The Management of Post Operative Pain - Assignment Example

EVIDENCE BASED PRACTICE CRITICAL ANALYSIS IS PATIENT CONTROLLED ANALGESIA MORE EFFECTIVE IN THE MANAGEMENT OF POSTOPERATIVE PAIN RATHER THAN CONVENTIONAL INTRAMUSCULAR INJECTION IN POST OPERATIVE ADULT INTRODUCTION The International Association for the study of pain defines pain as "an unpleasant sensory and emotional experience associated with actual and potential tissue damage or described in terms of such damage, or both"(Cole, 2002). The degree of post operative pain depends on the site of the surgery. Surgery on the thorax and upper abdominal regions are usually more painful and complicated than the lower abdominal regions. Pain causes an increase in the heart rate, cardiac work and oxygen consumption. Chronic pain reduces physical activity and leads to venous stasis and an increased risk of deep vein thrombosis and consequent pulmonary embolism, urinary tract motility that may lead, in turn, to postoperative ileus, nausea, vomiting and urinary retention. These problems are unpleasant for the patient and may prolong hospital stay. The standard method of treating postoperative pain is the use of intramuscular opioid (usually morphine). Recently, