Perspective on pain management in the 21st century

Efficacy of non-pharmacological interventions in pain relief and opioid consumption after cardiac surgery: A systematic review and Bayesian network meta-analysis

OBJECTIVE

To investigate and rank the evidence for the efficacy of non-pharmacological interventions in relieving pain after cardiac surgery using comprehensive comparisons.

BACKGROUND

Although several previous systematic reviews and meta-analyses showed that non-pharmacological interventions effectively control and reduce pain after cardiac surgery, none quantitatively compared the effect of these different types of interventions.

DESIGN

Systematic review and Bayesian network meta-analysis based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Network Meta-Analysis guidelines.

METHODS

Six databases were searched from inception to April 2021 to collect all published evidence from randomised clinical trials. One author extracted the relevant information from the eligible trials; a second author independently reviewed the data. Before analysing the extracted data, two investigators independently assessed the quality of the included studies. Conventional meta-analysis was conducted using either fixed- or random-effects models according to statistical heterogeneity. The Bayesian network meta-analysis was conducted using the consistency model.

RESULTS

We identified 42 randomised clinical trials comparing 14 groups with 4253 patients. Transcutaneous electrical nerve stimulation, acupressure, music and massage were effective for pain relief, with transcutaneous electrical nerve stimulation being associated with the best probability of successful pain relief after cardiac surgery (cumulative ranking curve surface, 0.97; probability, 77.03%). Acupressure (cumulative ranking curve surface, 0.79; probability, 30.69%) was the second-best option. However, there was no evidence that any pair-up intervention significantly reduced opioid use or anxiety.

CONCLUSIONS

These findings suggest that transcutaneous electrical nerve stimulation, acupressure, music and massage may effectively alleviate postoperative cardiac pain, with transcutaneous electrical nerve stimulation representing the best choice for pain relief.

RELEVANCE TO CLINICAL PRACTICE

The results of this network meta-analysis can guide patients after cardiac surgery and healthcare providers to make optimal decisions in managing postoperative cardiac pain.

TRIAL REGISTRATION

PROSPERO CRD42021246183.

Global transcriptome analysis of rat dorsal root ganglia to identify molecular pathways involved in incisional pain

To develop non-opioid therapies for postoperative incisional pain, we must understand its underlying molecular mechanisms. In this study, we assessed global gene expression changes in dorsal root ganglia neurons in a model of incisional pain to identify pertinent molecular pathways. Male, Sprague-Dawley rats underwent infiltration of 1% capsaicin or vehicle into the plantar hind paw (n = 6-9/group) 30 min before plantar incision. Twenty-four hours after incision or sham (control) surgery, lumbar L4-L6 dorsal root ganglias were collected from rats pretreated with vehicle or capsaicin. RNA was isolated and sequenced by next generation sequencing. The genes were then annotated to functional networks using a knowledge-based database, Ingenuity Pathway Analysis. In rats pretreated with vehicle, plantar incision caused robust hyperalgesia, up-regulated 36 genes and downregulated 90 genes in dorsal root ganglias one day after plantar incision. Capsaicin pretreatment attenuated pain behaviors, caused localized denervation of the dermis and epidermis, and prevented the incision-induced changes in 99 of 126 genes. The pathway analyses showed altered gene networks related to increased pro-inflammatory and decreased anti-inflammatory responses in dorsal root ganglias. Insulin-like growth factor signaling was identified as one of the major gene networks involved in the development of incisional pain. Expression of insulin-like growth factor -2 and IGFBP6 in dorsal root ganglia were independently validated with quantitative real-time polymerase chain reaction. We discovered a distinct subset of dorsal root ganglia genes and three key signaling pathways that are altered 24 h after plantar incision but are unchanged when incision was made after capsaicin infiltration in the skin. Further exploration of molecular mechanisms of incisional pain may yield novel therapeutic targets.

The objectivity and subjectivity of pain practices in older adults with dementia: A critical reflection

Providing nursing care for people with dementia residing in long-term care facilities poses specific challenges regarding pain practices. With underlying communication barriers unique to dementia pathologies, this population is often unable to communicate verbal sentiments and descriptions of pain. In turn, nurses caring for older persons with dementia have difficulty assessing, managing and treating pain. Objectivity is an imperative factor in healthcare pain practices; however, it is difficult to objectively evaluate someone who cannot accurately communicate their experience of pain. Therefore, the authors believe that subjectivity is also an essential part of evaluating the person with dementia's experience of pain. In this critical reflection, the authors explore objectivity and subjectivity in relation to pain practices for dementia in long-term care. A historical summary of pain is provided outlining the evolution of objectivity and subjectivity related to pain practices. The authors discuss the complexities of assessing and managing pain and offer a new perspective about the role of objectivity (and co-existence of subjectivity) for nurses treating pain in the older adults with dementia.

The impact of a standard pain assessment protocol on pain levels and consumption of analgesia among postoperative orthopaedic patients

BACKGROUND

Pain is a leading concern in post-surgical orthopaedic settings; andeffective pain assessment tools are important aspects of pain management.

OBJECTIVE

This study assessed the effect of using standard pain assessment protocols (SPAP) on pain levels, pain management, and analgesia consumption among patients in the first 24 h following orthopaedic surgery.

METHODS

In total, 101 patients were recruited and assigned to the comparison group (n = 50) and experimental group (n = 51). SPAP was used in the experimental group while the comparison group received routine care. Pain levels at rest and during movement and analgesic consumption were compared between the two groups.

FINDINGS

There were significant differences in pain levels between the comparison and experimental groups. The experimental group consumed significantly less pain medication at 8-11 h of opioid medications and 12-15 h of non-opioid medications (P < .001). The use of non-pharmacological modalities was significantly higher in the experimental group compared to the comparison group (P < .001).

CONCLUSIONS

Regular pain assessment and management using SPAP can promote pain management and reduce pain levels as well as reduce analgesia administration and promote the use of non-pharmacologic approaches. These outcomes can result in fewer side effects for patients.

IMPLICATIONS

The findings suggest that using SPAP can result in improved outcomes as well as the use of non-pharmacologic approaches to pain management. This approach can result in better outcomes and increased communication between the nurse and the patient.

Behavioral and Physiological Pain Responses in Brain-Injured Patients Who Are Unable to Communicate in the Intensive Care Unit

BACKGROUND

Assessing pain of critically ill patients with brain injuries who are unable to communicate is a challenge. Current behavioral scales are limited in accurate pain assessments for this population.

AIMS

This study sought to investigate the behavioral and physiological responses induced by routine painful procedures in patients with brain injuries who are unable to communicate.

METHODS

Using a repeated-measure within-subject observational study design, 12 participants admitted to an intensive care unit were observed before, during, and 15 minutes after a nonnociceptive (noninvasive blood pressure measurement) procedure and three nociceptive (suctioning, turning, and trapezius pinch) procedures. During each assessment, patients' behavioral and physiological responses were observed using video cameras and bedside monitors.

RESULTS

In the overall behavioral responses to the nociceptive procedures, clenched teeth with tense jaw, frowning, orbit tightening, closing of eyes, eye movement, fixation-staring, flushing, flexion withdrawal of arm, flexion withdrawal of leg, muscle rigidity, twitching, and coughing were more frequently observed during procedures than before and after procedures (p < .01). Regarding physiological responses, significant increases in systolic blood pressure, diastolic blood pressure, mean arterial pressure, heart rate, and respiratory rate were identified across assessments (p < .001).

CONCLUSIONS

The findings can be used as a basis for pain assessment and the development of pain assessment tools for brain-injured patients who are unable to communicate. However, since physiological responses may be influenced by various factors besides pain, physiological changes may be used as a sign of the need for pain assessment rather than being used alone as a basis for pain assessment.

Efficacy of Precise Foot Massage Therapy on Pain and Anxiety Following Cardiac Surgery: Pilot Study

BACKGROUND

Pain is the most pervasive distressing symptom following cardiac surgery. Forty percent of postoperative cardiac patients report inadequate pain management. Undertreated acute pain results in increased anxiety, delayed wound healing, and increased chance of persistent chronic pain. Foot massage is a safe, visible complementary approach to manage acute pain following surgery.

AIM

The aim of this study is to evaluate the efficacy of integrating foot massage therapy for managing postcardiac pain.

METHOD

A randomized placebo controlled single blinded trial comparing foot massage to placebo was conducted at a large hospital in Saudi Arabia. Thirty-one patients who had undergone cardiac surgery (16 in experimental and 15 in placebo group) participated in the study. Ten-minute foot massage was delivered to the experimental group by a nurse researcher, twice during one day, within 30 minutes after receiving an opioid pain medication.

RESULTS

The findings of this study indicate that foot massage significantly (p < .05) decreases pain intensity and anxiety in patients who have undergone cardiac surgery compared with a placebo control group.

CONCLUSION

Providing non-pharmacologic interventions for pain is the responsibility of the nursing staff. Foot massage is within the scope of nursing practice and is a safe and effective manner of improving patient care. Foot massage in conjunction with pharmacological interventions is effective in improving pain and anxiety. Future studies should consider focusing on frequency, dose, feasibility, acceptability, and participants' satisfaction.

Effect of the Standardized Management of Cancer Pain on Patients with Bone Metastasis of Lung Cancer in China

Objective

This study investigates the effect of the standardized management of cancer pain on patients with bone metastasis of lung cancer in China.

Patients and Methods

A total of 123 patients with bone metastasis of lung cancer were selected from the Respiratory Department of the Affiliated Hospital of North China University of Science and Technology. Among these patients, 62 patients who had not received standardized management of cancer pain from March 12, 2018, to September 11, 2018, were selected as the control group. In contrast, 61 patients who had received the standardized management of cancer pain from September 12, 2018, to March 11, 2019, were selected as the observation group. The former cohort accepted the conventional management of cancer pain, while the latter accepted the strict, standardized management of cancer pain. The demographic statistics, disease characteristics, and painkiller application of patients in these two groups were analyzed. Then, the analgesic effect and level of satisfaction were compared between these two groups.

