Post-operative pain management: a literature review

Contradições entre o Relato de Dor no Pós-Operatório e a Satisfação do Doente com a Analgesia

Estudos mostram que a dor no pós-operatório é freqüente e inadequadamente controlada. Este trabalho tem por objetivos caracterizar o quadro álgico de doentes oncológicos no pós-operatório, os analgésicos prescritos e a satisfação do doente com a analgesia. O estudo foi realizado em um hospital escola e a população foi constituída por 55 doentes oncológicos, maiores de 19 anos, submetidos a procedimento cirúrgico entre setembro e outubro de 1997. Observou-se que 78,2% dos doentes referiu dor nas primeiras 24 horas do pós-operatório. A média de intensidade de dor foi 5,6. Dor moderada foi referida por 58,3% dos doentes e intensa em 27,1% dos casos. Observou-se predomínio da dimensão afetiva na descrição da dor. Sono/repouso e movimentação no leito foram as atividades mais citadas como prejudicadas pela dor. A prescrição de antinflamatórios não hormonais associada a opiáceos foi a mais freqüente (57%). O regime de administração em horário fixo exclusivo e o regime misto representaram, respectivamente, 45,2% e 42,8% das prescrições. A via endovenosa foi utilizada em 57,8% dos casos, seguida da via intramuscular (25%). A análise comparativa entre os analgésicos prescritos e o recebido mostrou que a média de dose recebida foi de 92% para o regime de horário fixo e de 80% para o “se necessário” exclusivo. A maioria dos doentes (74,4%) mostrou-se satisfeita com a analgesia recebida, o que se contradiz à alta freqüência de dor, à intensidade da queixa álgica e ao prejuízo da dor para o desempenho das atividades de vida diária observados. Talvez o conceito de que a vivência dolorosa no pós-operatório é inevitável tenha influenciado esta apreciação.

The late effect of intraoperative wound infiltration with local anaesthetic in surgical patients; is there any? A randomized control trial

INTRODUCTION

Intraoperative wound infiltration with local anaesthetic is commonly used. Apart from the obvious immediate action it has been supported that a possible down regulation of pain receptors may lead to longer effects. Our aim was to compare the use of local anaesthetic versus placebo in order to assess if indeed there is a late beneficial effect.

METHODS

We conducted an RCT involving 400 consecutive general surgery patients randomized in 2 groups: Group A = placebo, Group B = wound infiltration with 15 ml of ropivacaine 10%. We recorded the preoperative and postoperative pain for the 1st week as well as the type and quantity of the analgesia used during the study period.

RESULTS

No significant difference was found between the groups in all known confounding factors recorded. No significant difference was found in the intensity of postoperative pain. More people of group A required NSAIDs during the first 3 PO days while more people of Group B required stronger painkillers. For those patients who underwent a non urgent operation and especially laparoscopic surgery higher pain score was recorded in the group B from the 3rd PO day onwards.

DISCUSSION

Intraoperative local infiltration of the wound with local anaesthetic offers no further benefit for the general surgery apart from that of the immediate PO period. There is no late effect for pain control. Considering that during the immediate postoperative period stronger systematic painkillers are given the intraoperative, infiltration of the wound with the local anaesthetic under study offers no obvious benefit.

A statistical analysis of pain relief after surgical operations

OBJECTIVES

Administering pain relief measures requires information about development of post-operative pain. Such information can be obtained from studying the patients' perception of pain. The aim of this study is to develop a statistical model that predicts the level of pain in different periods after the operation and the time effects of analgesics. The results can be used for an effective and timely application of pain medications.

METHODS

This paper applies an ordered response model to a sample of 392 observations from 49 patients undergoing orthopedic surgeries. The patients' subjective pain levels have been recorded for several intervals up to 24h after their respective operations. The adopted statistical model accounts for the unobserved heterogeneity among patients through random coefficients. Such heterogeneity could be due to differences in patients' perception of pain as well as their health status and sensitivity.

RESULTS

The analysis indicates that post-operative pain gradually increases over time but with a slightly diminishing rate. The results suggest that analgesics are quite effective in containing the development of pain. However, the analgesic effects manifest gradually, at a rate more or less similar to that of post-operative pain.

