Assessment, physiological monitoring, and consequences of inadequately treated acute pain

Comparison of analgesic effect of pericapsular nerve group block and supra-inguinal fascia iliaca compartment block on dynamic pain in patients with hip fractures: a randomized controlled trial

BACKGROUND

Patients with hip fracture often experience severe pain, particularly during movement or slight positional change, prior to the occurrence of surgery. It is essential to explore the appropriate analgesic methods before surgery in patients with hip fracture, especially those capable of alleviating dynamic pain. Pericapsular nerve group (PENG) block was introduced as a useful technique for hip analgesia. In this study, we aimed to compare the reduction in dynamic pain between the PENG block and supra-inguinal fascia iliaca compartment block (SIFICB).

METHODS

This prospective trial included 80 hip fracture patients aged ≥19 years, with an American Society of Anesthesiologists Physical Status of 1-4 and a baseline dynamic pain score ≥4 on the numerical rating scale. The patients were randomly allocated into the PENG block (n=40) and SIFICB group (n=40). For the PENG block and SIFICB, 20 mL and 30 mL of 0.3% ropivacaine was used, respectively. The primary outcome was reduction in dynamic pain scores at 30 min following the peripheral nerve block. Dynamic pain score was evaluated when the leg was passively raised.

RESULTS

A total of 79 patients were included in the final analysis, and the reductions in pain score during hip flexion were 3.1±2.4 and 2.9±2.5 in the PENG block and SIFICB groups, respectively, which was statistically insignificant (p=0.75). Moreover, no significant differences were observed in any of the outcomes.

CONCLUSIONS

PENG block and SIFICB could effectively provide analgesia for dynamic pain in patients with hip fractures, with no significant difference between the two groups.

TRIAL REGISTRATION NUMBER

NCT04677348.

The Effect of Listening to Holy Quran Recital on Pain and Length of Stay Post-CABG: A Randomized Control Trial

Background

Nearly, 75% of patients post-CABG complain of moderate to severe pain during their hospital stay. Nonpharmacological interventions have been investigated; however, the effect of Holy Quran recital post-CABG is still not well studied, especially in developing Islamic countries.

Objective

To investigate the effect of listening to the Holy Quran recital on pain and length of stay post-CABG.

Methods

This was a randomized control trial on 132 patients recruited from four hospitals in Amman, Jordan. The intervention group listened to the Holy Quran recited for 10 minutes twice daily while the control group received the usual care. Data were analyzed using paired and independent samples t-tests.

Results

Paired t-test testing showed that there was a significant reduction in the pain level, (M [SD], 6.82 [2.27] vs. 4.65 [2.18], t = 23.65, p < 0.001) for the intervention group. In addition, the intervention group had shorter LoS in the ICU and in the hospital compared to the control group, (M [SD], 5.0 [4.02] vs. 6.58 [4.18], t = -2.1, p < 0.05), (M [SD], 10.15 [9.21] vs. 15.01 [13.14], t = -2.6, p < 0.05), respectively.

Conclusions

Listening to the Quran was significantly effective in improving pain intensity among post-CABG patients and shortening their hospital/ICU stay. This trial is registered with NCT05419554.

Children's Pain Identification Based on Skin Potential Signal

Pain management is a crucial concern in medicine, particularly in the case of children who may struggle to effectively communicate their pain. Despite the longstanding reliance on various assessment scales by medical professionals, these tools have shown limitations and subjectivity. In this paper, we present a pain assessment scheme based on skin potential signals, aiming to convert subjective pain into objective indicators for pain identification using machine learning methods. We have designed and implemented a portable non-invasive measurement device to measure skin potential signals and conducted experiments involving 623 subjects. From the experimental data, we selected 358 valid records, which were then divided into 218 silent samples and 262 pain samples. A total of 38 features were extracted from each sample, with seven features displaying superior performance in pain identification. Employing three classification algorithms, we found that the random forest algorithm achieved the highest accuracy, reaching 70.63%. While this identification rate shows promise for clinical applications, it is important to note that our results differ from state-of-the-art research, which achieved a recognition rate of 81.5%. This discrepancy arises from the fact that our pain stimuli were induced by clinical operations, making it challenging to precisely control the stimulus intensity when compared to electrical or thermal stimuli. Despite this limitation, our pain assessment scheme demonstrates significant potential in providing objective pain identification in clinical settings. Further research and refinement of the proposed approach may lead to even more accurate and reliable pain management techniques in the future.

Are Prayer-Based Interventions Effective Pain Management Options? A Systematic Review and Meta-analysis of Randomized Controlled Trials

This review examined the effects of private and communal participatory prayer on pain. Nine databases were searched. Six randomized controlled trials were included. For private prayer, medium to large effects emerged for 67% to 69% of between-group comparisons; participants in the prayer condition reported lower pain intensity (0.59 < d < 26.17; 4 studies) and higher pain tolerance (0.70 < d < 1.05; 1 study). Pre- to post-intervention comparisons yielded medium to large effects (0.76 < d < 1.67; 2 studies); pain intensity decreased. Although firm conclusions cannot be made because meta-analysis was based on only two studies, the analysis suggested prayer might reduce pain intensity (SMD = - 2.63, 95% CI [- 3.11, - 2.14], I = 0%). (PROSPERO: CRD42020221733).

Association Between Initial Opioid Prescription Duration and 30-Day Risk of Receiving Repeat Opioid Among Children

OBJECTIVE

Our study evaluated the association between initial opioid prescription duration and receipt of a repeat opioid prescription in children.

METHODS

Eligible individuals were children between 1 and 17 years of age who enrolled in a Medicaid Managed Care plan and filled an incident opioid prescription during 2013 to 2018. An incident prescription was defined as receipt of an opioid analgesic without a prior use for 12 months. A repeat opioid prescription was defined as receipt of a subsequent opioid prescription within 30 days since the end of incident opioid prescription. A hierarchical multivariable logistic regression model was fitted to test the association between incident opioid prescription duration and the likelihood of receiving a repeat prescription.