Results

No significant differences were noticed between these two groups in terms of age, gender, smoking status, type of pathology, education level, previous treatment, and the Eastern Cooperative Oncology Group score, as well as other demographic and disease characteristics. As for the use of painkillers, opioid analgesics accounted for a higher proportion in the observation group than in the control group. Compared with the control group, pain improvement and patient satisfaction after analgesic treatment were significantly higher in the observation group (p < 0.05).

Conclusion

The standardized management of cancer pain can considerably alleviate the pain of patients with bone metastasis of lung cancer and improve their quality of life. Furthermore, this type of management can increase satisfaction.

Pain Management and Its Possible Implementation Research in North Ethiopia: A before and after Study

BACKGROUND

Though there is an effective intervention, pain after surgical intervention is undermanaged worldwide. A systematic implementation is required to increase the utilization of available evidence-based intervention to manage the inevitable pain after surgery. The aim of this research project is to develop a scalable model for managing pain after cesarean section by implementing the World Health Organization's (WHO) pain management guidelines through a combination of implementation research and quality improvement methods.

METHODS

We implemented the World Health Organization (WHO) pain management guidelines using effective implementation strategies. First, we conducted a formative qualitative exploration to identify enablers and obstacles. In addition, we took base-line assessment on pain management implementation process and outcome using a checklist prepared from the guideline and an adapted American Pain Outcome assessment tool version 2010, respectively. Then, we integrated the guidelines into the existing practice by using collaborative iterative learning strategy. We analyzed the data by Statistical Packages for Social Sciences (SPSS) version 21. We compared the before and after data using chi-squared and Fischer's exact test. A change in any measurement was considered as significant at p value 0.05.

RESULT

We collected data from 106 mothers before and 110 mothers after intervention implementation. We successfully integrated pain as a fifth vital sign in more than 87% (p value <0.001) of patient, and fidelity was approximately 59% (p value <0.001). In addition, we significantly improved pain outcome measures after the implementation of the intervention. Conclusion and Recommendations. A systematic approach to implement pain management guidelines was successful. We recommend the ward sustain these gains and that hospital, the region, and the nation to replicate the success.

Efficiency of multimodal anаlgesia in orthopedics and traumatology

Проведене клінічне дослідження на 200 пацієнтах, яким в умовах ортопедо­травматологічного стаціонару виконувалось тотальне ендопротезування кульшового та колінного суглобів, а також металоостеосинтез довгих кісток нижніх кінцівок. Усі хворі були розбиті на 2 підгрупи (по 100 пацієнтів у кожній), де в дослідній групі знеболювання проводилось за методикою мультимодальної аналгезії (з використанням вітчизняних препаратів “Інфулган”, інтраопераційно в операційну рану –“Логнокаїн” та “Налбуфін”), в контрольній знеболювання проводилось за традиційною методикою. Оцінка ефективності післяопераційного знеболювання здійснювалася за шкалою болю ВАШ на 2, 7, 14 та 30 добу після оперативного втручання. Проведене дослідження переконливо доводить ефективність призначення мультимодальної аналгезії в післяопераційному періоді хворих ортопедо­травматологічного профілю. Все це дозволило проводити ранню післяопераційну реабілітацію пацієнтів та забезпечило гарний функціональний результат у всіх прооперованих хворих. Мультимодальна аналгезія є сучасною методикою післяопераційного знеболювання при хірургічному лікуванні пацієнтів після перенесених травм і захворювань опорно­рухового апарату і вимагає ширшого застосування в практиці ортопедів­травматологів України.

The need for novel strategies to address postoperative pain associated with cardiac surgery: A commentary and introduction to "SMArTVIEW"

Background: With coronary heart disease affecting over 2.4 million Canadians, annual cardiac and major vascular surgery rates are on the rise. Unrelieved postoperative pain is among the top five causes of hospital readmission following surgery; little is done to address this postoperative complication. Barriers to effective pain assessment and management following cardiac and major vascular surgery have been conceptualized on patient, health care provider, and system levels. Purpose: In this commentary, we review common patient, health care provider, and system-level barriers to effective postoperative pain assessment and management following cardiac and major vascular surgery. We then outline the SMArTVIEW intervention, with particular attention to components designed to optimize postoperative pain assessment and management. Methods: In conceptualizing the SMArTVIEW intervention design, we sought to address a number of these barriers by meeting the following design objectives: (1) orchestrating a structured process for regular postoperative pain assessment and management; (2) ensuring adequate clinician preparation for postoperative pain assessment and management in the context of virtual care; and (3) enfranchising patients to become active self-managers and to work with their health care providers to manage their pain postoperatively. Conclusions: Innovative approaches to address these barriers are a current challenge to health care providers and researchers alike. SMArTVIEW is spearheading this paradigm shift within clinical research to address barriers that impair effective postoperative pain management by actively engaging health care providers and patients in an accessible format (i.e., digital health solution) to give primacy to the need of postoperative pain assessment and management following cardiac and major vascular surgery.

