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Sim GG, See AH, Quah LJJ. Patient-controlled analgesia for the management of adults with acute trauma in the emergency department: A systematic review and meta-analysis. J Trauma Acute Care Surg 2023; 95:959-968. [PMID: 37335181 DOI: 10.1097/ta.0000000000004004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Patient-controlled analgesia (PCA) has potential as a form of analgesia for trauma patients in the emergency department (ED). The objective of this review was to evaluate the effectiveness and safety of PCA for the management of adults with acute traumatic pain in the ED. The hypothesis was that PCA can effectively treat acute trauma pain in adults in the ED, with minimal adverse outcomes and better patient satisfaction compared with non-PCA modalities. METHODS MEDLINE (PubMed), Embase, SCOPUS, ClinicalTrials.gov , and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched from inception date to December 13, 2022. Randomized controlled trials involving adults presenting to the ED with acute traumatic pain who received intravenous (IV) analgesia via PCA compared with other modalities were included. The Cochrane Risk of Bias tool and the Grading of Recommendation, Assessment, Development, and Evaluation approach were used to assess the quality of included studies. RESULTS A total of 1,368 publications were screened, with 3 studies involving 382 patients meeting the eligibility criteria. All three studies compared PCA IV morphine with clinician-titrated IV morphine boluses. For the primary outcome of pain relief, the pooled estimate was in favor of PCA with a standard mean difference of -0.36 (95% confidence interval, -0.87 to 0.16). There were mixed results concerning patient satisfaction. Adverse event rates were low overall. The evidence from all three studies was graded as low-quality because of a high risk of bias from lack of blinding. CONCLUSION This study did not demonstrate a significant improvement in pain relief or patient satisfaction using PCA for trauma in the ED. Clinicians wishing to use PCA to treat acute trauma pain in adult patients in the ED are advised to consider the available resources in their own practice settings and to implement protocols for monitoring and responding to potential adverse events. LEVEL OF EVIDENCE Systematic Review/Meta-Analyses; Level III.
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Affiliation(s)
- Guek Gwee Sim
- From the Department of Emergency Medicine (G.G.S.) and Department of Surgery (A.H.S.), Changi General Hospital; and Department of Emergency Medicine (L.J.J.Q.), Singapore General Hospital, Singapore, Singapore
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Reede K, Bartholomew R, Nielsen D, Ahmeti M, Zreik K. Ketamine in Trauma: A Literature Review and Administration Guidelines. Cureus 2023; 15:e48099. [PMID: 37920424 PMCID: PMC10620013 DOI: 10.7759/cureus.48099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 11/04/2023] Open
Abstract
Ketamine is a phencyclidine (PCP) derivative, which primarily acts as a noncompetitive N-methyl-D-aspartate (NMDA) receptor antagonist. Ketamine serves as an analgesic and a dissociative sedative that produces potent analgesia, sedation, and amnesia while preserving spontaneous respiratory drive. It is rapidly gaining acceptance in the management of pain as multiple studies have demonstrated its reliable efficacy and a wide margin of safety. This article reviews some of these studies, the history of ketamine, and its pharmacological and pharmacokinetic properties. The article also discusses the use of ketamine in the trauma setting, including joint reductions, procedures, sedation, and pain control, as well as dosing recommendations.
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Affiliation(s)
- Kristen Reede
- General Surgery, University of North Dakota School of Medicine and Health Sciences, Grand Forks, USA
| | - Reid Bartholomew
- Trauma Surgery, University of Tennessee Health Science Center, Memphis, USA
| | - Dana Nielsen
- General Surgery, University of North Dakota School of Medicine and Health Sciences, Grand Forks, USA
| | | | - Khaled Zreik
- Surgical Critical Care, Sanford Medical Center, Fargo, USA
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Turner LJ, Martin-Bates AJ. Parenteral medications at Role 1: do doctors in the British Army require improved training and experience? BMJ Mil Health 2023; 169:463-468. [PMID: 34312299 DOI: 10.1136/bmjmilitary-2021-001841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/08/2021] [Indexed: 11/03/2022]
Abstract
Role 1 doctors in the British Army work predominantly in primary healthcare, but also provide prehospital emergency care and administer potent parenteral medications in the field. Role 1 doctors have theoretical training in the use of these medications on short courses but then have little refresher training and use them infrequently in their routine practice, introducing the risk of skill fade. This may lead to higher rates of medication errors in an environment where the consequences may be significant. This article explores the current training of Role 1 doctors, the threat of skill fade and how the safety of drug administration can be improved. This includes recommendations for the development of training competencies, bespoke courses and clinical placements, e-learning and the use of new technology. Application of these recommendations has the potential to improve patient safety and the confidence of doctors in the use of parenteral analgesia.
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Affiliation(s)
- Luke John Turner
- Army Medical Services Support Unit, Royal Army Medical Corps, Camberley, UK
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Seo CH, Howe KL, McAllister KB, McDaniel BL, Sharp HD, Lucktong TA, Bower KL, Collier BR, Gillen JR. Standardizing Opioids Prescribed at Discharge in Trauma Surgery. J Surg Res 2023; 290:52-60. [PMID: 37196608 DOI: 10.1016/j.jss.2023.03.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 03/18/2023] [Accepted: 03/26/2023] [Indexed: 05/19/2023]
Abstract
INTRODUCTION Excessive opioid use after sustaining trauma has contributed to the opioid epidemic. Standardizing the quantity of opioids prescribed at discharge can improve prescribing behavior. We hypothesized that adopting new electronic medical record order sets would be associated with decreased morphine milligram equivalents (MME) prescribed at discharge for trauma patients. METHODS This was a quasi-experimental study examining opioid prescribing practices at a Level 1 Trauma Center. All patients ages 18-89 admitted to the Trauma Service from January 2017 through March 2021 and hospitalized for at least 2 d were included. In November 2020, new trauma admission and discharge order sets were implemented with recommended discharge opioid quantity based on inpatient opioid usage the day prior to discharge multiplied by five. Postintervention prescribing practices were compared to historical controls. The primary outcome was MME at discharge. RESULTS Baseline characteristics between preintervention and postintervention cohorts were comparable. There was a significant reduction in median MME prescribed at discharge postintervention (112.5 versus 75.0, P < 0.0001). Median inpatient MME usage also significantly reduced postintervention (184.1 versus 160.5; P < 0.0001). There were trends toward increased ideal prescribing per order set recommendation and a reduction in overprescribing. Patients receiving the recommended opioid quantity at discharge had the lowest opioid refill prescription rate (under: 29.6%, ideal: 7.3%, over: 19.7%, P < 0.0001). CONCLUSIONS For trauma patients requiring inpatient opioid therapy, a pragmatic and individualized intervention was associated with a reduced quantity of discharge opioids without negative outcomes. Reduction in inpatient opioid use was also associated with standardizing prescribing practices of surgeons with electronic medical record order sets.
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Affiliation(s)
- Claire H Seo
- School of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia.
| | - Katherine L Howe
- School of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia; Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, Virginia
| | - Kelly B McAllister
- Department of Pharmacy, Carilion Roanoke Memorial Hospital, Roanoke, Virginia
| | - Bradford L McDaniel
- Department of Pharmacy, Carilion Roanoke Memorial Hospital, Roanoke, Virginia
| | - Hunter D Sharp
- Carilion Clinic Health Analytics Research, Carilion Roanoke Memorial Hospital, Roanoke, Virginia
| | - Tananchai A Lucktong
- School of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia; Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, Virginia
| | - Katie L Bower
- School of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia; Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, Virginia
| | - Brian R Collier
- School of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia; Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, Virginia
| | - Jacob R Gillen
- School of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia; Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, Virginia
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Perlman R, Bonge S. Regional anesthesia in trauma patients: a quality improvement study. Eur J Trauma Emerg Surg 2023; 49:495-504. [PMID: 36057887 DOI: 10.1007/s00068-022-02097-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 08/23/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Traumatic injury is associated with severe pain that is often inadequately managed. Opioids remain the mainstay of pain management in this population because of their ease of use. However, opioids have significant side effects including nausea, delirium, and respiratory depression. Regional anesthesia has been demonstrated in the perioperative setting to provide superior analgesia with fewer side effects and a reduced length of stay. Similarly, regional anesthesia has been shown to improve morbidity for extremity fractures and dislocations when introduced early. METHODS This was a prospective cohort quality improvement study evaluating the use of earlier and more consistent regional anesthesia procedures in 28 consecutive trauma patients at a large Canadian trauma center. In this quasi-experimental before and after study, we identified all trauma patients with an ISS < 15 that would have been candidates for a peripheral nerve block and compared them to the study population that received a regional anesthesia nerve block within 24 h of admission. RESULTS The introduction of a multidisciplinary pain program into our level 1 regional trauma center resulted in a decrease in pain severity and opioid consumption of 55% and 61%, respectively, after 24 h of admission. Length of stay in the emergency department decreased (11.5 ± 6.9 vs. 4.9 ± 4.4 h; p < 0.01) while hospital length of stay did not (338 ± 276 vs. 285 ± 205 h; p = 0.4). CONCLUSION This quality improvement proof-of-principle study reveals the potential advantages for regional anesthesia, such as decreased emergency department use, opioid consumption, and pain severity. Further randomized trials are necessary, however, to describe a direct benefit from peripheral nerve blockade on reducing length of stay for trauma patients.