RESULTS

The cohort consisted of 17,086 children receiving an incident opioid prescription in which 6272 (36.7%) received 1 to 3 days' supply, 8442 (49.4%) received 4 to 7 days' supply, 1434 (8.4%) received 8 to 10 days' supply, and 938 (5.5%) received >10 days' supply. Of these incident opioid recipients, 1780 (10.4%) filled a repeat opioid prescription. The multilevel model results indicated that, children receiving 4 to 7 days' supply (adjusted odds ratio [aOR]: 0.98 {0.9-1.1}), 8 to 10 days' supply (aOR: 1.03 [0.8-1.3]), and >10 days' supply (aOR: 0.85 [0.7-1.1]) had comparable likelihoods of receiving a repeat prescription as those receiving 1 to 3 days' supply.

DISCUSSION

Nearly 10% of children who filled an opioid prescription for acute pain received a repeat prescription. Initial prescription duration was not associated with the risk of receiving a repeat prescription.

Perioperative Optimization of the Cardiac Surgical Patient

Perioperative optimization of cardiac surgical patients is imperative to reduce complications, utilize health care resources efficiently, and improve patient recovery and quality of life. Standardized application of evidence-based best practices can lead to better outcomes. Although many practices should be applied universally to all patients, there are also opportunities along the surgical journey to identify patients who will benefit from additional interventions that will further ameliorate their recovery. Enhanced recovery programs aim to bundle several process elements in a standardized fashion to optimize outcomes after cardiac surgery. A foundational concept of enhanced recovery is attaining a better postsurgical end point for patients, in less time, through achievement and maintenance in their greatest possible physiologic, functional, and psychological state. Perioperative optimization is a broad topic, spanning multiple phases of care and involving a variety of medical specialties and nonphysician health care providers. In this review we highlight a variety of perioperative care topics, in which a comprehensive approach to patient care can lead to improved results for patients, providers, and the health care system. A particular focus on patient-centred care is included. Although existing evidence supports all of the elements reviewed, most require further improvements in implementation, as well as additional research, before their full potential and usefulness can be determined.

Immediate Effects of Hypnosis, Mindfulness Meditation, and Prayer on Cold Pressor Outcomes: A Four-Arm Parallel Experimental Study

Purpose

Previous research supports the usefulness of hypnosis (HYP), mindfulness meditation (MM), and prayer as pain self-management strategies in adults with chronic pain. However, their effects on acute pain have been less researched, and no previous head-to-head study compared the immediate effects of these three approaches on pain-related outcomes. This study compared the immediate effects of HYP, MM, and Christian prayer (CP) on pain intensity, pain tolerance, and stress as assessed by heart rate variability (HRV).

Participants and Methods

A total of 232 healthy adults were randomly assigned to, and completed, a single 20-minute session of MM, SH, CP, or an attention control (CN), and underwent two cycles (one pre- and one post-intervention) of Cold Pressor Arm Wrap (CPAW). Sessions were audio-delivered. Participants responded to pre- and post-intervention pain intensity measurements. Pain tolerance (sec) was assessed during the CPAW cycles. HRV was assessed at baseline, and at pre- and post-intervention CPAW cycles. The study protocol was pre-registered at the ClinicalTrials.gov registry (NCT04491630).

Results

Small within-group decreases in pain intensity and small increases in pain tolerance were found for HYP and MM from the pre- to the post-intervention. Small within-group improvements in the LH/HF ratio were also found for HYP. The exploratory between-group pairwise comparisons revealed a medium effect size effects of HYP on pain tolerance relative to the control condition. The effects of CP were positive, but small and not statistically significant. Only small to medium, though non-significant, Time × Group interaction effects were found.

Conclusion

Study results suggest that single short-term HYP and MM sessions, but not biblical-based CP, may be useful for acute pain self-management, with HYP being the slightly superior option. Future research should compare the effects of different types of prayer and examine the predictors and moderators of these pain approaches' effects on pain-related outcomes.

Knowledge about Pain in Spanish Nursing Students

BACKGROUND

All nurses should receive training and education regarding pain as part of their pre-graduate stage, as its assessment and appropriate management when treating patients largely depends on them. With the right knowledge it is possible to reduce its high prevalence, as well as the serious consequences it can lead to.

AIM

To determine the level of knowledge and attitudes towards pain of final-year nursing students in Spain.

METHODS

Descriptive cross-sectional study using a convenience sample of five Spanish universities during the academic year 2020-2021. The Spanish version of the Knowledge and Attitudes Survey Regarding Pain (KASRP) was used. In addition, socio-demographic variables such as age, sex, relationship status, employment status, and the number of dependants were collected. The specific palliative or oncology subjects of each university was also assessed.

RESULTS

A total of 224 questionnaires were collected. One of the nursing universities obtained the best score in the KASRP (59.75%) which was significant (p = .001). This university was the only one that offers specific subjects in palliative or oncologic care. A training deficit in aspects related to pain assessment and pharmacologic concepts was detected. We found no relationship between the KASRP and the different sociodemographic variables.

CONCLUSIONS

Specific training in palliative care improves the students' knowledge regarding pain, although the results did not reach an acceptable minimum. The universities' training programs for Spanish students need to be adapted in order to achieve better results.

Impact of Philosophy for Children and Its Challenges: A Systematic Review

Philosophy for children (P4C) has been implemented worldwide. P4C has been researched empirically in order to evaluate its effectiveness and address the current lack of a systemic literature review of research on P4C. Therefore, this SLR study aims to identify how P4C positively affects aspects other than students' thinking and the challenges that teachers and students face in implementing the program. The methodology and writing method used was PRISMA (preferred reporting items for systematic review and meta-analysis). Articles and materials related to the topic were located primarily using two databases, Web of Science and Scopus. Using thematic analysis, this SLR derived five main themes, namely (1) higher-order thinking skills (HOTS), (2) safe environments, (3) civilized students, (4) democracy in discussion, and (5) the culture of thinking in the classroom. There are also challenges faced by teachers and students.