Factors Associated with Postoperative Pain among Patients after Cardiac Surgery in the Tertiary Care Teaching Hospital of Karachi, Pakistan

Background

Pain is the subjective feeling of an individual, which affects the overall recovery of patients after cardiac surgery. Postoperative pain is the most inadequately managed symptom of cardiac surgery. Subsequently, there are many factors that can either hinder or facilitate pain management, including patients' beliefs, cultural values, physiological features, hospital policies, and healthcare providers' knowledge and beliefs. The purpose of this research was to identify factors associated with postoperative pain and its management, after cardiac surgery, among patients in a tertiary care hospital in Karachi, Pakistan.

Methods

Quantitative correlational study design was employed to attain the study purpose. Data were collected from 136 adult cardiac surgery patients admitted in the Cardiothoracic Surgery (CTS) Department, of tertiary care hospital. A self-developed questionnaire tool was used to gather information from patients. Data was then analyzed on SPSS version 19. Mann-Whitney U, Kruskal Wallis, and Spearman tests were applied to find the associations between the pain levels and of the independent variables.

Results

The mean pain scores of the first, second, and third postoperative days were found to be 2.98, 2.96, and 2.98, respectively. The findings also showed that BMI and the types of surgery were significantly associated with postoperative pain. Patients' beliefs regarding drug dependency, fear of adverse effects, and postoperative physical activities were also associated with pain. Furthermore, the nurses' education level and reluctance in medication administration due to fear of adverse effects were found to be significant too.

Conclusion

The study identified some of the important factors that were associated with postoperative pain. The results suggest the need for the enhancement of patients' education on drug dependency, adverse effects, and physical activity, before cardiac surgery. The nurses should be educated on pain management keeping the patients' culture and other perceptions of pain in mind.

Patient-Controlled Analgesia and Length of Hospital Stay in Orthognathic Surgery: A Randomized Controlled Trial

PURPOSE

The objective of this prospective, randomized controlled pilot study of patients undergoing orthognathic surgery was to compare the hospital length of stay (LOS) in patients using intravenous patient-controlled analgesia (PCA) versus patients receiving scheduled and as-needed oral analgesia.

PATIENTS AND METHODS

A total of 40 patients (19 male and 21 female patients) aged 16 to 56 years (mean, 20.73 years; standard deviation, 6.87 years) were recruited prospectively and randomized to PCA and non-PCA groups of equal size. Recording of the patient-reported pain score using a visual analog scale was commenced at 8:00 am on day 1 after surgery until discharge. The pain score from routine nursing observations during the postoperative period was recorded until the patient was discharged from the hospital.

RESULTS

Randomization resulted in approximately equal proportions of male patients (45% vs 50%) and median ages (18.5 years vs 20 years) for the PCA group versus the non-PCA group; however, the PCA group was noted to have a higher proportion of double-jaw surgery (65% vs 40%). The median LOS was 2 days for both the PCA and non-PCA groups (P = .06). No statistically significant difference in pain scores was found between the 2 groups either at rest (P = .27) or on movement (P = .13).

CONCLUSIONS

No evidence was found to indicate the superiority of either the PCA or non-PCA regimen with respect to LOS and pain scores; however, this is not evidence of equivalence of the 2 pain management approaches.

Levobupivacaine Thermogel for Long-acting Analgesia

The adequate management of analgesia, by pharmacological methods or not, is a great challenge. Local anesthetics are used for pain relief, mainly by parenteral, intramuscular, catheter, and other routes of administration. The use of in situ forming systems becomes an alternative for the control of pain. The present research investigates development of thermogels containing poloxamer and levobupivacaine. All formulations were prepared by the cold method; the compatibilities of the excipients were evaluated by DSC, rheology and viscosities, transition temperature, syringeability, release kinetics, and permeation. The compatibility of the tested excipients with the drug was initially observed; all formulations had a viscosity increase at 37°C. Different delivery rates were observed in both the release and permeation studies. The developed systems maintained the in vitro release of the drug for a long period, likely decreasing side effects in vivo and avoiding the need for supplementary analgesia by other routes.

Designing and Implementing Emergency Department Pain Management Curriculum: A Delphi Approach

OBJECTIVES

Our primary objective was to use the Delphi method (DM) to choose learning objectives for an Internet-based pain management teaching module for emergency care providers. The DM is a structured communication technique that uses systematic, interactive data gathering to reach a consensus among a panel of experts.

METHODS

We extracted preliminary educational objectives from nationwide pain fellowship training programs. After redundant objectives and those relating to procedures outside the scope of emergency medicine (EM) were removed, 23 preliminary objectives remained. We enlisted experts in EM, medical toxicology, anesthesia, pain, psychiatry, and medical education to evaluate the objectives in repeated rounds. Based on the time we had designated for teaching (3 hours) and our estimate of 15 to 20 minutes for each learning objective, we aimed for nine to 12 final learning objectives. The expert panel rated the 23 preliminary objectives with a 5-point Likert scale. Experts were blinded to each other's answers. When 80% of experts agreed with proposed objectives, objectives were considered "accepted" and retained. When 80% of experts disagreed with proposed objectives, the objectives were considered "rejected" and discarded. The remaining objectives were considered in subsequent rounds. In the first round, one objective was rejected and four were accepted. In the second round, four objectives were rejected and five were accepted. Having reached nine objectives the panel unanimously agreed that the nine objectives were sufficient to be used as a foundation for teaching modules.

RESULTS

Using the DM, our expert panel identified nine educational objectives that were used as the foundation for an educational module. Of the nine objectives, three were categorized as "medical knowledge," two as "pharmacologic knowledge," two as "patient communication," and two as "systems-based practice." The learning objectives are as follows: recognize common barriers to treating pain; understand alternative interventional therapies used to treat different kinds of pain their implications, benefits, and risks; identify common component symptoms that may exacerbate chronic pain (i.e., depression, anxiety, delirium, cachexia, dyspnea); study the major drug groups used to treat different kinds of pain; recognize the risks of polypharmacy; set realistic expectations with patients early in their presentation to the emergency department (ED); educate patients as the risks of different classes of pain medications, including risk of addiction; understand the legal and regulatory issues that govern pain management in the ED; and understand in-hospital resources available for patient follow up and referral to pain clinics.

CONCLUSIONS

We successfully used the DM to develop educational objectives for an e-learning module. Further work should evaluate educational outcomes of the teaching module.

Effective pain management and improvements in patients' outcomes and satisfaction

Adequate pain management is a compelling and universal requirement in health care. Despite considerable advancements, the adverse physiological and psychological implications of unmanaged pain remain substantially unresolved. Ineffective pain management can lead to a marked decrease in desirable clinical and psychological outcomes and patients' overall quality of life. Effective management of acute pain results in improved patient outcomes and increased patient satisfaction. Although research and advanced treatments in improved practice protocols have documented progressive improvements in management of acute and postoperative pain, little awareness of the effectiveness of best practices persists. Improved interventions can enhance patients' attitudes to and perceptions of pain. What a patient believes and understands about pain is critical in influencing the patient's reaction to the pain therapy provided. Use of interdisciplinary pain teams can lead to improvements in patients' pain management, pain education, outcomes, and satisfaction.

A Lens Model Approach to the Communication of Pain

Two studies examined the expression and detection of suppressed, genuine, and exaggerated pain. In Study 1, videotaped participants underwent an acute laboratory pain stressor and completed pain ratings. In Study 2, the lens model examined the cues encoders displayed while in pain (facial expressions of pain and viewers' global impressions), the cues decoders used to infer pain in the videotaped encoders, and decoders' accuracy in making judgments of pain. Results revealed expression differences between the suppressed, genuine, and exaggerated pain such that exaggerated expressions contained more tightened facial expressions while genuine expressions of pain contained more open facial expressions of pain. Decoders were accurate at detecting pain only in the exaggerated pain expressions. These results highlight the need for improving providers' accuracy in detecting pain intensity for suppressed, genuine, and exaggerated pain displays. Trainings should focus on teaching providers that patients who appear more agitated and less composed may be suppressing pain, while patients who appear more tense and determined may be exaggerating pain. Finally, patients who seem to not be in that much pain because they are not showing tightened facial expressions may actually be experiencing higher intensities of genuine pain.

POSTOPERATIVE PAIN: MANAGEMENT AND DOCUMENTATION BY IRANIAN NURSES

Background:

Pain is one of the most common symptoms experienced by patients after surgeries. Inadequate postoperative pain management is an international problem and the need to improve its management is well documented. The aim of the study was to assess nursing reports related to the patients’ pain intensity and quality, concomitant symptoms, use of scales in pain assessment, and compliance with the national guideline after surgery.

Methods:

This study was a retrospective cohort; samples were nurse records of patients who had elective surgery.

Result:

Only 6% of the patients’ pain records included pain intensity which was not measured with standard scales. More than half of all injections were opioid analgesic which is in contrast to the guidelines of the Iranian Ministry of Health. Pain assessment was higher in women and by nurses with more than 15 years of working experience.

Conclusion:

to conclude, the patients’ pain was not assessed properly in terms of intensity, quality, and associated symptoms. Therefore, training and motivating nurses is very important in this context and should be incorporated in nurses’ academic and continuous educational courses.

Effects of pain management program on the length of stay of patients with decreased level of consciousness: A clinical trial

Background:

Critical care patients are at higher risk for untreated pain. Pain has persistent and untreated effects on most of the body systems and results in development of complications, chronic pain, and increased length of stay. The aim of this study was to determine the effects of the implementation of a pain management program on the length of stay in patients with decreased level of consciousness, admitted in Al-Zahra hospital intensive care units (ICUs) in 2013.

Materials and Methods:

In this clinical trial, 50 subjects with decreased level of consciousness were selected by convenient sampling from the ICU wards of Al-Zahra hospital, Isfahan, Iran and were randomly assigned to two groups of study and control. Pain management program was applied on the study group and routine care was implemented in the control group. Data including demographic data and length of stay of patients in the ICUs were collected and analyzed using descriptive statistics and Chi-square test, independent t-test, and paired t-test.

Results:

Results showed that out of 50 subjects attending the study, there were 40% female and 60% male subjects in study, and 52% female and 48% male subjects in control group. (P = 0.395). Overall mean length of stay of the patients in the ICUs was significantly lower in the case group [3.2 (1.4)] days compared to the control group [7.4 (4.8) days] (P < 0.001).

Conclusions:

This study showed that overall mean length of stay of patients in the ICUs was significantly lower in the study group compared to the control group. It is suggested to use this program for patients in ICUs with decreased level of consciousness after a general surgery.

Knowledge and attitudes survey in bleeding disorders providers regarding pain

INTRODUCTION

The National Pain Study identified respondents (39%) were not satisfied with their pain management yet over 50% seek out their Haemophilia Treatment Centre (HTC) providers for pain management. This study's purpose was to assess the knowledge and attitudes of HTC providers regarding pain assessment and treatment.

METHODS

One hundred and fifty-two HTC providers responded to a Survey Monkey™ Questionnaire.

RESULTS

Knowledge deficits noted in pharmacology included (i) potentiators of opioids, (ii) time to peak effect of oral morphine, (iii) benzodiazepines usage as effective pain relievers and (iv) dose escalation/respiratory depression in an opioid tolerant patient. Areas of deficit in the substance abuse category involved (i) likelihood of a previous alcohol/drug abuse problem and (ii) signs and symptoms of discontinuation syndrome. Despite 100% confirmation from all providers that the patient is the best source of pain reporting, when presented with two identical case scenarios except for the patient's visual pain presentation; pain ratings were reported differently for patients who rated their pain similarly (8/10), yet displayed their pain symptoms differently resulting in different pain medication regimens. Responses were consistent between the provider groups but varied between case studies suggesting disparity between personal attitudes of providers when prescribing pain medication in the haemophilia population.

CONCLUSIONS

Continued research in the area of haemophilia pain as well as treatment is needed. In addition, continuing pain education is recommended for HTC provider's at the local, regional and national levels so providers could remain up to date in the changes and progress of pain management theory.

Overcoming barriers to effective pain management: the use of professionally directed small group discussions

Inadequate assessment and management of pain among critical care patients can lead to ineffective care delivery and an increased length of stay. Nurses' lack of knowledge regarding appropriate assessment and treatment, as well as negative biases toward specific patient populations, can lead to poor pain control. Our aim was to evaluate the effectiveness of professionally directed small group discussions on critical care nurses' knowledge and biases related to pain management. A quasi-experiment was conducted at a 383-bed Magnet(®) redesignated hospital in the southeastern United States. Critical care nurses (N = 32) participated in the study. A modified Brockopp and Warden Pain Knowledge Questionnaire was administered before and after the small group sessions. These sessions were 45 minutes in length, consisted of two to six nurses per group, and focused on effective pain management strategies. Results indicated that mean knowledge scores differed significantly and in a positive direction after intervention [preintervention mean = 18.28, standard deviation = 2.33; postintervention mean = 22.16, standard deviation = 1.70; t(31) = -8.87, p < .001]. Post-bias scores (amount of time and energy nurses would spend attending to patients' pain) were significantly higher for 6 of 15 patient populations. The strongest bias against treating patients' pain was toward unconscious and mechanically ventilated individuals. After the implementation of professionally directed small group discussions with critical care nurses, knowledge levels related to pain management increased and biases toward specific patient populations decreased.

Nurses Managing Patients’ Pain May Experience Moral Distress

Bedside nurses care for patients with pain every day but the task is often challenging. A previous qualitative study that investigated nurses’ experiences as they treated patients with pain suggested that nurses may suffer from moral distress if they are unsuccessful in providing adequate pain relief. As 20 of the original 48 nurses interviewed described frustration and distress when constrained from doing the right thing to provide pain relief for their patients, the purpose of this secondary qualitative analysis was to answer new research questions on nurse moral distress related to managing pain. Findings indicated that difficulties in nurse/physician communication and lack of pain education were contributors to nurses’ frustrations and provided barriers to optimal pain management. Many participants indicated a need for interprofessional pain management education. Further investigation is needed to clarify the impact of moral distress on nurses managing hospitalized patients’ pain.

No evidence of real progress in treatment of acute pain, 1993-2012: scientometric analysis

Over the past 2 decades, many new techniques and drugs for the treatment of acute pain have achieved widespread use. The main aim of this study was to assess the progress in their implementation using scientometric analysis. The following scientometric indices were used: 1) popularity index, representing the share of articles on a specific technique (or a drug) relative to all articles in the field of acute pain; 2) index of change, representing the degree of growth in publications on a topic compared to the previous period; and 3) index of expectations, representing the ratio of the number of articles on a topic in the top 20 journals relative to the number of articles in all (>5,000) biomedical journals covered by PubMed. Publications on specific topics (ten techniques and 21 drugs) were assessed during four time periods (1993–1997, 1998–2002, 2003–2007, and 2008–2012). In addition, to determine whether the status of routine acute pain management has improved over the past 20 years, we analyzed surveys designed to be representative of the national population that reflected direct responses of patients reporting pain scores. By the 2008–2012 period, popularity index had reached a substantial level (≥5%) only with techniques or drugs that were introduced 30–50 years ago or more (epidural analgesia, patient-controlled analgesia, nerve blocks, epidural analgesia for labor or delivery, bupivacaine, and acetaminophen). In 2008–2012, promising (although modest) changes of index of change and index of expectations were found only with dexamethasone. Six national surveys conducted for the past 20 years demonstrated an unacceptably high percentage of patients experiencing moderate or severe pain with not even a trend toward outcome improvement. Thus, techniques or drugs that were introduced and achieved widespread use for acute pain management within the past 20 years have produced no changes in scientometric indices that would indicate real progress and have failed to improve national outcomes for relief of acute pain. Two possible reasons for this are discussed: 1) the difference between the effectiveness of old and new techniques is not clinically meaningful; and 2) resources necessary for appropriate use of new techniques in routine pain management are not adequate.

Patient attitudes and beliefs regarding pain medication after cardiac surgery: barriers to adequate pain management

Several studies have outlined the impact of patient's beliefs on their level of pain relief after surgery and have underlined that misconceptions are barriers to effective pain relief. The aim of this survey was to evaluate the beliefs of the patients to help create a specifically adapted pain education program. After ethics approval, all patients scheduled to undergo cardiac surgery of any kind were approached and asked to complete a voluntary, non-nominative questionnaire that included the Barriers Questionnaire and the Screening Tool for Addiction Risk (STAR) Questionnaire. All completed questionnaires were collected from the charts every evening or the morning before surgery. Of 564 patients scheduled for surgery, 379 patients (67.5%) returned questionnaires. The average age was 60.3 years, and 66.0% were male. Results of the Barriers Questionnaire showed that 31% of patients were in strong agreement that "it is easy to become addicted to pain medication," 20% agreed that "good patients do not speak of their pain," and 36% believe that "pain medication should be saved in case pain worsens." Little or no gains have been made in decreasing misconceptions related to the treatment of pain. This study underlines the considerable need for and absolute necessity to provide pain education to patients undergoing cardiac surgery.

Improving knowledge, assessment, and attitudes related to pain management: evaluation of an intervention

Pain control in the acute care setting is repeatedly described in the literature as problematic. The purpose of this clinical research project was to evaluate an educational intervention designed to improve the management of pain in an acute care setting. A quasi-experimental pre- and post-intervention design was used. Three hundred and forty-one medical-surgical and critical care nurses completed the Brockopp-Warden Pain Knowledge/Bias Questionnaire (2004) (203 pre, 138 post). Data were collected before the intervention and 3 months following the educational experience. Sixty patients (30 pre, 30 post) recorded numerical assessments of their pain every 2 hours in a pain diary. Patient charts were reviewed to compare patients' pain assessments with nurses' documentation. A 50% decrease in the mean difference between patients' assessment of pain and nurses' documentation (p < .04) was found post-intervention. Although no significant differences were found on total knowledge or bias scores, 20% of nurses who participated responded incorrectly to six of 21 knowledge items both pre- and post-intervention. In keeping with earlier research on bias regarding pain management, patients with non-physiological conditions were not attended to as well as patients who had clearly defined physical problems. Results of this project have precipitated major changes regarding the management of pain in this institution. A pain steering committee has been formed and additional unit-based projects have been conducted. The challenge of finding the most effective method for changing biases toward specific patient populations and increasing knowledge regarding pain management remains.

Knowledge and attitudes of pain management among nursing faculty

A descriptive correlational design was used in this study to examine nursing faculty knowledge and attitudes in pain management. Relationships between age, education level, pain management preparation, length of time practicing as a nurse, length of time teaching nursing, time teaching pain management in the classroom, taught pain guidelines in the classroom, and additional continuing education about pain management were explored. Ninety-six nursing faculty participated from 16 schools of nursing in one Midwestern U.S. region. Findings identified that most of the nursing faculty recalled being taught about pain management in their basic education, but less than one-half felt adequately prepared. Most respondents said that they taught pain management, yet fewer than one-half identified that they used specific pain management guidelines. Faculty demonstrated adequate knowledge of pain assessment, spiritual/cultural issues, and pathophysiology. Areas of weakness were found in medications, interventions, and addiction. Faculty that reported teaching pain management in the classroom and reported more continuing education missed fewer items. Older nursing faculty reported more years of practice, more years of teaching, and more continuing education in pain management than younger faculty. Younger nursing faculty remembered being taught pain management in nursing school and felt more adequately prepared than older nursing faculty. Faculty that reported practicing for longer periods of time felt less prepared in pain management than faculty who practiced for shorter periods of time. More continuing education in pain management may be needed for older nurses to meet the recommendations of the Institute of Medicines' report on relieving pain in the U.S.