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Affiliation(s)
- Ryan Perlman
- Division of Trauma Anesthesia, Cedars-Sinai Medical Center, 8700 Beverly Blvd., North Tower, Suite 8211, Los Angeles, CA, 90048, USA.
| | - Sam Bonge
- Cedars-Sinai Medical Center, 8700 Beverly Blvd., North Tower, Suite 8211, Los Angeles, CA, 90048, USA
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Kuypers MI, Veldhuis LI, Mencl F, van Riel A, Thijssen WAHM, Tromp E, Goslings JC, Plötz FB. Procedural sedation and analgesia versus nerve blocks for reduction of fractures and dislocations in the emergency department: A systematic review and meta-analysis. J Am Coll Emerg Physicians Open 2023; 4:e12886. [PMID: 36704208 PMCID: PMC9867878 DOI: 10.1002/emp2.12886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 11/27/2022] [Accepted: 12/15/2022] [Indexed: 01/23/2023] Open
Abstract
Background Procedural sedation and analgesia (PSA) and peripheral nerve blocks (NBs) are techniques to manage pain and facilitate reduction of dislocated joints or fractures. However, it is unclear if either approach provides any distinct advantage in the emergency department (ED). The aim of this systematic review is to compare these 2 techniques on pain scores, adverse events, patient satisfaction, and length of stay (LOS) in the ED. Methods We performed an electronic search of MEDLINE, EMBASE, and the Cochrane Library, and references were hand-searched. Randomized controlled trials (RCTs) comparing PSA with NBs for orthopedic reductions in the ED were included. Outcomes of interest included pain scores, adverse events, patient satisfaction, and LOS in the ED. A total of 2 reviewers independently screened abstracts and extracted data into a standardized form. The Cochrane risk-of-bias tool was used to evaluate study quality. The Grading of Recommendation Assessment Development and Evaluation approach was used to assess the certainty and strength of the evidence. Data on pain scores were pooled using a random-effects model and are reported as standardized mean differences (SMDs) with 95% confidence intervals (CIs). Results A total of 6 RCTs (n = 256) were included in a qualitative review, and 4 RCTs (n = 101) were included in the meta-analysis. There was no significant difference in pain scores between the PSA and NB groups (P = 0.47; SMD, 0.45; 95% CI, -0.78 to 1.69; I2 = 0.94). There were less adverse events in the NB group (0%-3.3%) compared with the PSA group (0%-20%; n = 256). LOS times were consistently shorter in the NB group (n = 215). Patient satisfaction was comparable in both groups (n = 196). Conclusion Based on the available evidence, NBs performed by emergency physicians are as effective as PSA in managing pain during orthopedic reductions in the ED. NBs are associated with fewer adverse events and shorter LOS in the ED. The quality of evidence is low.
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Affiliation(s)
- Maybritt I. Kuypers
- Department of Emergency MedicineAmsterdam University Medical Center location Academisch Medisch CentrumAmsterdamthe Netherlands
| | - Lars I. Veldhuis
- Department of AnesthesiologyAmsterdam University Medical Center location Academisch Medisch CentrumAmsterdamthe Netherlands
| | - Francis Mencl
- Department of Emergency MedicinePenn State University Milton Hershey Medical CenterHersheyPennsylvaniaUSA
| | - Anne van Riel
- Department of Emergency MedicineCatharina ZiekenhuisEindhoventhe Netherlands
| | | | - Ellen Tromp
- Department of Epidemiology and StatisticsSint Antonius ZiekenhuisNieuwegeinthe Netherlands
| | - J. Carel Goslings
- Department of TraumatologyOnze Lieve Vrouwe GasthuisAmsterdamthe Netherlands
| | - Frans B. Plötz
- Department of PediatricsTergooi ZiekenhuisBlaricumthe Netherlands,Department of PediatricsAmsterdam UMC, Emma Children's HospitalAmsterdamthe Netherlands
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Sex specific effects of buprenorphine on behavior, astrocytic opioid receptor expression and neuroinflammation after pediatric traumatic brain injury in mice. Brain Behav Immun Health 2022; 22:100469. [PMID: 35620644 PMCID: PMC9127176 DOI: 10.1016/j.bbih.2022.100469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 04/29/2022] [Accepted: 05/06/2022] [Indexed: 12/31/2022] Open
Abstract
Children who suffered traumatic brain injury (TBI) often experience acute and chronic pain, which is linked to a poor quality of life. Buprenorphine (BPN) is commonly used to treat moderate to severe persistent pain in children, however, the efficacy and safety profile of BPN in the pediatric population is still inconclusive. This study investigated the sex-specific effects of BPN on body weight, motor coordination and strength, expression of opioid receptors in the white matter astrocytes, and neuroinflammation in a mouse impact acceleration model of pediatric TBI. Male and female littermates were randomized on postnatal day 20-21(P20-21) into Sham, TBI + saline and TBI + BPN groups. Mice in the TBI + saline and TBI + BPN groups underwent TBI, while the Sham group underwent anesthesia without injury. BPN (0.075 mg/kg) was administered to the TBI + BPN mice at 30 min after injury, and then every 6-12 h for 2 days. Mice in the TBI + saline group received the same amount of saline injections. The impact of BPN on body weight, motor function, opioid receptor expression, and neuroinflammation was evaluated at 1-day (d), 3-d and 7-d post-injury. We found that 1) TBI induced significant weight loss in both males and females. BPN treatment improved weight loss at 3-d post-injury in females. 2) TBI significantly impaired motor coordination and strength. BPN improved motor coordination and strength in both males and females at 1-d and 3-d post-injury. 3) TBI significantly decreased exploration activity at 1-d post-injury in males, and at 7-d post-injury in females, while BPN improved the exploration activity in females. 4) TBI significantly increased mRNA expression of mu-opioid receptors (MOR) at 7-d post-injury in males, but decreased mRNA expression of MOR at 1-d post-injury in females. BPN normalized MOR mRNA expression at 1-d post-injury in females. 5) MOR expression in astrocytes at corpus callosum significantly increased at 7-d post-injury in male TBI group, but significantly decreased at 1-d post-injury in female TBI group. BPN normalized MOR expression in both males and females. 6) TBI significantly increased the mRNA expression of TNF-α, IL-1β, IL-6 and iNOS. BPN decreased mRNA expression of iNOS, and increased mRNA expression of TGF-β1. In conclusion, this study elucidates the sex specific effects of BPN during the acute phase after pediatric TBI, which provides the rationale to assess potential effects of BPN on chronic pathological progressions after pediatric TBI in both males and females.
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Sinkler MA, Furdock RJ, Vallier HA. Treating trauma more effectively: A review of psychosocial programming. Injury 2022; 53:1756-1764. [PMID: 35491278 DOI: 10.1016/j.injury.2022.04.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 02/02/2023]
Abstract
IMPORTANCE Traumatic events are the leading cause of life-altering disability in adults of working age. The management of patients with traumatic injury has substantially improved due to development of sophisticated trauma centers increasing survival after injury. Unlike the adoption of the trauma system framework, the same has not occurred with specialized trauma recovery services to include mental and social health needs. This literature review will discuss unique issues facing trauma survivors, some current recovery programs available, outcomes and benefits of these programs, and barriers that impair widespread incorporation. OBSERVATIONS Studies have shown that patients with traumatic injury experience reduction in quality of life and concurrent threats to mental health, including post-traumatic stress disorder (PTSD), alcohol use disorder, and recreational substance abuse. Patients with traumatic injury also have high recidivism rates, low pain management satisfaction, and poor engagement in care following injury. Screening efforts for PTSD, mental illness, and alcohol and substance abuse are more widely available interventions. Early coordinated efforts included dedicated multidisciplinary recovery teams. Recently, more methodical and organized programs, such as the Trauma Survivors Network, trauma collaborative care, Trauma Recovery Services, and Center of Trauma Survivorship, have been implemented. CONCLUSIONS AND RELEVANCE The enrollment of patients with traumatic injury in novel programs to enhance recovery has led to heightened self-efficacy, better coping mechanisms, and increased use of mental health services. Additionally, trauma recovery services have been shown to reduce recidivism and have generated cost savings for hospital systems. While positive outcomes have been demonstrated, they are not consistently predictable. Barriers for widespread implementation include limitations of time, funding, and institutional support. This article describes models of successful programs initiated within some trauma centers, which may be duplicated to serve future trauma survivors.