Cognitive impairment and pain relief following hip fractures: a case control study

Hip fractures represent a significant workload of both emergency and orthopaedic departments within the National Health Service (NHS). Pain relief is key in treating hip fractures as highlighted by both National Institute of Clinical Excellence (NICE) and British Orthopaedic Association Standards for Trauma (BOAST) guidelines. However, the literature shows that patients with cognitive impairment tend to have inconsistent pain management, leading to worse outcomes. We conducted a case–control study looking at 296 patients who presented with hip fractures to a major trauma centre between 1 December 2019 and 30 May 2020. Cognition was assessed using pre-recorded Abbreviated Mental Test Scores (AMTS). There was no significant difference between pain relief provided to patients with or without cognitive impairment in both the pre-hospital (p = 0.208) and Accident & Emergency (A&E) (p = 0.154) setting. A larger proportion of patients in A&E did not receive any pain relief (18.6% versus 42.2%). Pre-hospital, the higher the pain score, the stronger the analgesia given (R = 0.435, p = 0.000). This relationship was present in both the cognitively impaired (R = 0.572, p = 0.000) and cognitively intact groups (R = 0.390 p = 0.000). Strength of analgesia and pain scores did not correlate in A&E (R = 0.014, p = 0.826). Cognition did not impact the time to analgesia both pre-hospital (p = 0.291) and in A&E (p = 0.332); however, patients waited significantly longer to receive pain relief in A&E (29.61 minutes versus 150.28 minutes). Fascia-iliaca blocks were administered to 58.4% of the cohort, with no significant difference noted between cognition status. Overall, cognition does not impact pain management both pre-hospital and in A&E. There is still room for improvement, particularly in the assessment of pain in the cognitively impaired. A possible solution is the utilisation of the Bolton Pain Assessment Tool, a validated pain assessment tool for the cognitively impaired that has been utilised in the trauma setting with good effect.

Pain Behaviors and Pharmacological Pain Management Among Newly Admitted Nursing Home Residents

BACKGROUND

Clinicians may place more weight on vocal complaints of pain than the other pain behaviors when making decisions about pain management.

OBJECTIVES

We examined the association between documented pain behaviors and pharmacological pain management among nursing home residents.

METHODS

We included 447,684 residents unable to self-report pain, with staff-documented pain behaviors (vocal, nonverbal, facial expressions, protective behaviors) and pharmacological pain management documented on the 2010-2016 Minimum Data Set 3.0. The outcome was no pharmacological pain medications, as needed only (pro re nata [PRN]), as scheduled only, or as scheduled with PRN medications. We estimated adjusted odds ratios and 95% confidence intervals from multinomial logistic models.

RESULTS

Relative to residents with vocal complaints only, those with one pain behavior documented (i.e., nonverbal, facial, or protective behavior) were more likely to lack pain medication versus scheduled and PRN medications. Residents with multiple pain behaviors documented were least likely to have no treatment relative to scheduled with PRN medications, PRN only, or scheduled only pain medication regimens.

DISCUSSION

The type and number of pain behaviors observed are associated with pharmacological pain management regimen. Improving staff recognition of pain among residents unable to self-report is warranted in nursing homes.

Prayer as a pain intervention: protocol of a systematic review of randomised controlled trials

BACKGROUND

Pain is a universal experience and the most common reason for seeking healthcare. Inadequate pain management negatively impacts numerous aspects of patient health. Multidisciplinary treatment programmes, including psychosocial interventions, are more useful for pain management than purely biomedical treatment alone. Recently, researchers showed increasing interest in understanding the role of spirituality/religiosity and spiritual/religious practices on pain experience, with engagement in religious practices, such as prayer, showing to positively impact pain experience in religious individuals. This systematic review will seek to summarise and integrate the existing findings from randomised controlled trials assessing the effects of prayer and prayer-based interventions on pain experience.

METHODS

The systematic review procedures and its report will follow the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement. Electronic searches in nine databases (Web of Science Core Collection, MEDLINE, SCIELO Citation Index, PubMed, Cochrane Central Register of Controlled Clinical Trial, PsycINFO, Scopus, LILACS and Open-SIGLE) will be performed to identify randomised controlled trials of prayer-based interventions. Two independent researchers will assess studies for inclusion and extract data from each paper. Risk of bias assessment will be assessed independently by two reviewers based on the Consolidated Standards of Reporting Trials statement. Qualitative synthesis of the body of research will be conducted using a narrative summary synthesis method. Meta-analysis will be limited to studies reporting on the same primary outcome. Formal searches are planned to start in June 2021. The final report is anticipated to be completed by September 2021.

DISCUSSION

Findings will be useful to (1) understand the condition of our knowledge in this field and (2) provide evidence for prayer effectiveness in reducing pain intensity and pain-related stress and increasing pain tolerance in adults experiencing acute or chronic pain.

PROSPERO REGISTRATION NUMBER

CRD42020221733.

Real-Time High-Level Acute Pain Detection Using a Smartphone and a Wrist-Worn Electrodermal Activity Sensor

The subjectiveness of pain can lead to inaccurate prescribing of pain medication, which can exacerbate drug addiction and overdose. Given that pain is often experienced in patients' homes, there is an urgent need for ambulatory devices that can quantify pain in real-time. We implemented three time- and frequency-domain electrodermal activity (EDA) indices in our smartphone application that collects EDA signals using a wrist-worn device. We then evaluated our computational algorithms using thermal grill data from ten subjects. The thermal grill delivered a level of pain that was calibrated for each subject to be 8 out of 10 on a visual analog scale (VAS). Furthermore, we simulated the real-time processing of the smartphone application using a dataset pre-collected from another group of fifteen subjects who underwent pain stimulation using electrical pulses, which elicited a VAS pain score level 7 out of 10. All EDA features showed significant difference between painless and pain segments, termed for the 5-s segments before and after each pain stimulus. Random forest showed the highest accuracy in detecting pain, 81.5%, with 78.9% sensitivity and 84.2% specificity with leave-one-subject-out cross-validation approach. Our results show the potential of a smartphone application to provide near real-time objective pain detection.

The Importance of Respiratory Rate Monitoring: From Healthcare to Sport and Exercise

Respiratory rate is a fundamental vital sign that is sensitive to different pathological conditions (e.g., adverse cardiac events, pneumonia, and clinical deterioration) and stressors, including emotional stress, cognitive load, heat, cold, physical effort, and exercise-induced fatigue. The sensitivity of respiratory rate to these conditions is superior compared to that of most of the other vital signs, and the abundance of suitable technological solutions measuring respiratory rate has important implications for healthcare, occupational settings, and sport. However, respiratory rate is still too often not routinely monitored in these fields of use. This review presents a multidisciplinary approach to respiratory monitoring, with the aim to improve the development and efficacy of respiratory monitoring services. We have identified thirteen monitoring goals where the use of the respiratory rate is invaluable, and for each of them we have described suitable sensors and techniques to monitor respiratory rate in specific measurement scenarios. We have also provided a physiological rationale corroborating the importance of respiratory rate monitoring and an original multidisciplinary framework for the development of respiratory monitoring services. This review is expected to advance the field of respiratory monitoring and favor synergies between different disciplines to accomplish this goal.

Determinants of Knowledge of Pain among Nurses in a Tertiary Hospital in Spain

BACKGROUND

Poorly controlled pain in patients is related to several complications, such as increased nosocomial infections and mortality, where nurses play a crucial role.

AIMS

To analyze determinants of pain as well as nurses' knowledge and attitudes towards pain in the inpatient services of a tertiary center in the Spanish public health network.

METHODS

The Knowledge and Attitudes Survey Regarding Pain questionnaire was administered to all nurses in the center from January to March 2019. Additional sociodemographic variables, such as gender, age, employment status, work experience, professional group, and academic degree, were collected and analyzed. Item Response Theory was used for discriminant analysis of each question and its relationship with the final score.

RESULTS

A total of 282 questionnaires were collected from those distributed among nurses working in medical, surgical, oncological, and intensive care services. The average score obtained on pain-related knowledge and attitudes was 58.89%. We found significant differences (p < .001) between the KASRP score and the professional group score. There were no differences in final score based on academic level or age. Questions related to pharmacology resulted in low scores and did not discriminate between levels of knowledge, being considered difficult. We did not find items that allowed discriminating between levels of knowledge.

CONCLUSIONS

A knowledge gap exists regarding nurses' pharmacological and assessment concepts, and there are differences in knowledge depending on professional group. The KASRP allows for a good discrimination of low levels of knowledge.

How should we approach parental refusals of opioids on behalf of children in the perioperative setting? A practical approach based on ethical theory

In the midst of the current opioid epidemic, we have encountered more parents who are concerned about the use of opioids in the perioperative setting. Some parents have completely refused the use of opioids on behalf of their children. How should we approach this treatment refusal? This article describes ethical theory related to the refusal of treatment by parents on behalf of their children, and when it is justified to override parental decisions. We propose a decision-making framework that focuses on improving communication and considering alternatives. Assessment of harm to the child from avoiding opioids, as well as potential harms from overriding parental autonomy must be undertaken prior to considering overriding parents.

Cold Therapy and the Effect on Pain and Physiological Parameters in Patients Recovering from Spine Surgery: A Randomized Prospective Study

BACKGROUND

This study aimed to determine the effect of cold therapy (CT) on pain and physiological parameters after spine surgery.

MATERIALS AND METHODS

This study was a prospective, randomized controlled trial. Study participants were randomly assigned to either a control group or a CT group. The outcome measured was pain intensity rated by a numeric rating scale. Psychological outcome measures were considered secondary.

RESULTS

Thirty-eight patients in each group completed the study. No statistically significant difference was found between the pain scores of patients in the CT and those in the control group during the 24-h period following surgery (group: F = 0.01, p = 0.922). However, it was found that the pain scores of patients in the CT group were significantly lower than those in the control group during the 48-h period (group: F = 10.59, p = 0.002).

CONCLUSION

CT reduced pain scores during the 48-h period following spine surgery. Our findings support the use of CT as an adjuvant therapy in pain management.

Nursing Workload, Knowledge about Pain, and Their Relation to Pain Records

PURPOSE

To study the relationship between frequency of pain assessment and nursing workload, and also to analyze the frequency of pain assessment and its relation to knowledge and attitudes toward pain on nursing professionals in intensive care unit.

METHODS

An ambispective study was conducted in a Spanish tertiary-level intensive care unit between October 2017 and April 2018. For measurement of workload, the Nursing Activities Score scale was used, and for measurement of pain knowledge, the Knowledge and Attitudes Survey Regarding Pain was used.

RESULTS

There were 1,207 measurements among 41 nurses and 1,838 among 317 patients. The average nursing workload was high (70.97 points). We found statistically significant positive association between nursing workload and the frequency of assessment (p < .001), as well as frequency of assessment and patients with communicative capacity (p = .008).

CONCLUSIONS

Nursing workload affects the registration and assessment of patients' pain, resulting in a greater number of records as the workload performed by nurses increases. It is necessary to study in greater depth how the severity of pain, gender of the patients, and workload of nurses influence pain registration and assessment.

Spanish Version of the Knowledge and Attitudes Survey Regarding Pain

A variety of valid tools are available to assess staff knowledge and attitudes regarding pain, among which is the Knowledge and Attitudes Survey Regarding Pain. Although this instrument has been widely and successfully used, a valid and adapted Spanish version is yet to be developed. The purpose of this study was to validate the Spanish version of the Knowledge and Attitudes Survey Regarding Pain. After translating and back-translating this tool, we conducted a cross-cultural adaptation and construct validation with 102 participants, including nursing professionals (in palliative care, oncology, and intensive care) from five health centers and final-year nursing students. All participants were recruited in the Principality of Asturias, Spain. We also evaluated the internal consistency and test-retest correlations. Cronbach's α was .781, and Pearson's r and the intraclass correlation coefficient between the test and retest scores were .881 and .883, respectively. The mean questionnaire scores in the test and retest phases were 65.8% and 67.6%, respectively. Palliative care nurses had the highest score, 70.8%, which differed significantly from the rest of the groups. The Spanish version of the Knowledge and Attitudes Survey Regarding Pain can effectively differentiate nursing staff in terms of their pain expertise. The results indicate that Spanish nurses have a gap in pharmacologic knowledge that is comparable to that found in other countries, but their foundation in general pain concepts was solid.