The fragmented story of pain: a saga of economic discourse, confusion and lack of holistic assessment in the residential care of older people

The long-standing problem of overlooked and/or undertreated pain experienced by so many older people living in Australian residential care facilities condemns these people to a life robbed of quality. Such a degree of suffering experienced by older people calls into question the pain assessment skills of staff who work in residential care. However, the problem of undetected and unresolved pain experienced by older people is not simply a skill or knowledge issue. It is much broader than that. In this paper we portray pain as likened to a story; a narrative that only the older person, as the author, can impart and one in which only they can communicate their experience of pain. Nevertheless, as opposed to seeking the older person's pain narrative, nurses attempt to measure the immeasurable. In part, their actions relate to the confusing terminology which envelops pain assessment. However, political policy and economic discourse also influences nurses' pain assessment practises to the detriment of older people and the profession of gerontological nursing. Discussion in this paper includes the experience of pain for the older person, an overview of the specific role of pain-screening tools compared with the requirements of a person-centred pain assessment, and person-centred pathways to help nurses and others interpret and heed the older person's pain story. Analysis also incorporates the argument that current and previous Federal Government funding tools for residential care subtly impact on holistic pain assessment causing confusion for caregivers and fragmentation of the older person's pain story.

A randomized controlled trial of auricular transcutaneous electrical nerve stimulation for managing posthysterectomy pain

Background. A patient- and assessor-blinded randomized controlled trial was conducted to examine the effectiveness of auricular transcutaneous electrical nerve stimulation (TENS) in relieving posthysterectomy pain. Method. Forty-eight women who had undergone a total abdominal hysterectomy were randomly assigned into three groups (n = 16 each) to receive either (i) auricular TENS to therapeutic points (the true TENS group), (ii) auricular TENS to inappropriate points (the sham TENS group), or (iii) 20 minutes of bed rest with no stimulation (the control group). The intervention was delivered about 24 hours after the operation. A visual analogue scale was used to assess pain while resting (VAS-rest) and upon huffing (VAS-huff) and coughing (VAS-cough), and the peak expiratory flow rate (PEFR) was assessed before and at 0, 15, and 30 minutes after the intervention. Result. As compared to the baseline, only the true TENS group reported a significant reduction in VAS-rest (P = .001), VAS-huff (P = .004), and VAS-cough (P = .001), while no significant reduction in any of the VAS scores was seen in the sham TENS group (all P > .05). In contrast, a small rising trend was observed in the VAS-rest and VAS-huff scores of the control group, while the VAS-cough score remained largely unchanged during the period of the study. A between-group comparison revealed that all three VAS scores of the true TENS group were significantly lower than those of the control group at 15 and 30 minutes after the intervention (all P < .02). No significant between-group difference was observed in PEFR at any point in time. Conclusion. A single session of auricular TENS applied at specific therapeutic points significantly reduced resting (VAS-rest) and movement-evoked pain (VAS-huff, VAS-cough), and the effects lasted for at least 30 minutes after the stimulation. The analgesic effects of auricular TENS appeared to be point specific and could not be attributed to the placebo effect alone. However, auricular TENS did not produce any significant improvement in the performance of PEFR.

Pain management in critically ill obese patients

Achieving pain control in critically ill patients is a challenging problem for the health care team, which becomes more challenging in morbidly obese patients. Obese patients may experience drug malabsorption and distribution, which may lead to either subtherapeutic or toxic drug levels. To manage pain effectively for the critically ill obese patient, nurses must have an understanding of how obesity alters a patient's physiologic response to injury and illness. In addition, nurses must be knowledgeable about physiologic pain mechanisms, types and manifestations of pain, differing patterns of drug absorption and distribution, pharmacokinetic properties of analgesic medications, and pain management strategies. This article explores factors affecting pharmacokinetics in obese patients, trends in pain management, and treatment strategies for the obese patient.

Is guided imagery effective in reducing pain and anxiety in the postoperative total joint arthroplasty patient?

PURPOSE

To evaluate the effect of guided imagery as an intervention to reduce pain and anxiety in patients undergoing a total joint arthroplasty.

SAMPLE

A total of 121 patients scheduled for elective total joint arthroplasty.

METHODS

The design for this study was a 2-group quasi-experimental design. The intervention group listened to a guided imagery CD containing a message to develop a sense of relaxation and harmony. The intervention and control groups were compared on self-reported pain and anxiety levels postoperatively on Days 1, 2, and 3.

RESULTS

There was no significant difference in pain and anxiety levels between the groups. However, the intervention group had lower levels of anxiety and pain at all time points. Both groups followed a similar anxiety and pain pattern with the highest reported levels at Day 2.

CONCLUSIONS

Conduct further research of guided imagery as an intervention for reducing pain and anxiety utilizing randomized controlled trials with a diverse sample of patients.

Pain management after cardiac surgery

Pain levels after cardiac surgery are often severe and undertreated. The effects of undertreatment may be both severe and prolonged. The incidence of chronic pain after cardiac surgery varies between 21% and 55%. Pain syndromes that occur following cardiac surgery may be multiple and may be of visceral, musculoskeletal, or neurogenic origin. Risk factors for acute pain vary depending on the study but generally include younger age, longer duration of surgery, and the location of the surgery. Risk factors for chronic pain include depression and psychological vulnerability, both preoperative and postoperative. Other independent risk factors for chronic pain are more extensive surgery, surgery lasting longer than 3 hours, and ASA grade greater than III. Pain control is achieved with regular and systematic evaluation and the use of multimodal regimens. Treatment strategies that are commonly used include opioids, paracetamol, NSAIDS, and more recently anticonvulsants.