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Affiliation(s)
- Margaret A Sinkler
- Department of Orthopaedic Surgery, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Ryan J Furdock
- Department of Orthopaedic Surgery, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Heather A Vallier
- Department of Orthopaedic Surgery, Case Western Reserve University School of Medicine, Cleveland, OH.
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Teeter BS, Thannisch MM, Martin BC, Zaller ND, Jones D, Mosley CL, Curran GM. Opioid overdose counseling and prescribing of naloxone in rural community pharmacies: A pilot study. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2022; 2. [PMID: 35128518 PMCID: PMC8813166 DOI: 10.1016/j.rcsop.2021.100019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Introduction Fatal overdoses from opioids increased four-fold from 1999 to 2009, and they are now the leading cause of death among Americans under 50. Legislation has been passed by every state to increase access to naloxone but dispensing by community pharmacies remains low. Objectives The objective of this study was to pilot test a proactive opioid overdose counseling intervention and a passive naloxone intervention, and the implementation strategies developed to support their delivery, in rural community pharmacies on relevant implementation outcomes. Methods The interventions, implementation strategies, and the overall pilot study approach were developed in a collaborative partnership with a regional supermarket pharmacy chain. They selected 2 rural pharmacies to participate in the pilot study and 2 non-intervention pharmacies to serve as comparison sites. Two interventions were pilot tested in the 2 intervention pharmacies: 1)a proactive opioid overdose counseling intervention and 2) a passive naloxone intervention. An explanatory sequential mixed-methods design was utilized to evaluate adoption, feasibility, acceptability, and appropriateness outcomes after the 3-month observation period. Results Between the 2 intervention pharmacies, 130 patients received the opioid overdose counseling intervention. 44 (33.8%) were prescribed and dispensed naloxone. Zero naloxone prescriptions were written or dispensed at the comparison pharmacies. Interviews with pharmacy staff found the interventions to be feasible, acceptable, and appropriate in their settings. Conclusion This small scale pilot study in partnership with a regional supermarket pharmacy chain had positive results with a third of patients who received the opioid overdose counseling intervention being dispensed naloxone. However, the majority of patients did not receive naloxone indicating additional revisions to the intervention components and/or implementation strategies are needed to improve the overall impact of the interventions.
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Affiliation(s)
- Benjamin S Teeter
- Center for Implementation Research, Department of Pharmacy Practice, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States of America
| | - Mary M Thannisch
- University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States of America
| | - Bradley C Martin
- Division of Pharmaceutical Evaluation and Policy, Department of Pharmacy Practice, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States of America
| | - Nickolas D Zaller
- Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States of America
| | - Duane Jones
- Harps Food Stores, Inc., Springdale, AR 72762, United States of America
| | - Cynthia L Mosley
- Center for Implementation Research, Department of Pharmacy Practice, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States of America
| | - Geoffrey M Curran
- Center for Implementation Research, Departments of Pharmacy Practice and Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States of America.,Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR 72114, United States of America
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Schwartz HEM, Matthay ZA, Menza R, Fernández A, Mackersie R, Stein DM, Bongiovanni T. Inequity in discharge pain management for trauma patients with limited English proficiency. J Trauma Acute Care Surg 2021; 91:898-902. [PMID: 34039923 DOI: 10.1097/ta.0000000000003294] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Pain management is critical for optimal recovery after trauma. Previous work at our institution revealed differences in pain assessment by patient language, which may impact management. This study aimed to understand differences in discharge opioid prescribing for trauma patients with limited English proficiency (LEP). METHODS We conducted a cross-sectional study of adult trauma patients discharged to the community from a diverse, urban level 1 trauma center in 2018. Opioid prescriptions were obtained from discharge pharmacy records and converted to standard oral morphine equivalents (OMEs). Multivariable logistic and quantile regression was used to examine the relationship between LEP, opioid prescriptions, and OMEs at discharge, controlling for demographic and clinical characteristics. RESULTS Of 1,419 patients included in this study, 83% were English proficient (EP) and 17% were LEP. At discharge, 56% of EP patients received an opioid prescription, compared with 41% of LEP patients. In multivariable models, EP patients were 1.63 times more likely to receive any opioid prescription (95% CI, 1.17-2.25; p = 0.003). Mean OME was 147 for EP and 94 for LEP patients. In multivariable models, the difference between EP and LEP patients was 40 OMEs (95% CI, 21.10-84.22; p = 0.004). In adjusted quantile regression models, differences in total OMEs increased with the amount of OMEs prescribed. There was no difference in OMEs at the 20th and 40th percentile of total OMEs, but LEP patients received 26 fewer OMEs on average at the 60th percentile (95% CI, -3.23 to 54.90; p = 0.081) and 45 fewer OMEs at the 80th percentile (95% CI, 5.48-84.48; p = 0.026). CONCLUSION Limited English proficiency patients with traumatic injuries were less likely to receive any opioid prescription and were prescribed lower quantities of opiates, which could contribute to suboptimal pain management and recovery. Addressing these disparities is an important focus for future quality improvement efforts. LEVEL OF EVIDENCE Care Management, level IV.
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Affiliation(s)
- Hope E M Schwartz
- From the Department of Surgery, School of Medicine (H.E.M.S.), Department of Surgery (Z.A.M., R. Menza, R. Mackersie, D.M.S., T.B.), Department of Physiological Nursing (R. Menza), and Department of Medicine (A.F.), University of California, San Francisco, San Francisco, California
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Vysokovsky M, Avital G, Betelman-Mahalo Y, Gelikas S, Fridrich L, Radomislensky I, Tsur AM, Glassberg E, Benov A. Trends in prehospital pain management following the introduction of new clinical practice guidelines. J Trauma Acute Care Surg 2021; 91:S206-S212. [PMID: 34039920 DOI: 10.1097/ta.0000000000003287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Early pain treatment following injury has been shown to improve long-term outcomes, while untreated pain can facilitate higher posttraumatic stress disorder rates and worsen outcomes. Nonetheless, trauma casualties frequently receive inadequate analgesia. In June 2013, a new clinical practice guideline (CPG) regarding pain management was introduced in the Israel Defense Forces (IDF) Medical Corps, recommending oral transmucosal fentanyl citrate (OTFC) and low-dose intravenous (IV)/intramuscular ketamine. The purpose of this study was to examine trends in prehospital pain management in the IDF. METHODS All cases documented in the IDF trauma registry between 2008 and 2020 were examined. This study compared casualty parameters before and after the introduction of analgesia CPG in 2013. Parameters compared included demographics, injury parameters, treatment modalities, and types of analgesia provided. RESULT Overall, 5,653 casualties were included in our study. During the 6 years before the introduction of the CPG, 289 (26.7%) of 1,084 casualties received an analgesic treatment, compared with 1,578 (34.5%) of 4,569 casualties during the 7 years following (p < 0.001). Since its introduction, OTFC was administered to 41.8% of all casualties who received analgesia and became the most used analgesic drug in 2020 (61.1% of casualties receiving analgesia). The rate of IV morphine significantly decreased after 2013 (22.6-16%, p < 0.001). CONCLUSION Pain management has become more common in trauma patients' prehospital care in the IDF in recent years. There has been a significant increase in analgesia administration, with the increased use of OTFC, along with a significant reduction in the use of IV morphine. These results may be attributed to introducing a pain management CPG and implementing OTFC among medical teams. The perception of OTFC as a safe user-friendly analgesic may have contributed to its use by medical providers, increasing analgesia rates overall. LEVEL OF EVIDENCE Therapeutic/care management, level III.
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Affiliation(s)
- Moshe Vysokovsky
- From the The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel (M.V., G.A., Y.M., S.G., A.M.T., A.B.); Department of Military Medicine, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel (M.V.); Division of Anesthesia, Intensive Care, and Pain Management, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel (G.A.); Department of Physiology and Pharmacology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel (L.F.); The National Center for Trauma and Emergency Medicine research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel-HaShomer, Israel (I.R.); Department of Medicine 'B'. Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer; affiliated with Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel (A.M.T.); The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel (E.G., A.B.); Uniformed Services University of the Health Sciences, Bethesda, Maryland (E.G.); and Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel (E.G.)
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Khokhar A, Gupta R, Boehmer S, Olympia R. Acute pain assessment and management depicted in medical television shows. Am J Emerg Med 2021; 45:543-545. [DOI: 10.1016/j.ajem.2020.07.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 07/11/2020] [Accepted: 07/11/2020] [Indexed: 10/23/2022] Open
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Fortune S, Frawley J. Optimizing Pain Control and Minimizing Opioid Use in Trauma Patients. AACN Adv Crit Care 2021; 32:89-104. [PMID: 33725102 DOI: 10.4037/aacnacc2021519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Adverse effects of opioids and the ongoing crisis of opioid abuse have prompted providers to reduce prescribing opioids and increase use of multiple nonpharmacologic therapies, nonopioid analgesics, and co-analgesics for pain management in trauma patients. Nonopioid agents, including acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, ketamine, central α2 agonists, and lidocaine, can be used as adjuncts or alternatives to opioids in the trauma population. Complementary therapies such as acupuncture, virtual reality, and mirror therapy are modalities that also may be helpful in reducing pain. Performing pain assessments is fundamental to identify pain and evaluate treatment effectiveness in the critically ill trauma patient. The efficacy, safety, and availability of opioid-sparing therapies and multimodal pain regimens are reviewed.
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Affiliation(s)
- Shanna Fortune
- Shanna Fortune is Advanced Practice Registered Nurse, Trauma Acute Pain Management Service, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - Jennifer Frawley
- Jennifer Frawley is Trauma Critical Care Clinical Pharmacy Specialist, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201
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Pain Management in the Unstable Trauma Patient. CURRENT TRAUMA REPORTS 2020. [DOI: 10.1007/s40719-020-00197-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hachimi-Idrissi S, Coffey F, Hautz WE, Leach R, Sauter TC, Sforzi I, Dobias V. Approaching acute pain in emergency settings: European Society for Emergency Medicine (EUSEM) guidelines-part 1: assessment. Intern Emerg Med 2020; 15:1125-1139. [PMID: 32930965 DOI: 10.1007/s11739-020-02477-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 08/13/2020] [Indexed: 10/23/2022]
Abstract
Pain management is a vital component of patient care, particularly in the emergency setting. Pain can hinder the opportunities to treat and manage pain-causing conditions and remains one of the primary reasons patients seek emergency medical care, yet despite this, pain often remains under-acknowledged, under-assessed and undertreated. Despite the importance of effective management of acute pain, there are currently no well-defined emergency medicine guidelines at a European level to support healthcare professionals in achieving this goal. The European Society for Emergency Medicine (EUSEM) identified this as a significant unmet requirement, for improving day-to-day patient management and for providing guidance to trainees and non-emergency medicine physicians. Under the auspices of EUSEM, a programme-the European Pain Initiative-was launched with the aim of providing information, advice and guidance on pain management in pre-hospital and emergency department settings. Search terms were developed to search MEDLINE, Cochrane database, Google Scholar and EMBASE online databases to return English language articles published in the last 10 years. A working package of reference materials was evaluated against inclusion and exclusion criteria and levels of evidence ascribed. A short survey was developed by the European Pain Initiative Steering Committee for completion by EUSEM members to evaluate actual clinical practice. A working document of > 800 publications was identified for further review and evaluation against agreed criteria. Some further publications were included by the Steering Committee to explore older literature for long-established analgesics, or newly emergent literature that was considered important for inclusion but was identified as the guideline development was underway. This article provides the methodology used to inform the guidelines, including survey results of EUSEM members on assessment and treatment of acute pain. A companion manuscript in this issue presents an evidence-based review and recommendations for individualised evaluation of acute pain in patients in emergency settings.
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Affiliation(s)
- Saïd Hachimi-Idrissi
- Department of Emergency Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
| | - Frank Coffey
- Nottingham University Hospitals' NHS Trust, Nottingham, UK
| | - Wolf E Hautz
- Department of Emergency Medicine, Inselspital University Hospital, University of Bern, Bern, Switzerland
| | - Robert Leach
- Department of Emergency Medicine, Centre Hospitalier de Wallonie Picarde, Tournai, Belgium
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital University Hospital, University of Bern, Bern, Switzerland
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Dogrul BN, Kiliccalan I, Asci ES, Peker SC. Blunt trauma related chest wall and pulmonary injuries: An overview. Chin J Traumatol 2020; 23:125-138. [PMID: 32417043 PMCID: PMC7296362 DOI: 10.1016/j.cjtee.2020.04.003] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 03/15/2020] [Accepted: 04/08/2020] [Indexed: 02/04/2023] Open
Abstract
Physical traumas are tragic and multifaceted injuries that suddenly threaten life. Although it is the third most common cause of death in all age groups, one out of four trauma patients die due to thoracic injury or its complications. Blunt injuries constitute the majority of chest trauma. This indicates the importance of chest trauma among all traumas. Blunt chest trauma is usually caused by motor vehicle accident, falling from height, blunt instrument injury and physical assault. As a result of chest trauma, many injuries may occur, such as pulmonary injuries, and these require urgent intervention. Chest wall and pulmonary injuries range from rib fractures to flail chest, pneumothorax to hemothorax and pulmonary contusion to tracheobronchial injuries. Following these injuries, patients may present with a simple dyspnea or even respiratory arrest. For such patient, it is important to understand the treatment logic and to take a multidisciplinary approach to treat the pulmonary and chest wall injuries. This is because only 10% of thoracic trauma patients require surgical operation and the remaining 90% can be treated with simple methods such as appropriate airway, oxygen support, maneuvers, volume support and tube thoracostomy. Adequate pain control in chest trauma is sometimes the most basic and best treatment. With definite diagnosis, the morbidity and mortality can be significantly reduced by simple treatment methods.
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Pain management in trauma patients affected by the opioid epidemic: A narrative review. J Trauma Acute Care Surg 2020; 87:430-439. [PMID: 30939572 DOI: 10.1097/ta.0000000000002292] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Acute and chronic pain in trauma patients remains a challenging entity, particularly in the setting of the escalating opioid epidemic. It has been reported that chronic opioid use increases the likelihood of hospital admissions as a result of traumatic injuries. Furthermore, patients admitted with traumatic injuries have a greater than average risk of developing opioid use disorder after discharge. Practitioners providing care to these patients will encounter the issue of balancing analgesic goals and acute opioid withdrawal with the challenge of reducing postdischarge persistent opioid use. Additionally, the practitioner is faced with the worrisome prospect that inadequate treatment of acute pain may lead to the development of chronic pain and overtreatment may result in opioid dependence. It is therefore imperative to understand and execute alternative nonopioid strategies to maximize the benefits and reduce the risks of analgesic regimens in this patient population. This narrative review will analyze the current literature on pain management in trauma patients and highlight the application of the multimodal approach in potentially reducing the risks of both short- and long-term opioid use. LEVEL OF EVIDENCE: Narrative review, moderate to High.
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Fischer T, Hosie A, Luckett T, Agar M, Phillips J. Strategies for Pain Assessment in Adult Patients With Delirium: A Scoping Review. J Pain Symptom Manage 2019; 58:487-502.e11. [PMID: 31195076 DOI: 10.1016/j.jpainsymman.2019.05.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 05/31/2019] [Accepted: 05/31/2019] [Indexed: 01/19/2023]
Abstract
CONTEXT Pain and delirium are highly prevalent in the same patient groups. Disturbances in attention, awareness, and cognition are characteristics for delirium and can compromise pain assessment. OBJECTIVES The aim of this review was to examine and map models and understandings of pain and delirium as well as pain assessment instruments and strategies for adult patients with delirium. METHODS A scoping review of all publications that reported on pain assessment in adult patients with delirium was conducted with no time and language constraints, searching Medline, CINAHL, Scopus, Embase, and PsycINFO and systematically assessing for inclusion. Standardized data extraction and a narrative synthesis followed. RESULTS A total of 90 publications were included in the final analysis. Despite being recommended for practice, no evidence for the use of self-report or behavioral pain assessment instruments in patients with delirium was identified, with the exception of limited evidence for the validity of the Critical Care Pain Observation Tool and Behavioral Pain Scale in delirious intensive care patients. Proxy ratings of pain and comprehensive pain assessment hierarchies were also recommended, but not supported by evidence. Current models and/or understandings of pain and delirium were not applied in most publications. CONCLUSION The current literature is insufficient to guide clinical practice in pain assessment in patients with delirium. Future research will be needed to address the validity of existing pain assessment instruments, apply theoretical and conceptual understandings of pain and delirium, and build on prior studies to close evidence gaps.
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Affiliation(s)
| | - Annmarie Hosie
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia
| | - Tim Luckett
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia
| | - Meera Agar
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia
| | - Jane Phillips
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Ultimo, Australia
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Saranteas T, Kostroglou A, Anagnostopoulos D, Giannoulis D, Vasiliou P, Mavrogenis AF. Pain is vital in resuscitation in trauma. SICOT J 2019; 5:28. [PMID: 31414982 PMCID: PMC6694744 DOI: 10.1051/sicotj/2019028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 07/17/2019] [Indexed: 12/14/2022] Open
Abstract
Implementation of the ATLS algorithm has remarkably improved the resuscitation of trauma patients and has significantly contributed to the systematic management of multi-trauma patients. However, pain remains the most prevalent complaint in trauma patients, and can induce severe complications, further deterioration of health, and death of the patient. Providing appropriate and timely pain management to these patients prompts early healing, reduces stress response, shortens hospital Length of Stay (LOS), diminishes chronic pain, and ultimately reduces morbidity and mortality. Pain has been proposed to be evaluated as the fifth vital sign and be recorded in the vital sign charts in order to emphasize the importance of pain on short- and long-term outcomes of the patients. However, although the quality of pain treatment seems to be improving we believe that pain has been underestimated in trauma. This article aims to provide evidence for the importance of pain in trauma, to support its management in the emergency setting and the acute phase of patients’ resuscitation, and to emphasize on the necessity to introduce the letter P (pain) in the ATLS alphabet.