CONCLUSION

Highlighting the importance of pain from both clinical and economic perspectives, the analysis indicates that a timely application of analgesics is crucial for an effective pain relief after surgical operations. In particular, the results indicate that the optimal time of administering analgesics is immediately after the operation. The main policy implication of this finding is that preemptive measures of pain relief could be most effective and should be favored to similar analgesic treatments after the manifestation of pain. The results also show that the post-operative pain risks differ significantly across individual cases, which suggests that case-specific clinical assessments supersede any statistical analysis. The proposed statistical model can be used to identify high-risk categories and explore the variations across different analgesic types.

Pain assessment and management relating to an indwelling catheter

This care study describes and critically examines the nursing role in continence care and the management of pain using the Roper et al (2000) model as a framework. Current practice in pain management and care of a patient with an indwelling urinary catheter is evaluated against best practice suggested by recent research evidence. A multidimensional and multidisciplinary team approach was taken to alleviate pain and promote independence in catheter care. Imagination and a positive attitude led to greater patient comfort and dignity. Recommendations for evidence-based practice are made.

Why is pain management suboptimal on surgical wards?

BACKGROUND

During a patient's stay on a surgical ward, nurses hold a great deal of responsibility for pain management, especially when analgesics are prescribed on a PRN ('as needed') basis. Despite the availability of effective analgesics and new technologies for drug administration, studies continue to demonstrate suboptimal pain management.

AIM OF THE STUDY

To identify perceived barriers to effective pain management in nursing practice.

METHODS

The data are drawn from six nurse interviews and a survey of 180 nurses in 14 United Kingdom (UK) hospitals, which built upon detailed observations of nurses on surgical wards.

RESULTS

In a question about possible reasons for suboptimal pain management, nurses identified a number of barriers that concerned organizational aspects such as workload and lack of staff, and also legal or institutional constraints. Nurses further stated that analgesic prescribing was sometimes inadequate, or that doctors or the pain team were unavailable to review medication. Further barriers that nurses may be less aware of were identified in a question concerning nurses' reasons for not asking patients a pain-related question during drug rounds. Previous observations had shown this to be the predominant time for pain questioning. The most commonly mentioned reasons were that patients were asleep, on epidural or patient controlled analgesia (PCA), or had recently had an analgesic. Nurses' replies also revealed that they relied considerably on patients' nonverbal behaviour and used this to assess analgesia requirements. Nurses' views and judgements regarding pain management were further supported in replies to a number of attitude statements and a question about the aim of administering analgesia.

CONCLUSION

The strength of this work is that it identified two types of potential barriers to effective pain management, recognized and more subconscious ones, and both need to be addressed before introducing systems aimed at improving pain management.

Effects of performance feedback on patient pain outcomes

The purpose of this study was to examine the effects of an individual feedback intervention provided to nurses on selected patient outcomes related to postoperative pain management Individual performance feedback served as the intervention. Thirty orthopedic staff nurses received feedback information on their past performance of recommended pain management practices. Data were collected preintervention and postintervention on selected patient pain outcomes from the medical records of 240 patients who had undergone total knee arthroplasty. The patient outcome measures were mean 4-hour pain intensity ratings, mean highest pain intensity ratings, mean number of times pain ratings exceeded patients' acceptable level of pain, mean administered morphine equivalents, and mean pain ratings on reassessment following analgesia administration. An improvement was noted in all pain outcomes following the feedback intervention. Results indicate that providing nurses with feedback on their past performance of pain management practices may contribute to decreased postoperative pain.

Factors influencing nurses' inferences about patient pain

This study examined the factors that influence nurses' perception of patient pain. Sixteen vignettes were constructed on the basis of interviews with nurses about factors affecting their perception of patient pain and previous published literature. Four variables were systematically varied within a factorial design: diagnosis (surgery vs oncology), level of patient mobility, presence or absence of physical and behavioural signs, and patient gender. Twenty-seven nurses rated each vignette for degree of inferred patient pain and degree of patient psychological distress. Mobility and positive signs of pain had statistically significant effects on nurses' judgments of inferred pain (P < 0.001), but diagnosis had no main effect. Significant interactions showed that: inferred pain in male patients was seen to be greater when immobile while mobility had no effect on the inferred pain of female patients (P < 0.003); oncology patients (compared with surgical patients) had greater inferred pain when displaying positive signs (P < 0.024); and positive signs yielded higher ratings where patients were immobile (P < 0.001). Female patients were perceived to experience higher psychological distress than men (P < 0.037) and oncology patients were perceived to experience higher distress than surgical patients (P < 0.005). Ratings of perceived pain and distress were significantly correlated but did not differ in magnitude. Offered a choice of analgesics to relieve pain for each of the patients depicted, nurses typically chose those with the lowest strength.

