Current interventions and approaches to postoperative pain management

Intrathecal Morphine for Cardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

ABSTRACT

Cardiac surgeries often result in significant postoperative pain, leading to considerable use of opioids for pain management. However, excessive opioid use can lead to undesirable side effects and chronic opioid use. This systematic review and meta-analysis aimed to evaluate whether preoperative intrathecal morphine could reduce postoperative opioid consumption in patients undergoing cardiac surgery requiring sternotomy. We conducted a systematic search of Cochrane, EMBASE, and MEDLINE databases from inception to May 2022 for randomized controlled trials that evaluated the use of intrathecal morphine in patients undergoing cardiac surgery. Studies that evaluated intrathecal administration of other opioids or combinations of medications were excluded. The primary outcome was postoperative morphine consumption at 24 h. Secondary outcomes included time to extubation and hospital length of stay. The final analysis included ten randomized controlled trials, with a total of 402 patients. The results showed that postoperative morphine consumption at 24 h was significantly lower in the intervention group (standardized mean difference -1.43 [-2.12, -0.74], 95% CI, P < 0.0001). There were no significant differences in time to extubation and hospital length of stay. Our meta-analysis concluded that preoperative intrathecal morphine is associated with lower postoperative morphine consumption at 24 h following cardiac surgeries, without prolonging the time to extubation. The use of preoperative intrathecal morphine can be considered part of a multimodal analgesic and opioid-sparing strategy in patients undergoing cardiac surgery.

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

BACKGROUND

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

METHODS

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

RESULT

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

Assessment and Management of Postoperative Pain among Nurses at a Resource-Constraint Teaching Hospital in Ghana

Background

Postoperative pain remains one of the greatest concerns for patients following surgical procedures. Nurses play an essential role in postoperative pain assessment and management, especially within the first few days after surgery.

Objective

The study investigated how nurses in a resource-constraint hospital in Ghana assessed and managed postoperative pain.

Methods

This was an explorative qualitative study involving 12 registered nurses practising in the largest referral hospital in Ghana. Data was gathered using a semistructured interview guide. Demographic characteristics of participants were summarized using descriptive statistics. Data were analysed using Kvale's three phases for analysing qualitative data. First, the entire text was read again to identify meaning units which were then condensed. Second, the condensed texts were read again and interpreted. Finally, the condensed data containing similar meaning were coded and then sorted into subthemes.

Results

It was found that some nurses have never used any pain assessment tool due to lack of standard tool for assessing postoperative pain. The majority of nurses reported that managing pain by using medication was the norm especially in the first 24 hours after surgery.

Conclusion

Although participants may have some knowledge of assessing and managing postoperative pain, this knowledge was not largely used to manage postoperative pain effectively, partly because of resource constraints. Therefore, there is the need for adequate training and with provision of resources, it is imperative that the use of standardized pain assessment scales could help in the proper assessment and management of postoperative pain in this setting.

A comparative study of efficacy and safety of flupirtine versus piroxicam in postoperative pain in patients undergoing lower limb surgery

Background

Effective control of pain postoperatively is essential in providing enhanced patient care and a cost-effective hospital stay. Though many treatment modalities exist for postoperative pain management in orthopedic surgeries they are often accompanied by adverse effects. This study was carried out to assess the efficacy of flupirtine and piroxicam in postoperative pain reduction using visual analog scale (VAS) score.

Materials and methods

An open-label, parallel group, comparative study was conducted on patients undergoing lower limb orthopedic surgery, randomized into two groups of 38 patients each. They received either flupirtine 100 mg or piroxicam 20 mg 6 hours after surgery and then twice daily orally for 5 days. Pain was measured using VAS score, total pain relief score (TOTPAR₂₄), and patient satisfaction score (PSS); the other scales used were behavioral pain assessment scale (BPAS) and functional activity score (FAS). Rescue medication used was tramadol 100 mg intravenously. WHO causality scale was used for assessing adverse effects. Descriptive and inferential statistics were used for assessment of various parameters.

Results

A total of 76 patients with mean ± standard deviation age of 35.08±10.3 years were recruited; 34 in the flupirtine and 37 in the piroxicam groups completed the study. Patients in both groups were comparable in baseline characteristics. Flupirtine and piroxicam reduced VAS score 48 hours postoperatively compared to baseline (p=0.006 and 0.001) and piroxicam produced significant reduction in pain at 8, 12, and 120 hours compared to flupirtine (p=0.028, 0.032, 0.021). TOTPAR₂₄ and PSS at 24 hours were comparable between the treatments. BPAS scores at 24 hours were reduced significantly in patients receiving either drug (p=0.001). FAS improved at 72 hours in patients receiving piroxicam. Adverse effects were similar with both the medications.