Perception of pain in post-surgical patients in intensive care units

INTRODUCTION

Pain assessment and treatment are essential for ensuring quality of care as well as for improving patient's satisfaction and clinical outcomes.

OBJECTIVES

1) To describe pain perception of surgical patients admitted to our Intensive Care Unit(ICU). 2) To compare the patients' pain perception with the assessment carried out by nurses. 3) To correlate International Pain Outcomes Questionnaire results with socio-demographical data.

METHODOLOGY

A prospective descriptive observational study was carried out in the ICU of a third level university hospital over a period of 3 months. Surgical patients' pain-perception was assessed 24hours after their admission to the ICU using the Spanish translation of International Pain Outcomes Questionnaire.

RESULTS

The highest pain score recorded among 109 patients by nurses was 4.47±2.75, while, the lowest was .69±1,25. However, the highest and lowest pain scores reported by patients were 5.59±2.72 and 2.13±2.03, which showed significant differences (P <0.001). The highest pain score seemed to be related to the type of surgery (P <0.027). There are significant variations in the lowest pain score depending on age (P=0.005 r=-0.270). Likewise, the worst pain score correlated with the patients' sex (P=0.004). Patients who reported that pain made them feel very anxious or helpless scored highest with the worst pain, 7.35±1.98, 7.44±1.85 respectively. These differences were statistically significant (P=0.001, P <0.001). Regarding to the score of less pain, there is an association with feeling anxiety (P=0.032) and not with feeling helpless (P=-0.088).

CONCLUSIONS

The post-surgical patients reported pain during the first 24hours following admission to ICU (max score 5.59±.26). The nurses underestimated the patients' reported pain. Improving nurses' education would provide them with assessment strategies for better pain management. Age, sex, anxiety and helplessness caused by pain, were variables that significantly influenced pain.

Thoracostomy Tube Removal: Implementation of a Multidisciplinary Procedural Pain Management Guideline

OBJECTIVE

Thoracostomy tubes are placed following cardiothoracic surgery for the repair or palliation of congenital heart defects. The aim of this project was to develop and implement a clinical practice guideline for the provision of optimal analgesia during removal of thoracostomy tubes in pediatric postoperative cardiothoracic surgery patients.

METHODS

Methods used include a nonexperimental design utilizing chart audits to determine baseline documentation as well as procedure note evaluation to determine both baseline documentation and compliance with the new guideline. A convenience sample of unit-based nurses completed a knowledge test and a post-implementation survey.

RESULTS

There was a significant increase in nursing knowledge related to the clinical practice guideline education and implementation. Documentation compliance was observed. Nursing satisfaction and feasibility of the new guideline was demonstrated.

DISCUSSION

This project was successful in increasing nursing knowledge of available resources for optimal procedural pain management in pediatric patients requiring thoracostomy tube removal on one in-patient acute care unit.

Effect of Environmental and Behavioral Interventions on Pain Intensity in Preterm Infants for Heel Prick Blood Sampling in the Neonatal Intensive Care Unit

BACKGROUND

Recent researches suggest that preterm infants understand pain and stress. Because of the wide range of effects of pain on infants, the present study was conducted on the effect of environmental and behavioral interventions on pain due to heel-prick blood sampling in preterm infants.

MATERIALS AND METHODS

A clinical trial was conducted among 32 infants with gestational age of 32-37 weeks in the intervention and control groups. The effects of noise reduction by earplugs, light reduction by blindfolds, reduction of nursing manipulation, and creation of intrauterine position for neonates, 30 minutes before taking blood samples until 30 minutes after it, were measured during the intervention stage. Data were collected using the Neonatal Infant Pain Scale (NIPS) in 5 stages (before intervention, 2 minutes before sampling, during the sampling, and 5 minutes and 30 minutes after the sampling). The data were analyzed using analysis of variance (ANOVA) and paired t-test in SPSS software.

RESULTS

The paired t-test results showed no significant differences between the control and intervention stages in terms of pain scores at base time (P = 0.42) and 2 minutes before sampling (P = 0.12). However, at the sampling time (P = 0.0), and 5 minutes (P = 0.001) and 30 minutes after the sampling (P = 0.001), mean pain score in the intervention stage was significantly less than that in the control stage.

CONCLUSIONS

Based on the findings, environmental and behavioral interventions reduced pain and facilitated heel-prick blood sampling in preterm infants.

Pain Assessment of Elderly Patients with Cognitive Impairment in the Emergency Department: Implications for Pain Management-A Narrative Review of Current Practices

Elderly people are susceptible to both falls and cognitive impairment making them a particularly vulnerable group of patients when it comes to pain assessment and management in the emergency department (ED). Pain assessment is often difficult in patients who present to the ED with a cognitive impairment as they are frequently unable to self-report their level of pain, which can have a negative impact on pain management. This paper aims to review how cognitive impairment influences pain assessment in elderly adults who present to the ED with an injury due to a fall. A literature search of EMBASE, ProQuest, PubMed, Science Direct, SciFinder and the Curtin University Library database was conducted using keyword searches to generate lists of articles which were then screened for relevance by title and then abstract to give a final list of articles for full-text review. Further articles were identified by snowballing from the reference lists of the full-text articles. The literature reports that ED staff commonly use visual or verbal analogue scales to assess pain, but resort to their own intuition or physiological parameters rather than using standardised observational pain assessment tools when self-report of pain is not attainable due to cognitive impairment. While studies have found that the use of pain assessment tools improves the recognition and management of pain, pain scores are often not recorded for elderly patients with a cognitive impairment in the ED, leading to poorer pain management in this patient group in terms of time to analgesic administration and the use of strong opioids. All healthcare professionals involved in the care of such patients, including pharmacists, need to be aware of this and strive to ensure analgesic use is guided by appropriate and accurate pain assessment in the ED.

Pain Assessment and Control in the Injured Elderly

Elderly trauma patients may be at increased risk for underassessment and inadequate pain control in the emergency department (ED). We sought to characterize risk factors for oligoanalgesia in the ED in elderly trauma patients and determine whether it impacts outcomes in elderly trauma patients. We included elderly patients (age ≥55 years) with Glasgow Coma Scale scores 13 to 15 and Injury Severity Score (ISS) ≥9 admitted through the ED at a Level I trauma center. Patient characteristics and outcomes were compared between those who reported pain and received analgesics medication in the ED (MED) and those who did not (NO MED). A total of 183 elderly trauma patients were identified over a three-year study period, of whom 63 per cent had pain assessed via verbal pain score; of those who reported pain, 73 per cent received analgesics in the ED. The MED and NO MED groups were similar in gender, race, ED vitals, ISS, and hospital length of stay. However, NO MED was older, with higher head Abbreviated Injury Scale score and longer intensive care unit length of stay. Importantly, as patients aged they reported lower pain and were less likely to receive analgesics at similar ISS. Risk factors for oligoanalgesia may include advanced age and head injury.

Pathophysiology, assessment, and management of pain in critically ill adults

PURPOSE

The pathophysiology of pain in critically ill patients, the role of pain assessment in optimal pain management, and pharmacologic and nonpharmacologic strategies for pain prevention and treatment are reviewed.

SUMMARY

There are many short- and long-term consequences of inadequately treated pain, including hyperglycemia, insulin resistance, an increased risk of infection, decreased patient comfort and satisfaction, and the development of chronic pain. Clinicians should have an understanding of the basic physiology of pain and the patient populations that are affected. Pain should be assessed using validated pain scales that are appropriate for the patient's communication status. Opioids are the cornerstone of pain treatment. The use of opioids, administered via bolus dosing or continuous infusion, should be guided by patient-specific goals of care in order to avoid adverse events. A multimodal approach to pain management, including the use of regional analgesia, may improve patient outcomes and decrease opioid-related adverse events, though there are limited relevant data in adult critically ill patient populations. Nonpharmacologic strategies have been shown to be effective adjuncts to pharmacologic regimens that can improve patient-reported pain intensity and reduce analgesic requirements. Analgesic regimens need to take into account patient-specific factors and be closely monitored for safety and efficacy.

CONCLUSION

Acute pain management in the critically ill is a largely underassessed and undertreated area of critical care. Opioids are the cornerstone of treatment, though a multimodal approach may improve patient outcomes and decrease opioid-related adverse events.

Postoperative pain documentation in a hospital setting: A topical review

Background and aims

Nursing documentation supports continuity of care and provides important means of communication among clinicians. The aim of this topical review was to evaluate the published empirical studies on postoperative pain documentation in a hospital setting.

Methods

The review was conducted through a systematic search of electronic databases: Web of Science, PubMed/Medline, CINAHL, Embase, Ovid/Medline, Scopus and Cochrane Library. Ten studies were included. Study designs, documented postoperative pain information, quality of pain documentation, reported quality of postoperative pain management and documentation, and suggestions for future research and practice improvements were extracted from the studies.

Results

The most commonly used study design was a descriptive retrospective patient record review. The most commonly reported types of information were pain assessment, use of pain assessment tools, useof pain management interventions, reassessment, types of analgesics used, demographic information and pain intensity. All ten studies reported that the quality of postoperative pain documentation does not meet acceptable standards and that there is a need for improvement. The studies found that organization of regular pain management education for nurses is important for the future.

Conclusions

Postoperative pain documentation needs to beimproved. Regular educational programmes and development of monitoring systems for systematic evaluation of pain documentation are needed. Guidelines and recommendations should be based on the latest research evidence, and systematically implemented into practice.

Implications

Comprehensive auditing tools for evaluation of pain documentation can make quality assessment easier and coherent. Specific and clear documentation guidelines are needed and existing guidelines should be better implemented into practice. There is a need to increase nurses’ knowledge of postoperative pain management, assessment and documentation. Studies evaluating effectiveness of high quality pain documentation are required.

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.

Acute Pain Medicine in the United States: A Status Report

BACKGROUND

Consensus indicates that a comprehensive,multimodal, holistic approach is foundational to the practice of acute pain medicine (APM),but lack of uniform, evidence-based clinical pathways leads to undesirable variability throughout U. S. healthcare systems. Acute pain studies are inconsistently synthesized to guide educational programs. Advanced practice techniques involving regional anesthesia assume the presence of a physician-led, multidisciplinary acute pain service,which is often unavailable or inconsistently applied.This heterogeneity of educational and organizational standards may result in unnecessary patient pain and escalation of healthcare costs.

METHODS

A multidisciplinary panel was nominated through the APM Shared Interest Group of the American Academy of Pain Medicine. The panel met in Chicago, IL, in July 2014, to identify gaps and set priorities in APM research and education.

RESULTS

The panel identified three areas of critical need: 1) an open-source acute pain data registry and clinical support tool to inform clinical decision making and resource allocation and to enhance research efforts; 2) a strong professional APM identity as an accredited subspecialty; and 3) educational goals targeted toward third-party payers,hospital administrators, and other key stake holders to convey the importance of APM.

CONCLUSION

This report is the first step in a 3-year initiative aimed at creating conditions and incentives for the optimal provision of APM services to facilitate and enhance the quality of patient recovery after surgery, illness, or trauma. The ultimate goal is to reduce the conversion of acute pain to the debilitating disease of chronic pain.

Pain management in trauma patients in (pre)hospital based emergency care: current practice versus new guideline

INTRODUCTION

Acute pain in trauma patients in emergency care is still undertreated. Early pain treatment is assumed to effectively reduce pain in patients and improve long-term outcomes. In order to improve pain management in the chain of emergency care, a national evidence-based guideline was developed. The aim of this study was to assess whether current practice is in compliance with the guideline 'Pain management for trauma patients in the chain of emergency care' from the Netherlands Association for Emergency Nurses (in Dutch NVSHV), and to evaluate early and initial pain management for adult trauma patients in emergency care.

METHODS

Chart reviews were conducted in three regions of the Netherlands using electronic patient files of trauma patients from the chain of emergency care. We included one after-hours General Practitioner Co-operation (GPC), one ambulance Emergency Medical Services (EMS), two Helicopter Emergency Medical Services (HEMS), and three Emergency Departments (EDs). Organisation of pain management, pain assessment, and pain treatment was examined and compared with national guideline recommendations, including quality indicators.

