturients, epidural analgesia (EDA, 20 ml bupivacaine 0.625 mg/ml and fentanyl 2 μg/ml) was associated with lower pain scores (5.2 vs. 7.3 with remifentanil, p =  0.004) but variables related to satisfaction with analgesia (pain relief score, proportion of mothers with desire to continue with the given medication and termination of the study due to inadequate pain relief) were similar. A comparison of two methods for timing the remifentanil bolus during the uterine contraction cycle suggested that delaying the bolus does not improve analgesia. A period effect was noted in the cross-over trial with higher pain scores and increased drug consumption during the second study period suggesting acute hyperalgesia. Side effects of remifentanil analgesia included respiratory depression warranting oxygen supplementation in 33% of parturients. Sedation was experienced by the parturients using remifentanil and this was scored as stronger than sedation during nitrous oxide and EDA. The number of parturients with nausea did not increase during remifentanil analgesia. Other maternal side effects included dizziness, a difficulty in visual focusing and itching. Foetal heart rate tracing abnormalities were noted. The incidence of abnormal tracings and decreased UapH were not different, however, from that observed during nitrous oxide or EDA. Apgar scores at 1 and 5 minute indicated no neonatal depression.

Abstract Excessive pain after surgery causes many kinds of endocrine, metabolic and inflammatory responses, which may increase postoperative morbidity and mortality - especially among elderly patients. This study evaluated the effect of peripheral and central pain relief techniques after joint surgery. Intravenously administered doses of 100 mg, 200 mg and 300 mg of ketoprofen decreased the requirement for opioid (fentanyl) in a dose-dependent manner by 38%, 45% and 53%, respectively, compared with a placebo, without any noticeable ceiling-effect, when administered after hip and knee arthroplasty. Patients receiving a 300 mg dose of ketoprofen had significantly lower postoperative pain scores than those receiving a placebo. There were no significant differences in incidences of nausea and vomiting, or in the amount of bleeding between the ketoprofen and placebo groups. Intravenous doses of 200 mg of ketoprofen, 150 mg of diclofenac, and 120 mg of ketorolac produced similar postoperative pain scores and requirement for opioid (fentanyl) with no intergroup differences in the incidence of nausea and vomiting and in the amount of bleeding, when administered after hip arthroplasty. The addition of ropivacaine, 1 mg·ml-1, did not decrease the requirement for epidural fentanyl administered via a patient-controlled analgesia device for postoperative pain relief after hip arthroplasty. Both drug infusions provided effective pain relief. The most common adverse effect was pruritus, which occurred in a similar number of patients in both groups. An interscalene brachial plexus block with ropivacaine decreased the dose of PCA-delivered oxycodone by 78% after arthroscopic shoulder surgery while subacromial bursa blockade with ropivacaine decreased it by only 11 % compared to a placebo during the 20 hour study period. Postoperative pain scores were significantly lowest with a interscalene brachial plexus block.

Master of Science / Department of Computing and Information Sciences / John Hatcliff / Medical devices are safety-critical systems whose failure may put human life in danger. They are becoming more advanced and thus more complex. This leads to bigger and more complicated code-bases that are hard to maintain and verify. Model-driven development provides high-level and abstract description of the system in the form of models that omit details, which are not relevant during the design phase. This allows for certain types of verification and hazard analysis to be performed on the models. These models can then be translated into code. However, errors that do not exist in the models may be introduced during the implementation phase. Automated translation from verified models to code may prevent to some extent. This thesis proposes approach for model-driven development and verification of medical devices. Models are created in AADL (Architecture Analysis & Design Language), a language for software and hardware architecture modeling. AADL models are translated to SPARK Ada, contract-based programming language, which is suitable for software verification. Generated code base is further extended by developers to implement internals of specific devices. Created programs can be verified using SPARK tools. A PCA (Patient Controlled Analgesia) pump medical device is used to illustrate the primary artifacts and process steps. The foundation for this work is "Integrated Clinical Environment Patient-Controlled Analgesia Infusion Pump System Requirements" document and AADL Models created by Brian Larson. In addition to proposed model-driven development approach, a PCA pump prototype was created using the BeagleBoard-xM device as a platform. Some components of PCA pump prototype were verified by SPARK tools and Bakar Kiasan.

Bakgrund: Patientkontrollerad smärtlindring och patientkontrollerad sedering (PCA/PCS) är kliniskt sett säkra metoder för att leverera smärtlindring eller sedering till patienter utan direkt åtgärd från sjuksköterskor. Metoderna anses av sjuksköterskor vara metoder som stärker patienters autonomi, men riskerar att distansera sjuksköterskor från patienter. För att skapa ett bredare perspektiv på metoderna undersöks i detta arbete patienters upplevelser av PCA/PCS. Syfte; Syftet är att beskriva patienters upplevelse i samband med användning av patientkontrollerad smärtlindring och sedering (PCA/PCS). Metod: Integrativ litteraturöversikt baserad på 19 artiklar. Resultat: Två teman med tre respektive två subteman framkom från analysen. Det första temat var Möjligheter med PCA/PCS beskrivet av subteman Att ha färre biverkningar, Att ha ökad autonomi och Att vara bekväm med administreringsmetoden av läkemedel. Det andra temat var Utmaningar med PCA/PCS, beskrivet av subteman Att inte få individuella behov bemötta och Att känna minskad trygghet. Slutsats: Patienters upplevelser av PCA/PCS har varit generellt positiva, med goda möjligheter att öka tillfredställelsen med den vård som erbjuds. Resultatet visar att metoderna är användbara för att stärka patienters upplevelse av autonomi. Vidare påvisas att utmaningar som metoderna innebär kan motverkas av välinformerade patienter. / Background: Patient-controlled analgesia and patient-controlled sedation (PCA/PCS) are clinically safe methods for sedation and pain management for patients without direct intervention from nurses. The methods are viewed by nurses to be a way to strengthen patients' autonomy but poses a risk of distancing patients from nurses. To broaden the perspective on these methods, this paper studies patients' experiences of PCA/PCS. Aim: The aim of this paper is to describe the patients’ experience in relation with the use of patient-controlled analgesia and sedation (PCA/PCS). Method: Integrative review based on 19 articles. Result: Two themes emerged from the analysis. The first theme was Possibilities of PCA/PCS, described by the three subthemes To have fewer side effects, To have strengthened autonomy and To be comfortable the method of drug administration. The second theme was Challenges of PCS/PCS described by the two subthemes To not have individual needs met and To feel unsafe. Conclusion: Patients' experiences of PCA/PCS have been generally positive, with strong possibilities of increasing patients satisfaction with provided care. The result shows that the methods are useful for strengthening patients' autonomy. Additionally, eventual challenges that may occur while using these methods may be alleviated with well-informed patients.