Conclusion

Flupirtine and piroxicam reduced pain effectively but the onset of pain relief was earlier with piroxicam.

Comparison of Efficacy and Safety of Intramuscular Piroxicam and Tramadol for Post-operative Pain in Patients Undergoing Caesarean Delivery

INTRODUCTION

Post-caesarean section pain can be both stressful and unfavourable. Effective and rapid reduction of pain facilitates early ambulation and care of the new born. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and opioids are used for pain relief but they are associated with adverse effects both in the mother and the child.

AIM

To evaluate efficacy and safety of piroxicam and tramadol in post-caesarean section pain.

MATERIALS AND METHODS

Primigravidae who underwent elective caesarean section received either piroxicam 20mg or tramadol 100mg intra-muscularly, following recovery from anaesthesia. Severity of pain was assessed using Visual Analogue Scale (VAS) and side-effects to study drugs were noted. Rescue analgesic butorphanol 2mg was administered if VAS score was more than four. Patient's satisfaction score was assessed at 12 hours post-operatively.

RESULTS

Mean age in piroxicam and tramadol groups were 23.32±3.43 and 22.03±2.0 years respectively. Significant reduction in pain was observed at 2, 4, 8, 12 and 24 hours in both groups (p<0.001). Pain relief was significant at 2, 4 and 8 hours in piroxicam group compared to tramadol. Twenty-one and 12 patients in tramadol and piroxicam groups received rescue analgesic respectively. Sedation and nausea was significantly higher in tramadol group (p<0.001), 46.66% of patients graded their satisfaction score as good and 15% as excellent in piroxicam group.

CONCLUSION

Intra-muscular piroxicam was effective in reducing post-caesarean section pain for 24 hours with minimal side-effects compared to tramadol.

What are the risks and knowledge deficits for prescribing and administering opioids in the ward environment? A quality project on assessing and improving knowledge

Investigations into Medical Emergency Team (MET) calls and related clinical incident reviews at a large district teaching hospital provided evidence that over sedation can be a significant issue post opioid administration and that safe and effective pain management requires accurate opioid knowledge and patient assessment skills. The aim of the study was to develop education that was directed at identified knowledge deficits, and to evaluate the impact of this tailored education program on knowledge of safe prescribing and administration of opioids. Knowledge levels were explored using a structured questionnaire in a pre and post-test design. A convenience sample of 34 nurses and 5 junior medical officers across three surgical wards in a tertiary referral hospital had their knowledge assessed. Results showed significant improvement when repeat questionnaires were given two weeks post-delivery of education. Mean scores were 68% at baseline and 89% two weeks post completion of the education program. The greatest improvement in scores was recorded for drug knowledge including dose, half-life and administration. The findings from this study suggest that the opioid education program is effective in improving the knowledge of safe prescribing and administration of opioids, however further studies are required.

The pain experience of inpatients in a teaching hospital: revisiting a strategic priority

For hospital executives and clinicians to improve pain management, organizations must examine the current pain experience of in-patients beyond simply measuring patient satisfaction. The aim of this study was to quantify the prevalence of pain among adult in-patients and the degree of interference pain had on daily activities. A descriptive, cross-sectional study was undertaken in a 530 bed tertiary care, teaching hospital in central Canada. A convenience sample (N = 88) of adult medical-surgical patients completed the Short Form-Brief Pain Inventory survey. Pain prevalence was 70.4%. The mean pain severity score was 3.76 (standard deviation, SD = 2.88) and mean pain interference score on daily activities was 4.56 (SD = 3.93). The most frequently identified site of pain was the lower extremities (n = 15, 28%). Women had higher mean scores on pain "right now" compared to men (p < 0.05). The sample majority (n = 81) indicated hospital staff asked about the presence of pain. Seventy-nine percent (n = 57) reported hospital staff "always" did everything they could to help manage pain. Eighty-four percent (n = 61) selected "always" or "usually" to describe their ability to be involved in deciding pain treatments. The mean pain relief score from treatments was 61% (SD = 34.79). Significant positive correlations were found between pain intensity ratings and pain interference on all daily activities (p < 0.001). Pain prevalence remains high with a significant relationship between pain and activities of daily living. The study provides baseline data to direct future initiatives at improving pain management.

Pain management after cardiac surgery

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