RESULTS

We assessed a random sample of 1066 electronic patient files. The use of standardised tools to assess pain was registered in zero to 52% of the electronic patient files per organisation. Registration of (non-)pharmacological pain treatment was found in less than half of the files. According to the files, pharmacological pain treatment deviated from the guideline in 73-99% of the files. Time of administration of medication was missing in 73-100%. Reassessment of pain following pain medication was recorded in half of the files by the HEMS, but not in files of the other organisations.

CONCLUSIONS

The (registration of) current pain management in trauma patients in the chain of emergency care varies widely between healthcare organisation, and deviates from national guideline recommendations. Although guideline compliance differs across groups of healthcare professionals, maximum compliance rate with indicators registered is 52%. In order to improve pain management and evaluate its effectiveness, we recommend to improve pain registration in patient files. Furthermore, we advise to identify barriers and facilitators related to the implementation of the national guideline in all emergency care organisations.

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.

Generating and selecting pain indicators for brain-injured critical care patients

Current pain assessment tools for nonverbal critical care patients may not be appropriate for those with brain injury, as these patients demonstrate specific responses to pain. The aim of this study was to generate and select items that could be used to assess pain in brain-injured patients. A sequential mixed-method design was chosen with three consecutive steps: 1. Generate items with a literature review, the results of a pilot study, and interviews with 18 clinicians using the nominal group technique. 2. Evaluate content validity with 10 clinicians and four scientists, using a web-based questionnaire. 3. Describe and reduce items with the observation of 116 brain-injured patients in the intensive care unit during common painful procedures. This study took place between May 2010 and October 2011 in two tertiary hospitals in Western Switzerland. Forty-seven items were generated and reduced to 33 during the content validity process. The behaviors most frequently observed during turning were closing the eyes (58.6%), eye movements (57.8%), ventilator asynchrony (55.2%), and frowning/brow lowering (50%). Five items were observed in less than 5% of the patients during nociceptive procedure. Constant motor activity was observed more frequently at rest than during nociceptive stimulation. All physiologic items showed little variability and their reliability was low. Based on these results, the number of items was reduced to 23. This study identified items that could be specific to brain-injured patients and found that the variability of physiologic items was poorly assessed by clinicians.

Development of a Management Algorithm for Post-operative Pain (MAPP) after total knee and total hip replacement: study rationale and design

BACKGROUND

Evidence from clinical practice and the extant literature suggests that post-operative pain assessment and treatment is often suboptimal. Poor pain management is likely to persist until pain management practices become consistent with guidelines developed from the best available scientific evidence. This work will address the priority in healthcare of improving the quality of pain management by standardising evidence-based care processes through the incorporation of an algorithm derived from best evidence into clinical practice. In this paper, the methodology for the creation and implementation of such an algorithm that will focus, in the first instance, on patients who have undergone total hip or knee replacement is described.

METHODS

In partnership with clinicians, and based on best available evidence, the aim of the Management Algorithm for Post-operative Pain (MAPP) project is to develop, implement, and evaluate an algorithm designed to support pain management decision-making for patients after orthopaedic surgery. The algorithm will provide guidance for the prescription and administration of multimodal analgesics in the post-operative period, and the treatment of breakthrough pain. The MAPP project is a multisite study with one coordinating hospital and two supporting (rollout) hospitals. The design of this project is a pre-implementation-post-implementation evaluation and will be conducted over three phases. The Promoting Action on Research Implementation in Health Services (PARiHS) framework will be used to guide implementation. Outcome measurements will be taken 10 weeks post-implementation of the MAPP. The primary outcomes are: proportion of patients prescribed multimodal analgesics in accordance with the MAPP; and proportion of patients with moderate to severe pain intensity at rest. These data will be compared to the pre-implementation analgesic prescribing practices and pain outcome measures. A secondary outcome, the efficacy of the MAPP, will be measured by comparing pain intensity scores of patients where the MAPP guidelines were or were not followed.

DISCUSSION

The outcomes of this study have relevance for nursing and medical professionals as well as informing health service evaluation. In establishing a framework for the sustainable implementation and evaluation of a standardised approach to post-operative pain management, the findings have implications for clinicians and patients within multiple surgical contexts.

Comparison of 2 Methods of Local Anesthetic-Based Injection as Part of a Multimodal Approach to Pain Management After Total Knee Arthroplasty

BACKGROUND

It is estimated that up to 50% of patients undergoing total knee arthroplasty (TKA) receive suboptimal postoperative pain management.

METHODS

In a retrospective study, 224 patients who underwent TKA between January 1, 2011, and September 30, 2012, were identified by surgical records for 2 surgeons at Community Medical Center in Missoula, Montana. Patient records were reviewed and data collected for patient hospital length of stay (LOS), postoperative opioid use, opioid-associated adverse events, and nonopioid analgesic use. Data were analyzed for differences in outcomes between patients who received an intraoperative intra-articular (IOIA) injection followed by a postoperative infusion (0.25%-0.5% bupivacaine) or an intraoperative periarticular (IOPA) injection (ropivacaine, ketorolac, epinephrine, and clonidine) for sustained analgesia after TKA.

RESULTS

Patients who received an IOPA injection had a statistically significant decrease in hospital LOS (67.0 vs 75.9 hours; P = .027) and postoperative nausea and vomiting (39.3% vs 54.9%; P = .023) when compared to patients who received an IOIA infusion. The incidence of having either oversedation or pruritus did not differ between groups (9.8% vs 9.8%; P = 1.00).

CONCLUSION

The use of IOPA injections containing ropivacaine, epinephrine, ketorolac, and clonidine during TKA offered some benefit over IOIA infusions containing 0.25% to 0.5% bupivacaine at our institution.