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Affiliation(s)
- Theodosios Saranteas
- Second Department of Anesthesiology, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
| | - Andreas Kostroglou
- Second Department of Anesthesiology, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
| | - Dimitrios Anagnostopoulos
- Second Department of Anesthesiology, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
| | - Dimitrios Giannoulis
- Second Department of Anesthesiology, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
| | - Pantelis Vasiliou
- Fourth Department of Surgery, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
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Torabi M, Mehri A, Mirzaei M. The effect of pain management in reducing limb and spine radiography in stable traumatic patients admitted to the emergency department. TRAUMA-ENGLAND 2019. [DOI: 10.1177/1460408617752206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Musculoskeletal pain caused by trauma is one of the common complaints of patients referred to the emergency department. Due to the lack of a proper pain control protocol, doctors and nurses do not pay attention to pain, and physicians may tend to request too many radiographs, many of which will be unnecessary. We aimed to study the effect of pain management by fentanyl in reducing the number of radiographs, reducing hospital costs and increasing satisfaction in the patients on patients with isolated trauma in limbs and spine causing musculoskeletal pain. Patients and methods A cohort of patients who were referred to the fast-track emergency department with isolated trauma of the upper and lower limbs or spine and triage levels 3, 4 and 5, were visited twice by an emergency medicine resident – before and after application of a pain management protocol using intravenous fentanyl as the principle analgesic. The primary outcome measure was the reduction in the number of radiographs requested; secondary outcomes included alterations in pain levels and patient satisfaction. Results A total of 158 patients were included in the study. The median age was 27.5 years, three quarters were male and 20.88% had a positive history of opium addiction. The number and costs of diagnostic radiography significantly decreased after the administration of fentanyl (P < 0.0001), as did pain levels measured on visual analogue scale with a consequent increase in patient satisfaction. There were only six complications resulting from fentanyl administration which were mild and transient. Follow-up after 24–72 h, revealed no missed fractures. Conclusions The administration of fentanyl as a strong analgesic as part of an emergency department pain management protocol for trauma patients can be performed with limited minor complications; it can reduce the number of unnecessary X-rays performed, exposure to ionizing radiation and hospital costs as well as improving patient satisfaction without missing fractures.
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Affiliation(s)
- Mehdi Torabi
- Department of Emergency Medicine, Kerman University of Medical Sciences, Clinical Research Center, Afzalipour Hospital, Kerman, Iran
| | - Ali Mehri
- Department of Emergency Medicine, Kerman University of Medical Sciences, Clinical Research Center, Afzalipour Hospital, Kerman, Iran
| | - Moghaddameh Mirzaei
- Department of Biostatistics and Epidemiology, School of Public Health, University of Medical Sciences, Kerman, Iran
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Assessment of Acute Pain Management and Associated Factors among Emergency Surgical Patients in Gondar University Specialized Hospital Emergency Department, Northwest Ethiopia, 2018: Institutional Based Cross-Sectional Study. PAIN RESEARCH AND TREATMENT 2019; 2018:5636039. [PMID: 30631598 PMCID: PMC6304567 DOI: 10.1155/2018/5636039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 10/12/2018] [Accepted: 11/05/2018] [Indexed: 11/17/2022]
Abstract
Background Adequate pain management has led to increased comfort in emergency patients, reducing morbidity and improving long term outcomes. Different pain management modalities have been applied in the emergency department among which systemic analgesia is commonly used by preceding a nerve block. Several factors have been associated with poor pain management in low resource setting areas. We aimed to determine pain management modalities and associated factors among emergency surgical patients. Patients and Methods After obtaining ethical approval from Ethical Review Committee, 203 volunteer patients were enrolled. Institutional based cross-sectional prospective study was conducted from April to May 2018 in Gondar University Specialized Hospital Emergency Department. The severity of pain was measured through Numerical Rating Scale and statistical analysis was performed using SPSS statistical package version 23. Descriptive statistics cross-tab and binary logistics were performed to identify factors related to pain management in emergency department. Results A total of 203 patients, 138 (68%) males and 65 (32%) females with response rate of 94%, participated in this study. Among them, 66% patients received analgesia within two hours of ED presentation with a mean ± SD of 61.0 ± 34.1 minutes. 70.4 % of patients complained of moderate and severe pain after receiving analgesia. There was a significant difference between trauma and nontrauma patients in mean time of analgesia receiving and residual pain severity (p < 0.001). Age, trauma, physician pain assessment, and severity of pain were the predicting factors for analgesia delivery. Conclusion The overall practice of pain management in Gondar University Specialized Hospital Emergency Department was not adequate. Therefore, it is vital to implement an objective pain assessment method and documentation of the pain severity to improve pain management practice.
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Weinberg B, Roos R, van Aswegen H. Effectiveness of non-pharmacological interventions for pain and physical function in adults with rib fractures: a systematic review protocol. ACTA ACUST UNITED AC 2018; 16:1599-1605. [PMID: 30113543 DOI: 10.11124/jbisrir-2017-003600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
REVIEW QUESTION/OBJECTIVES The review question is: what are the effects of non-pharmacological therapeutic interventions on pain and physical function in adults with rib fractures?The objectives of this systematic review are to determine.
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Affiliation(s)
- Beverley Weinberg
- Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ronel Roos
- Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,The Wits-JBI Centre for Evidenced-Based Practice: a Joanna Briggs Institute Centre of Excellence
| | - Heleen van Aswegen
- Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Salottolo K, Peck L, Tanner Ii A, Carrick MM, Madayag R, McGuire E, Bar-Or D. The grass is not always greener: a multi-institutional pilot study of marijuana use and acute pain management following traumatic injury. Patient Saf Surg 2018; 12:16. [PMID: 29946360 PMCID: PMC6007004 DOI: 10.1186/s13037-018-0163-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 05/24/2018] [Indexed: 12/26/2022] Open
Abstract
Background Widespread legislative efforts to legalize marijuana have increased the prevalence of marijuana use and abuse. The effects of marijuana on pain tolerance and analgesic pain management in the acute pain setting have not been reported. Although marijuana has been shown to have antinociceptive effects and is approved for medical use to treat chronic pain, anecdotal evidence suggests marijuana users admitted with traumatic injuries experience poorer pain control than patients who do not use marijuana. We hypothesized that marijuana users would report higher pain scores and require more opioid analgesia following traumatic injury. Methods This retrospective pilot study included all patients involved in motor vehicle crashes, consecutively admitted to four trauma centers from 1/1/2016–4/30/2016. Marijuana status was examined as non-use and use, and was further categorized as chronic and episodic use. We performed a repeated measures mixed model to examine the association between marijuana use and a) average daily opioid consumption and b) average daily pain scores (scale 0–10). Opioid analgesics were converted to be equianalgesic to 1 mg IV hydromorphone. Results Marijuana use was reported in 21% (54/261), of which 30% reported chronic use (16/54). Marijuana use was reported more frequently in Colorado hospitals (23–29%) compared to the hospital in Texas (6%). Drug use with other prescription/street drugs was reported in 9% of patients. Other drug use was a significant effect modifier and results were presented after stratification by drug use. After adjustment, marijuana users who did not use other drugs consumed significantly more opioids (7.6 mg vs. 5.6 mg, p < 0.001) and reported higher pain scores (4.9 vs. 4.2, p < 0.001) than non-marijuana users. Conversely, in patients who used other drugs, there were no differences in opioid consumption (5.6 mg vs. 6.1 mg, p = 0.70) or pain scores (5.3 vs. 6.0, p = 0.07) with marijuana use compared to non-use, after adjustment. Chronic marijuana use was associated with significantly higher opioid consumption compared to episodic marijuana use in concomitant drug users (11.3 mg vs. 4.4 mg, p = 0.008) but was similar in non-drug users (p = 0.41). Conclusion These preliminary data suggest that marijuana use, especially chronic use, may affect pain response to injury by requiring greater use of opioid analgesia. These results were less pronounced in patients who used other drugs.