A tentative model for developing strategic and clinical nursing quality indicators: postoperative pain management

The purpose of the study was to evaluate the usefulness of a tentative model, based on important aspects of surgical nursing care, for designing strategic and clinical quality indicators. Objective postoperative pain management was chosen for the model because it is a priority area in surgical nursing care. Items within a questionnaire were designed by using the tentative model as a base and by means of a literature review. The questionnaire, directed to clinical nurses (n = 233), was compiled to establish the validity and the usefulness of the indicators. Fourteen items were assessed as essential for achieving high quality outcomes in postoperative pain management (11 as realistic to carry out, and 13 as possible for nurses to influence) with mean scores > or = 4 (on a 5-point scale). The conclusion reached was that the tentative model combined with a literature search was found to be effective for designing items that might be useful as strategic and clinical indicators of quality in postoperative pain management.

Accountability and responsibility underpins successful pain management

Does having a registered nurse as a peri-anesthesia nurse make a difference to patient outcomes? Although technicians may have the technical expertise, they lack the versatility and educational preparation of a registered nurse to provide holistic care for the patient at the most crucial periods of peri-anesthesia care. This report addresses the accountability and responsibility of the peri-anesthesia nurse in pain management, highlighting the need for a knowledgeable and competent practitioner so that quality patient care is given and a positive patient outcome is achieved.

AHCPR clinical practice guideline on surgical pain management: adoption and outcomes

Pain management practices and short-term patient outcomes in nine acute care hospitals in Milwaukee, Wisconsin, were studied at two points in time. One-and-a-half years after the Agency for Health Care Policy and Research's (AHCPR) Clinical Practice Guideline on Acute Pain Management was published, data from 330 adult surgical patients were collected (Time I). These data were contrasted with data from 373 adult surgical patients collected 2 years later (Time II). There were significant increases in the percentage of patients who reported being taught how to report pain using a pain rating scale and about setting a pain goal preoperatively; in the percentage of patient hospital records with at least one documented numeric pain rating; and in the percentage of patients who received analgesics by intravenous administration. However, pain management practices continued to differ from recommendations in the AHCPR guideline. No significant improvement was noted in the short-term outcomes of patient-rated pain or patient satisfaction with pain management. Availability of well-published guidelines alone may be insufficient to ensure comprehensive adoption of guidelines that are multidimensional in nature and to obtain improvements in patient outcome.

Thinking of the future and walking back to normal: an exploratory study of patients' experiences during recovery from lower limb fracture

Admission to hospital following a traumatic lower limb fracture is undoubtedly a stressful life event; however, few studies have detailed this from the patient's perspective. By exploring patients' experiences of hospitalization with lower limb trauma, this study aimed to explicate some of the factors impinging on the recovery trajectory. Patients' perceptions of the events influencing their strategies for coping with stress, hospitalization and temporary incapacity were investigated using a qualitative methodology. A convenience sample of nine patients was recruited from an orthopaedic ward in a district general hospital in Wales. The respondents used health diaries to document their recovery for up to 6 weeks after emergency surgery. These diaries were validated and supplemented by semi-structured interviews. Following their traumatic injuries, our respondents were subjected to a variety of stressors and uncertainties. They coped with this period of uncertainty by positive attempts to gain control over their situations, guided by an over-riding desire to 'return to normal' and assisted by the caring attributes of their nurses. From the experiences and events documented, this study was able to identify several stressors which could have been mitigated by optimization of the technical aspects of care, including the management of pain.

Introduction of the use of structured pain assessment for post-operative patients in Kenya: implementing change using a research-based co-operative approach

A research-based project was conducted to introduce structured pain assessment on a surgical ward at a general hospital in Kenya, East Africa. The aim was to improve pain control, and subsequently patients' recovery and satisfaction with care. It was agreed that the ultimate aim was to develop and use a common tool for pain assessment throughout the hospital, thereby reducing disparity in various clinical areas, and raising standards of patient care. The project was seen as a pilot, and planned introduction of the pain assessment took place over 1 month. This paper describes the findings in relation to the patient sample, and perceptions of nurses taking part. It also contains reflections about action research, and how it may enter the scene as a way of understanding the whole picture retrospectively.