Preventive analgesia for postoperative pain control: a broader concept

Pain from surgical procedures occurs as a consequence of tissue trauma and may result in physical, cognitive, and emotional discomfort. Almost a century ago, researchers first described a possible relationship between intraoperative tissue damage and an intensification of acute pain and long-term postoperative pain, now referred to as central sensitization. Nociceptor activation is mediated by chemicals that are released in response to cellular or tissue damage. Pre-emptive analgesia is an important concept in understanding treatment strategies for postoperative analgesia. Pre-emptive analgesia focuses on postoperative pain control and the prevention of central sensitization and chronic neuropathic pain by providing analgesia administered preoperatively but not after surgical incision. Additional research in pre-emptive analgesia is warranted to better determine good outcome measurements and a better appreciation with regard to treatment optimization. Preventive analgesia reduces postoperative pain and consumption of analgesics, and this appears to be the most effective means of decreasing postoperative pain. Preventive analgesia, which includes multimodal preoperative and postoperative analgesic therapies, results in decreased postoperative pain and less postoperative consumption of analgesics.

Is adequate pain relief and time to analgesia associated with emergency department length of stay? A retrospective study

OBJECTIVES

Evaluate the association of adequate analgesia and time to analgesia with emergency department (ED) length of stay (LOS).

SETTING AND DESIGN

Post hoc analysis of real-time archived data.

PARTICIPANTS

We included all consecutive ED patients ≥18 years with pain intensity >6 (verbal numerical scale from 0 to 10), assigned to an ED bed, and whose pain was re-evaluated less than 1 h after receiving analgesic treatment.

OUTCOME MEASURES

The main outcome was ED-LOS in patients who had adequate pain relief (AR=↓50% pain intensity) compared with those who did not have such relief (NR).

RESULTS

A total of 2033 patients (mean age 49.5 years; 51% men) met our inclusion criteria; 58.3% were discharged, and 41.7% were admitted. Among patients discharged or admitted, there was no significant difference in ED-LOS between those with AR (median (25th-75th centile): 9.6 h (6.3-14.8) and 18.2 h (11.6-25.7), respectively) and NR (median (25th-75th centile): 9.6 h (6.6-16.0) and 17.4 h (11.3-26.5), respectively). After controlling for confounding factors, rapid time to analgesia (not AR) was associated with shorter ED-LOS of discharged and admitted patients (p<0.001 and <0.05, respectively). When adjusting for confounding variables, ED-LOS is shortened by 2 h (95% CI 1.1 to 2.8) when delay to receive analgesic is <90 min compared with >90 min for discharged and by 2.3 h (95% CI 0.17 to 4.4) for admitted patients.

CONCLUSIONS

In our study, AR was not linked with short ED-LOS. However, rapid administration of analgesia was associated with short ED-LOS.

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.

A review of the efficacy, safety, and cost-effectiveness of COX-2 inhibitors for Africa and the Middle East region

Despite an increasingly sophisticated understanding of pain mechanisms, acute and chronic pain remain undertreated throughout the world. This situation reflects the large gap that exists between evidence and practice in pain management and is typified by inappropriate use of nonsteroidal anti-inflammatory drugs (NSAIDs). The scientific evidence around these drugs continues to expand at a high rate, yet physicians are often unaware of best practice. To address this gap among physicians in Africa and the Middle East, an Expert Panel meeting was convened with representatives from the region. The principal objective of the meeting was to review the latest guidelines on the management of acute and chronic pain and to review the efficacy, safety, and cost-effectiveness of cyclooxygenase-2 (COX-2) inhibitors in these settings. The main outcome of this review process was a number of consensus statements concerning the definitions of acute and chronic pain, and the efficacy, safety and cost-effectiveness of traditional nonselective NSAIDs (nsNSAIDs) and selective COX-2 inhibitors (coxibs). The panel agreed that nsNSAIDs and coxibs are effective analgesics with similar efficacy for acute pain; for chronic musculoskeletal pain, NSAIDs are significantly more effective than either placebo or paracetamol. Coxibs offer important safety advantages over nsNSAIDs, including gastrointestinal safety and preservation of platelet function; notably, the cardiovascular safety of coxibs has been the subject of much recent debate. Furthermore, the panel agreed there is substantial evidence to indicate that cost savings can be achieved by using celecoxib in patients at moderate to high risk of gastrointestinal adverse events, even in countries with moderate healthcare expenditures.

Pain indicators in brain-injured critical care adults: an integrative review

INTRODUCTION

Health professionals are confronted with the difficulty of adequately evaluating pain in critically ill, brain-injured patients, as these patients are often unable to self-report. In addition, their confused and stereotyped behaviours may change their responses to pain; the indicators and descriptors generally used to evaluate pain in the critically ill may therefore not be appropriate for brain-injured patients.

AIM

The aim of this integrative review was to identify clinically measurable and observable pain indicators and descriptors for brain-injured, critically ill adults.

METHOD

A search of electronic databases (Medline, CINAHL, Embase) combined with cross-referencing was performed. Articles were included if they described pain indicators in critically ill adults and included brain-injured patients in their population.

RESULTS

Seven articles met the inclusion criteria. They were critically appraised for their quality and their relevance for the population of brain-injured patients. Behavioural pain indicators such as facial expressions, body movements and muscle tension were found in all of the articles. However, the descriptions of the indicators differ from one article to another. The intensity and nature of behavioural pain responses vary according to the level of consciousness. Changes in physiological parameters have also been reported, but these results are inconclusive.

CONCLUSION

Additional research is needed to identify and better describe pain indicators that are specific to brain-injured patients in the ICU. Studies with large samples, different brain injury diagnoses and various levels of consciousness are warranted.

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.

[Descriptive study of the postoperative pain assessment and documentation process in a university hospital]

Several studies have shown that patients often receive inadequate treatment of postoperative pain. The aim of the present descriptive study was to examine and analyze various data related to the postoperative pain assessment of 40 patients who underwent elective surgery. Pain journals were to be completed by patients during every waking hour for the first three postoperative days to assess both pain intensity and pain unpleasantness. A post hoc analysis of patient records permitted verification of pain assessment by nurses for each patient. The results showed that not only was postoperative pain rarely assessed using a valid scale, it was also poorly documented. In addition, when nurses assessed and documented postoperative pain using a numerical scale, their results were very different from patients' assessments. For the first postoperative day, the mean (± SD) pain intensity documented by nurses on a 0 to 10 numerical scale was 1.57±0.23, while the mean pain intensity noted by patients using the same scale was 3.82±0.41. Statistical analysis showed that there was no significant correlation between mean pain intensity documented by nurses and the mean pain intensity noted by 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.