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Affiliation(s)
- Kristin Salottolo
- 1Trauma Research Department, Swedish Medical Center, 501 E. Hampden Ave, Englewood, CO 80113 USA.,2Trauma Research Department, St. Anthony Hospital, 11600 W. 2nd Place, Lakewood, CO 80228 USA.,Trauma Research Department, Medical City Plano, 3901 West 15th Street, Plano, TX 75075 USA.,4Trauma Research Department, Penrose Hospital, 2222 N Nevada Drive, Colorado Springs, CO 80907 USA
| | - Laura Peck
- 5Trauma Services Department, Swedish Medical Center, 499 E. Hampden Ave, Englewood, CO 80113 USA
| | - Allen Tanner Ii
- 6Trauma Services Department, Penrose Hospital, 2222 N Nevada Drive, Colorado Springs, CO 80907 USA
| | - Matthew M Carrick
- Trauma Services Department, Medical City Plano, 3901 W 15th St, Plano, TX 75075 USA
| | - Robert Madayag
- 8Trauma Services Department, St. Anthony Hospital, 11600 West 2nd Place, Lakewood, CO 80228 USA
| | - Emmett McGuire
- 5Trauma Services Department, Swedish Medical Center, 499 E. Hampden Ave, Englewood, CO 80113 USA
| | - David Bar-Or
- 1Trauma Research Department, Swedish Medical Center, 501 E. Hampden Ave, Englewood, CO 80113 USA.,2Trauma Research Department, St. Anthony Hospital, 11600 W. 2nd Place, Lakewood, CO 80228 USA.,Trauma Research Department, Medical City Plano, 3901 West 15th Street, Plano, TX 75075 USA.,4Trauma Research Department, Penrose Hospital, 2222 N Nevada Drive, Colorado Springs, CO 80907 USA
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Farčić N, Barać I, Pačarić S, Lovrić I, Ilakovac V. Acute Postoperative Pain in Trauma Patients - The Fifth Vital Sign. Open Access Maced J Med Sci 2017; 5:310-315. [PMID: 28698748 PMCID: PMC5503728 DOI: 10.3889/oamjms.2017.067] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 03/20/2017] [Accepted: 04/18/2017] [Indexed: 11/05/2022] Open
Abstract
AIM To determine average pain intensity perceived by trauma patients at hospital admission, lowest and highest pain intensity during their hospitalisation and their satisfaction with provided pain treatment. PATIENTS AND METHODS The research included 114 operated patients at the Clinical Department of Trauma Surgery. We used the standard Numerical Rating Scale (NRS) for a clinical measure of pain. RESULTS The average pain intensity at hospital admission was NRS median 7 (range 4-10), the severest perceived rate of pain during hospitalisation was NRS median 5 (range 4-7). Ninety-four percent of our respondents were satisfied with provided pain treatment. Thirty-two percent of patients were not asked to assess their pain during their hospitalisation, and 40.4% of patients assessed their pain occasionally. CONCLUSION Female patients, as well as patients admitted to the emergency department, reported higher NRS scores. Those respondents who perceived severe pain answered more often that medical staff didn't ask them to assess their pain on any occasion. Good communication between medical staff and patients, together with adequate assessment and evaluation of acute pain are of great importance in its treatment.
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Affiliation(s)
- Nikolina Farčić
- University Hospital Centre Osijek, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croati
| | - Ivana Barać
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Stana Pačarić
- University Hospital Centre Osijek, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croati
| | - Ivana Lovrić
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Vesna Ilakovac
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
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Yin Y, Zhang L, Xiao H, Wen CB, Dai YE, Yang G, Zuo YX, Liu J. The pre-amputation pain and the postoperative deafferentation are the risk factors of phantom limb pain: a clinical survey in a sample of Chinese population. BMC Anesthesiol 2017; 17:69. [PMID: 28549447 PMCID: PMC5446733 DOI: 10.1186/s12871-017-0359-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 05/14/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND To provide an overview of phantom limb pain (PLP) in China. This includes the prevalence of PLP and possible risk factors. METHODS In a retrospective study, telephone interviews were conducted with 391 amputation patients who underwent extremity amputations at a tertiary hospital in China. RESULTS PLP was found in 29% of the amputees. Pre-amputation pain (OR = 10.4, P = 0.002) and postoperative analgesia (OR = 4.9, P = 0.008) were identified as high-risk factors for PLP. 82.1% of PLP patients experienced pre-amputation pain. The average pain intensity of PLP was 5.1 ± 2.2, with 31.9% having severe intensity. The effects of PLP on the quality of the PLP patients were as follows: 7.8% of the patients had to limit their daily life and 29.0% of the patients had to limit their social activities. 17.3 and 25.7% of patients experienced depression and sleeping disorder respectively, while 18.9% had loss of interest and even 16.1% of PLP patients had attempted suicide. No effective treatments were found in 78.9% of these patients. CONCLUSIONS PLP has markedly affected the lives of patients. Pre-amputation pain and postoperative epidural analgesia might be risk factors for the phantom limb pain after amputation. Prevention of pre-amputation pain and sudden post-amputation deafferentation should be recommended to the amputees.
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Affiliation(s)
- Yan Yin
- Department of Pain management, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China
| | - Lan Zhang
- Department of Anesthesiology, Sichuan Orthopedics Hospital, Chengdu, Sichuan, 610041, China
| | - Hong Xiao
- Department of Pain management, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China.
| | - Chuan-Bing Wen
- Department of Anesthesiology, Sichuan Academy of Medical Sciences & Sichuan provincial People's Hospital, Chengdu, Sichuan, 610000, China
| | - Yue-E Dai
- Department of Anesthesiology, Sichuan Academy of Medical Sciences & Sichuan provincial People's Hospital, Chengdu, Sichuan, 610000, China
| | - Guang Yang
- Department of Anesthesiology, Sichuan Orthopedics Hospital, Chengdu, Sichuan, 610041, China
| | - Yun-Xia Zuo
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Jin Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
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Ahmadi A, Bazargan-Hejazi S, Heidari Zadie Z, Euasobhon P, Ketumarn P, Karbasfrushan A, Amini-Saman J, Mohammadi R. Pain management in trauma: A review study. J Inj Violence Res 2016; 8:89-98. [PMID: 27414816 PMCID: PMC4967367 DOI: 10.5249/jivr.v8i2.707] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 06/09/2016] [Indexed: 11/28/2022] Open
Abstract
Background: Pain in trauma has a role similar to the double-edged sword. On the one hand, pain is a good indicator to determine the severity and type of injury. On the other hand, pain can induce sever complications and it may lead to further deterioration of the patient. Therefore, knowing how to manage pain in trauma patients is an important part of systemic approach in trauma. The aim of this manuscript is to provide information about pain management in trauma in the Emergency Room settings. Methods: In this review we searched among electronic and manual documents covering a 15-yr period between 2000 and 2016. Our electronic search included Pub Med, Google scholar, Web of Science, and Cochrane databases. We looked for articles in English and in peer-reviewed journals using the following keywords: acute pain management, trauma, emergency room and injury. Results: More than 3200 documents were identified. After screening based on the study inclusion criteria, 560 studies that had direct linkage to the study aim were considered for evaluation based World Health Organization (WHO) pain ladder chart. Conclusions: To provide adequate pain management in trauma patients require: adequate assessment of age-specific pharmacologic pain management; identification of adequate analgesic to relieve moderate to severe pain; cognizance of serious adverse effects of pain medications and weighting medications against their benefits, and regularly reassessing patients and reevaluating their pain management regimen. Patient-centered trauma care will also require having knowledge of barriers to pain management and discussing them with the patient and his/her family to identify solutions.
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Affiliation(s)
- Alireza Ahmadi
- Department of Anesthesiology, Critical Care and Pain Management, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran.
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Wilby KJ, Wilbur K. Cross-national analysis of estimated narcotic utilization for twelve Arabic speaking countries in the Middle East. Saudi Pharm J 2016; 25:83-87. [PMID: 28223866 PMCID: PMC5310135 DOI: 10.1016/j.jsps.2016.01.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 01/08/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Access to narcotics has been described as suboptimal in the Middle East. The objectives of this study were to characterize estimated narcotic use in twelve Arabic-speaking nations and compare across world regions. METHODS This was a population-based cross-sectional analysis of estimated average consumption of narcotic drugs in defined daily doses per million inhabitants, as provided by the International Narcotics Control Board Technical Reports (2008-2012). Five years of data (2008-2012) were extracted from reports for 12 Arabic-speaking countries: Lebanon, Jordan, Syria, Qatar, United Arab Emirates, Saudi Arabia, Oman, Bahrain, Kuwait, Iraq, Egypt, and Yemen. Data were also obtained for world regions. RESULTS In 2012, Bahrain and Kuwait had the highest estimates (364 and 352 defined daily doses per million inhabitants per day, respectively), while Yemen and Iraq had the lowest (9 and 6 defined daily doses per million inhabitants per day, respectively). North America, Oceania, and Europe had the highest rates (32,264, 9978, and 7937 defined daily doses per million inhabitants per day, respectively), while Arabic-Countries were only ahead of Africa and Central America (128, 91, 87 defined daily doses per million inhabitants per day, respectively). CONCLUSIONS Great variability was observed in estimates between 12 Arabic countries and even larger disparity when Arabic-Countries were benchmarked against world regions, suggesting a need for future studies to determine reasons for these discrepancies.
