Improving patients' postoperative sleep: a randomized control study comparing subcutaneous with intravenous patient-controlled analgesia

Benefit of subcutaneous patient controlled analgesia after total knee arthroplasty

Purpose

Subcutaneous patient-controlled analgesia (PCA) has been widely used for orthopedic surgeries including total knee arthroplasty (TKA). This study aims to clarify the usefulness of subcutaneous PCA in the early phase after TKA.

Methods

Our subjects consisted of 88 osteoarthritis knee patients who underwent primary TKA, and were classified into two groups: 42 patients received a subcutaneous PCA (containing fentanyl and droleptan) after operation (PCA group), and 46 patients were managed without a subcutaneous PCA (control group). We compared the incidence of side effects for 3 days postoperatively, measuring the number of times patients used adjuvant analgesia and range of motion on day 7 between the two groups. 34 of 42 patients in the PCA group tolerated PCA use until POD 3 (continuation sub-group), while 8 patients could not continue PCA (interruption sub-group). Demographic data of the two sub-groups were compared.

Results

The mean number of times adjunctive analgesics were used by the PCA group (3.7 ± 2.2) was significantly less than in the control group (5.4 ± 2.8) (p = 0.0049). There were no significant differences in the frequency of side effects between the two groups. There was no significant difference in range of motion between the two groups. Comparing the continuation and interruption sub-groups, patients over 80 years old were at risk to discontinue a subcutaneous PCA (p = 0.0319, odds ratio 5.4).

Conclusion

These findings demonstrate that subcutaneous PCA would be a safe postoperative pain regimen for TKA patients, but the effect was not enough to promote early functional recovery.

Levels of evidence

Therapeutic, Level Ⅱ.

A Behavioral-Educational Intervention to Promote Pediatric Sleep During Hospitalization: A Pilot Randomized Controlled Trial

OBJECTIVE/BACKGROUND

Hospitalization can contribute to common sleep difficulties in children. Interventions aimed at hospitalized children need to be developed and piloted with rigorous evaluative methods. The primary purpose of this study was to examine the feasibility and acceptability of a behavioral-educational intervention aimed at increasing nighttime sleep for hospitalized children.

PARTICIPANTS

Hospitalized children aged 4-10 years and their caregivers.

METHODS

A pilot randomized, controlled trial with concealed-group allocation was conducted. Forty-eight hospitalized children (ages 4-10) and their care-givers were randomized to either the Relax to Sleep (RTS) intervention group (n = 24) or the Usual Care (UC) comparison group (n = 24). The RTS intervention was comprised of a one-on-one educational session for the parent that was guided by a standardized booklet containing information on sleep and instructions for training the child in the use of a diaphragmatic breathing exercise. UC participants received no information about sleep or relaxation. Children wore actigraphs for 3 days and nights and completed sleep diaries. Outcome measures included feasibility, acceptability, and sleep outcomes.

RESULTS

Parental reports indicated they enjoyed the discussion on sleep, found the information helpful, and their child found diaphragmatic breathing easy to use, and would use it again in the future. Children in the RTS group averaged 50 minutes more nighttime sleep, and had less wake after sleep onset time compared to children in the UC group.

CONCLUSION

Sleep is critically important to children's health and well-being and should be given important consideration during hospitalization. Although the results of this pilot trial seem promising, more interventional studies are needed.

Patients’ experiences of sleep in hospital: a qualitative interview study

Many patients experience sleep disturbances and a reduced quality of sleep while hospitalised. Studies have shown that a person with a disease and/or a bodily injury has an increased need for sleep. Patients' experiences of sleep should govern how sleep disturbances should be managed. It is thus necessary to focus upon and describe patients’ needs and experiences. The aim of this study was to explore and describe patients’ experiences of sleeping in hospital. This study is based on qualitative semi-structured interviews with 10 consecutively included patients. The interviews were conducted between October 2010 and March 2011 and were audio recorded and transcribed verbatim. Collected data were analysed by qualitative content analysis. The participants reported physical and psychological experiences that had affected their sleep. Their experiences were categorised using four themes: bedside manner, physical factors, being involved and integrity. Patients considered that experiencing some degree of control, feeling involved and preserving one’s integrity affect sleep during hospitalisation. Several factors have an impact on patients’ sleep. It is not only physical factors but also psychological factors such as bedside manner and having the opportunity to influence and be involved. The patients’ accounts provide a new perspective and open the door to changes in nursing care regarding patients’ sleep.

Postoperative pain and quality of recovery

PURPOSE OF REVIEW

Quality of recovery is recognized as a valid and important outcomes measurement in clinical care and research. The increasing interest in evaluating quality of recovery reflects the overall increased interest in patient-focused assessments. Assessment of quality of recovery incorporates measuring many dimensions or domains including physiologic endpoints, adverse events and psychosocial status. Unlike 'traditional' outcomes that focus on major morbidity and mortality, quality of recovery assesses 'nontraditional' outcomes focused around patient-oriented endpoints. By adversely influencing the many domains assessed by quality of recovery, postoperative pain may have a general detrimental effect on quality of recovery.

