RESUMEN
Adequate postoperative analgesia is a key element of enhanced recovery programmes. Thoracic epidural analgesia is associated with superior postoperative analgesia but can lead to complications. Rectus sheath catheter analgesia may provide an alternative. In a nested qualitative study (within a two-year randomised controlled trial) focussing on the acceptability, expectations and experiences of receiving the interventions, participants (n = 20) were interviewed 4 weeks post-intervention using a grounded theory approach. Constant comparative analysis, with patient and public involvement, enabled emerging findings to be pursued through subsequent data collection. We found no notable differences regarding postoperative acceptability or the experience of pain management. Pre-operatively, however, thoracic epidural analgesia was a source of anticipatory fear and anxiety. Both interventions resulted in some experienced adverse events (proportionately more with thoracic epidural analgesia). Participants had negative experiences of the insertion of thoracic epidural analgesia; others receiving the rectus sheath catheter lacked confidence in staff members' ability to manage the local anaesthetic infusion pump. The anticipation of the technique of thoracic epidural analgesia, and concerns about its impact on mobility, represented an additional, unpleasant experience for patients already managing an illness experience, anticipating a life-changing operation and dealing with concerns about the future. The anticipation of rectus sheath catheter analgesia was not associated with such anxieties. Patients' experiences start far earlier than the experience of the intervention itself through anticipatory anxieties and fears about receiving a technique and its potential implications. Complex pain packages can take on greater meaning than their actual efficacy in relieving postoperative pain. Future research into patient acceptability and experience should not focus solely on efficacy of pain relief but should include anticipatory fears, anxieties and experiences.
Asunto(s)
Analgesia Epidural , Humanos , Analgesia Epidural/métodos , Motivación , Manejo del Dolor , Dolor Postoperatorio/etiología , Catéteres/efectos adversos , Analgésicos OpioidesRESUMEN
Somatotrophs of male Wistar rats fed a carcinogenic dose of the potent hepatocarcinogen 3'methyl-4-dimethylaminoazobenzene-(3'MeDAB) in a complete diet for up to 21 weeks, showed ultrastructural changes within one week of the start of the experiment. Morphometric analysis showed that the area of the somatotrophs occupied by hormone storage granules was reduced significantly at all stages up to 21 weeks, when the experiment was terminated. The cell area occupied by rough endoplasmic reticulum (RER) was significantly increased after three weeks and RER surface density increased after eight weeks, whilst granule size was reduced after four weeks. Pituitary content of radioimmunoassayable growth hormone (RIA-GH) was also lower in treated rats than in controls, from one week after the start of the experiment, but only significantly so at eight and twelve weeks, owing to large standard errors. Serum levels of RIA-GH were similarly lower in 3'MeDAB treated rats than in controls. Withdrawal of 3'MeDAB diet after twelve weeks treatment permitted partial recovery of some cell organelles, in that the content of hormone storage granules increased and the area of the RER decreased compared to rats fed 3'MeDAB continuously. There was also a partial, but non-significant, increase in pituitary RIA-GH. The pituitaries of rats pair-fed 3'MeDAB diet for 15 weeks contained significantly less RIA-GH than matched controls. These results suggest that 3'MeDAB, or its metabolites, may react with pituitary somatotrophs and impair their ability to synthesise and secrete hormone.