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Affiliation(s)
- Kyle John Wilby
- PO Box 2713, College of Pharmacy, Qatar University, Doha, Qatar
| | - Kerry Wilbur
- PO Box 2713, College of Pharmacy, Qatar University, Doha, Qatar
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Nonopioid management of acute pain associated with trauma: Focus on pharmacologic options. J Trauma Acute Care Surg 2015; 79:475-83. [PMID: 26307883 DOI: 10.1097/ta.0000000000000755] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Frazilio FDO, DeRossi R, Jardim PHDA, Marques BC, Martins ARDC, Hermeto LC. Effects of epidural nalbuphine on intraoperative isoflurane and postoperative analgesic requirements in dogs. Acta Cir Bras 2014; 29:38-46. [DOI: 10.1590/s0102-86502014000100006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 12/12/2013] [Indexed: 11/22/2022] Open
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Abstract
Numerous studies have identified strategies to reduce mechanical ventilation duration by targeting appropriate sedation levels. However, applicability of these strategies to critically injured patients with burn injury has not been established. At our medical center, methadone is commonly used early in the care of burn patients to treat background pain and limit the development of opioid tolerance. The aim of this study is to evaluate the effect of early methadone initiation in critically injured burn patients requiring mechanical ventilation. This retrospective study compared patients who received early methadone with patients who did not while mechanically ventilated with the primary outcome of ventilator-free days in a 28-day period. Those who received methadone within 4 days of intubation and remained ventilated for 2 days after the first dose were included in the methadone group. Propensity scores were used to match up to three control patients to each methadone patient. Seventy patients (18 methadone and 52 matched control patients) were included in the final evaluation. Patients in the methadone group averaged 16.5 ventilator-free days compared with 11.5 in the control group (P = .03). There was no statistical difference in the duration of intensive care unit or hospital length of stay between groups. Our results suggest that early methadone initiation may have a significant effect on ventilator outcomes in critically injured patients with burn injury. However, further research is warranted.
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Salinas FA, Lugo LH, García HI. Efficacy of Early Treatment with Carbamazepine in Prevention of Neuropathic Pain in Patients with Spinal Cord Injury. Am J Phys Med Rehabil 2012; 91:1020-7. [DOI: 10.1097/phm.0b013e3182643c85] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Salah Eldin W, Hirshon JM, Smith GS, Kamal AAM, Abou-El-Fetouh A, El-Setouhy M. Health-related quality of life after serious occupational injury in Egyptian workers: a cross-sectional study. BMJ Open 2012; 2:e000413. [PMID: 23187968 PMCID: PMC3533107 DOI: 10.1136/bmjopen-2011-000413] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Occupational injuries can have severe socioeconomic consequences; however, little research has examined the health-related quality of life (HRQoL) of workers following occupational injuries, especially in developing countries. This study was to employ the European Quality of Life Five Dimensions (EQ-5D) tool to measure HRQoL 6 months following serious occupational injury sustained by insured workers in the East Delta Region of Egypt. DESIGN This cross-sectional study was conducted from July to December 2008 among workers injured severely enough to be off work for at least 6 months after an occupational injury. SETTING The Nile Insurance Hospital in Qalyubia, Egypt. PARTICIPANTS Adult workers returning for follow-up evaluation after being given 6 months off work by a physician for an occupational injury. OUTCOMES The workers described their health and quality of life using the EQ-5D instrument. RESULTS Most study participants were male (n=118 (90%)), with mean age of 41.5 years. Fractures were the most common type of injury (n=96 (73%)), mostly involving the lower limbs (n=70 (53%)). Participants identified persistent problems related to mobility (n=78 (60%)), self-care (n=69 (53%)), performing usual activities (n=109 (83%)), pain/discomfort (n=119 (91%)) and anxiety/depression (n=51 (40%)). The perceived HRQoL estimated by the mean (±SD) visual analogue scale (VAS) score among injured workers was 61.6±17.9. Multivariate linear regression showed an association between poor VAS score and amputations, mobility limitation, self-care problems, pain/discomfort and anxiety/depression. CONCLUSIONS Some people with occupational injuries experience significant problems such as pain/discomfort, functional limitations and anxiety/depression, long after the injury. Improvement in pain management strategies and physical and psychological rehabilitation may improve their health-related quality of life.
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Affiliation(s)
- Waleed Salah Eldin
- Community, Environmental and Occupational Medicine Department, Ain Shams University, Cairo, Egypt
| | - Jon Mark Hirshon
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Charles McMathias, Jr., National Study Center for Trauma and Emergency Medical Systems, of the Shock, Trauma, and Anesthesia Research Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Gordon S Smith
- Charles McMathias, Jr., National Study Center for Trauma and Emergency Medical Systems, of the Shock, Trauma, and Anesthesia Research Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Abdel-Aziz Mohamad Kamal
- Community, Environmental and Occupational Medicine Department, Ain Shams University, Cairo, Egypt
| | - Aisha Abou-El-Fetouh
- Community, Environmental and Occupational Medicine Department, Ain Shams University, Cairo, Egypt
| | - Maged El-Setouhy
- Community, Environmental and Occupational Medicine Department, Ain Shams University, Cairo, Egypt
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Boscan P, Monnet E, Mama K, Twedt DC, Congdon J, Steffey EP. Effect of maropitant, a neurokinin 1 receptor antagonist, on anesthetic requirements during noxious visceral stimulation of the ovary in dogs. Am J Vet Res 2011; 72:1576-9. [DOI: 10.2460/ajvr.72.12.1576] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Cole BE. The need for chronic opioids to treat persistent noncancer pain. Gen Hosp Psychiatry 2011; 33:419-22. [PMID: 21868101 DOI: 10.1016/j.genhosppsych.2011.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 08/08/2011] [Accepted: 08/08/2011] [Indexed: 11/30/2022]
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Boscan P, Monnet E, Mama K, Twedt DC, Congdon J, Eickhoff JC, Steffey EP. A dog model to study ovary, ovarian ligament and visceral pain. Vet Anaesth Analg 2011; 38:260-6. [DOI: 10.1111/j.1467-2995.2011.00611.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Phantom pain is pain caused by elimination or interruption of sensory nerve impulses by destroying or injuring the sensory nerve fibers after amputation or deafferentation. The reported incidence of phantom limb pain after trauma, injury or peripheral vascular diseases is 60% to 80%. Over half the patients with phantom pain have stump pain as well. Phantom pain can also occur in other parts of the body; it has been described after mastectomies and enucleation of the eye. Most patients with phantom pain have intermittent pain, with intervals that range from 1 day to several weeks. Even intervals of over a year have been reported. The pain often presents itself in the form of attacks that vary in duration from a few seconds to minutes or hours. In most cases, the pain is experienced distally in the missing limb, in places with the most extensive innervation density and cortical representation. Although there are still many questions as to the underlying mechanisms, peripheral as well as central neuronal mechanisms seem to be involved. Conservative therapy consists of drug treatment with amitriptyline, tramadol, carbamazepine, ketamine, or morphine. Based on the available evidence some effect may be expected from drug treatment. When conservative treatment fails, pulsed radiofrequency treatment of the stump neuroma or of the spinal ganglion (DRG) or spinal cord stimulation could be considered (evidence score 0). These treatments should only be applied in a study design.
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Affiliation(s)
- Andre Wolff
- Department of Anesthesiology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Impact of the Implementation of the Critical-Care Pain Observation Tool (CPOT) on Pain Management and Clinical Outcomes in Mechanically Ventilated Trauma Intensive Care Unit Patients. J Trauma Nurs 2011. [DOI: 10.1097/jtn.0b013e3181ff2675] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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McGuire JM, Burkard JF. Risk Factors for Emergence Delirium in U.S. Military Members. J Perianesth Nurs 2010; 25:392-401. [DOI: 10.1016/j.jopan.2010.07.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Revised: 07/14/2010] [Accepted: 07/25/2010] [Indexed: 10/18/2022]
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Barry DT, Beitel M, Cutter CJ, Garnet B, Joshi D, Rosenblum A, Schottenfeld RS. Exploring relations among traumatic, posttraumatic, and physical pain experiences in methadone-maintained patients. THE JOURNAL OF PAIN 2010; 12:22-8. [PMID: 20646965 DOI: 10.1016/j.jpain.2010.04.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2010] [Revised: 04/01/2010] [Accepted: 04/19/2010] [Indexed: 12/22/2022]
Abstract
UNLABELLED Differences in lifetime trauma exposure and screened symptoms of posttraumatic stress disorder (PTSD) were examined in methadone maintenance treatment (MMT) patients with a variety of pain experiences. Parametric and nonparametric statistical tests were performed on data obtained from 150 patients currently enrolled in MMT. In comparison to MMT patients reporting no pain in the previous week, those with chronic severe pain (CSP) (ie, pain lasting at least 6 months with moderate to severe pain intensity or significant pain interference) exhibited comparable levels of trauma involving sexual assault but reported significantly higher levels of trauma involving physical assault, number of traumatic events, and screened symptoms of PTSD. A third group, non-CSP MMT patients reporting some pain in the past week, differed significantly from the CSP group on number of traumatic events but reported comparable levels of sexual assault and physical assault. In comparison to men, women reported higher levels of sexual assault and were more likely to score above the cutoff on the PTSD screener but reported comparable levels of physical assault and number of traumatic events. Pain-related differences in trauma and screened symptoms of PTSD exist in MMT patients and may have implications for program planning and outreach efforts. PERSPECTIVE This article demonstrates that trauma and screened symptoms of PTSD vary as a function of sex and pain status in methadone-maintained patients. Future studies may benefit from developing and assessing interventions that address chronic pain, PTSD, and opioid dependence in MMT.