RECENT FINDINGS

Studies utilizing validated instruments to assess quality of recovery have revealed that different levels of postoperative pain may differentially affect quality of recovery. In addition, quality of recovery in the immediate postoperative period may predict long-term quality of life.

SUMMARY

Higher levels of postoperative pain typically correlate with a decrease in quality of recovery. Different analgesic techniques and regimens may differentially influence quality of recovery, with preliminary evidence suggesting that some regional analgesic techniques may provide superior quality of recovery, quality of life and patient satisfaction. Further studies are needed to elucidate the effects of different analgesic techniques on quality of recovery.

The nurse’s role in promoting a good night’s sleep for patients

Sleep is a vital activity of daily living as it restores and refreshes. However, there are environmental, physiological and psychological factors that can affect normal sleep patterns. There are many ways in which nurses can help patients achieve a good night's sleep. This article discusses environmental, non-pharmacological and pharmacological interventions that can be used to promote sleep in hospital and community settings.

Patient-controlled analgesia: Finding a balance between cost and comfort

PURPOSE

Despite the growing movement in acute pain management, acute postoperative pain continues to be undermanaged. Although numerous clinical practice guidelines for pain management have been published throughout the last 12 years, inadequate pain relief remains a significant health care issue. Insufficient dosage of analgesics is a common problem, and therapy for those patients still with pain represents a considerable health care dilemma.

SUMMARY

Patient-controlled analgesia (PCA) refers to a process in which patients determine when and how much medication they receive, regardless of analgesic technique. Patient-controlled modalities using intravenous (i.v.) and epidural routes have dramatically improved postoperative pain management. PCA has emerged as an effective way for patients to manage their pain, allowing self-administration of small doses of analgesics to maintain a certain level of pain control. PCA is most commonly delivered via an intravenous or epidural route, and while patient satisfaction is higher with PCA than with conventional methods of analgesic administration, the invasiveness, costs, health care resources, and risk of errors associated with currently available modalities may limit their utility. The overall effectiveness of any analgesic technique depends on both the degree of pain relief and the incidence of side effects or complications. These adverse events of acute pain complicate postoperative recovery and may lead to longer hospital stays, as well as increased health care costs. Several new PCA modalities are being developed to address these limitations. These systems deliver drugs through a variety of routes (for example, transdermal). Most notable is a self-contained, credit card-sized fentanyl transdermal patient-activated system. It provides pain relief therapeutically equivalent to that of standard regimen of morphine i.v. PCA, with pharmacokinetics similar to those of intravenous fentanyl infusion. Fentanyl HCl patient-activated transdermal systems (PATS) may be an effective, noninvasive alternative to currently available i.v. PCA modalities. Whichever drug or device is utilized, the overall success relies on the expert supervision of nurses, pharmacists, and anesthesiologists in an acute pain service.

CONCLUSION

Current PCA techniques using i.v. or epidural administration have limitations. Development of new technology offering alternative routes for PCA administration is at the forefronts of PCA research.

Patient-controlled analgesia

One of the most common methods for providing postoperative analgesia is via patient-controlled analgesia (PCA). Although the typical approach is to administer opioids via a programmable infusion pump, other drugs and other modes of administration are available. This article reviews the history and practice of many aspects of PCA and provides extensive guidelines for the practice of PCA-administered opioids. In addition, potential adverse effects and recommendations for their monitoring and treatment are reviewed.

Misrepresenting random sampling? A systematic review of research papers in the Journal of Advanced Nursing

AIM

This paper discusses the theoretical limitations of the use of random sampling and probability theory in the production of a significance level (or P-value) in nursing research. Potential alternatives, in the form of randomization tests, are proposed.

BACKGROUND

Research papers in nursing, medicine and psychology frequently misrepresent their statistical findings, as the P-values reported assume random sampling. In this systematic review of studies published between January 1995 and June 2002 in the Journal of Advanced Nursing, 89 (68%) studies broke this assumption because they used convenience samples or entire populations. As a result, some of the findings may be questionable.

DISCUSSION

The key ideas of random sampling and probability theory for statistical testing (for generating a P-value) are outlined. The result of a systematic review of research papers published in the Journal of Advanced Nursing is then presented, showing how frequently random sampling appears to have been misrepresented. Useful alternative techniques that might overcome these limitations are then discussed. REVIEW LIMITATIONS: This review is limited in scope because it is applied to one journal, and so the findings cannot be generalized to other nursing journals or to nursing research in general. However, it is possible that other nursing journals are also publishing research articles based on the misrepresentation of random sampling. The review is also limited because in several of the articles the sampling method was not completely clearly stated, and in this circumstance a judgment has been made as to the sampling method employed, based on the indications given by author(s).

CONCLUSION

Quantitative researchers in nursing should be very careful that the statistical techniques they use are appropriate for the design and sampling methods of their studies. If the techniques they employ are not appropriate, they run the risk of misinterpreting findings by using inappropriate, unrepresentative and biased samples.