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Affiliation(s)
- Declan T Barry
- Yale University School of Medicine, 34 Park Street, New Haven, CT 06519, USA.
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Abstract
Buprenorphine is a mixed opiate receptor agonist-antagonist growing in popularity as an office-based treatment for opioid-dependent patients. It has high affinity, but only partial agonism at the μ-opioid receptor resulting in a ceiling analgesic effect. At higher doses, buprenorphine potentiates antagonism at the κ-opioid receptor. These properties make buprenorphine an effective maintenance treatment for opioid-dependent patients. These same properties, however, can interfere with the management of acute pain in patients on maintenance buprenorphine therapy. We present a case of a young multisystem trauma patient in whom adequate analgesia could not be achieved due to buprenorphine treatment before and through the early course of admission. Discontinuation of buprenorphine allowed for appropriate pain management and successful analgesia. Further education of acute care clinicians about buprenorphine pharmacology and careful selection of patients for buprenorphine maintenance therapy are needed to avoid delays of pain control in trauma patients.
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Affiliation(s)
- Colin J. Harrington
- Departments of Psychiatry and Medicine, Brown Medical School and Rhode Island Hospital, Providence, Rhode Island
| | - Victor Zaydfudim
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Grabinsky A, Sharar SR. Regional anesthesia for acute traumatic injuries in the emergency room. Expert Rev Neurother 2010; 9:1677-90. [PMID: 19903026 DOI: 10.1586/ern.09.110] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Since the introduction of cocaine in 1884, regional nerve block procedures have been used in anesthesia practice for over 100 years. While almost all medical specialties use simple regional anesthesia techniques, anesthesia providers use a wider variety of more specific nerve block techniques than any other speciality. Anesthesiologists have assumed a vital role in recent military conflicts and, together with surgeons and emergency physicians, have introduced regional anesthesia techniques for the treatment and transport of injured soldiers. While such techniques have only been applied to a limited extent in civilian emergency settings, it is likely that current military experience will enhance future use of regional anesthesia techniques for the care of trauma patients in the civilian prehospital and emergency room settings.
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Affiliation(s)
- Andreas Grabinsky
- Department of Anesthesiology, Harborview Medical Center, #359724, 325 Ninth Avenue, Seattle, WA 98104, USA.
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Wuest J, Merritt-Gray M, Ford-Gilboe M, Lent B, Varcoe C, Campbell JC. Chronic Pain in Women Survivors of Intimate Partner Violence. THE JOURNAL OF PAIN 2008; 9:1049-57. [PMID: 18701353 DOI: 10.1016/j.jpain.2008.06.009] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2008] [Revised: 04/26/2008] [Accepted: 06/11/2008] [Indexed: 11/28/2022]
Affiliation(s)
- Judith Wuest
- University of New Brunswick, Faculty of Nursing, Fredericton, New Brunswick, Canada.
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Hines S, Theodorou S, Williamson A, Fong D, Curry K. Management of acute pain in methadone maintenance therapy in-patients. Drug Alcohol Rev 2008; 27:519-23. [PMID: 18696299 DOI: 10.1080/09595230802245519] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Methadone maintained treatment (MMT) patients may be given less opioid analgesia for acute pain than the general patient, due to requests for analgesia being misinterpreted as craving for drugs. Pain studies have showed that MMT patients have hyperalgesic responses and that cross-tolerance to opioids may be present, suggesting that they may need more analgesia than the non-MMT patient. This study compares the pain management of MMT patients and controls during an acute hospital stay. It is a retrospective study of MMT in-patients and controls matched for medical condition, age and gender, comparing the analgesia given and pain stated in hospital notes. Patients with a chronic pain condition were excluded. MMT patients and controls did not differ in relation to median morphine dose received or average number of pain reports per day, and only a small proportion of both groups engaged in drug-seeking behaviour. Behavioural problems were significantly more common among MMT patients (39% versus 5%, p < 0.001). The fact that the opioid doses were not significantly different between subjects and controls seems to contradict the experimental evidence that patients on methadone tend to be hyperalgesic. Alternatively, MMT patients may be hyperalgesic, and statistically equal levels of opioid analgesia given to both groups may indicate an effective under-treatment of pain in the hyperalgesic MMT group. Inadequate analgesia may contribute to both behavioural problems and premature discharge. Resolving these uncertainties will require prospective studies.
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Affiliation(s)
- Susan Hines
- Drug Health Services, Canterbury Hospital, SSWAHS, Campsie, NSW, Australia.
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The evolution of pain management in the critically ill trauma patient: Emerging concepts from the global war on terrorism. Crit Care Med 2008; 36:S346-57. [DOI: 10.1097/ccm.0b013e31817e2fc9] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Ulvik A, Kvåle R, Wentzel-Larsen T, Flaatten H. Quality of life 2-7 years after major trauma. Acta Anaesthesiol Scand 2008; 52:195-201. [PMID: 18005377 DOI: 10.1111/j.1399-6576.2007.01533.x] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The aim of the present study was to assess potential long-term reduction in health-related quality of life (HRQOL) in adult trauma patients 2-7 years after discharge from an intensive care unit (ICU), and to study possible determinants of the HRQOL reduction. METHODS Follow-up study of a cohort of 341 trauma patients admitted to the ICU of a university hospital during 1998-2003. Of the 228 eligible patients, 210 (92%) completed the study. A telephone interview using the EuroQol 5-D (EQ-5D) was conducted. Patients reported their HRQOL both at present and before trauma. RESULTS Before trauma 88% reported in retrospect no problem in any EQ-5D dimension, compared with 20% at follow-up. After trauma (median 4.0 years) 58% suffered pain/discomfort, 44% reported alterations in usual activities, 40% reduced mobility, 35% anxiety/depression, and 15% limited autonomy. A total of 74% experienced reduction in HRQOL. Severe problems were reported by 16%. Women experienced more anxiety/depression than men. Simplified Acute Physiology Score (SAPS) II and Injury Severity Score (ISS) were significantly associated with impaired HRQOL, while age was not. Patients with severe head injury reported better HRQOL than those without severe head injury. CONCLUSION More than 2 years post-injury, 74% reported impaired HRQOL but only 16% had severe problems. The majority still suffered pain/discomfort, indicating that pain management is a key factor in improving long-term outcome after severe trauma.
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Affiliation(s)
- A Ulvik
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway.
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Affiliation(s)
- Cynthia A Fleck
- Clinical Marketing, Medline Industries, Advanced Skin and Wound Care Division, Mundelein, IL, USA.
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Dreinhöfer KE, Reichel H, Käfer W. Strategies for prevention and management of musculoskeletal conditions. Lower limb pain. Best Pract Res Clin Rheumatol 2007; 21:135-52. [PMID: 17350549 DOI: 10.1016/j.berh.2006.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
This article summarises lower limb pathology, which results in lower limb pain. It mainly addresses injuries and deliberately omits osteoarthritis and rheumatoid arthritis, since these entities are described in detail in other chapters in this volume. As major trauma is not a focal point for rheumatologists and repetitive strain injuries of the lower limb are rare, sports and leisure injuries are the main focus. Regarding lower limb pain, this chapter describes the most important problems and quantifies the size of the problem. Furthermore, it informs the reader about different treatment modalities, their goals and methods of measuring the effectiveness of the treatment. Evidence is given for different interventions, such as lifestyle, pharmacological, surgery and rehabilitation. In addition, opportunities to apply these interventions for prevention and treatment to those who will potentially benefit most are shown. Finally, strategies (care pathways) are given for prevention and treatment based on this evidence.
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Affiliation(s)
- Karsten E Dreinhöfer
- Department of Orthopaedics, Ulm University, Oberer Eselsberg 45, D-89081 Ulm, Germany.
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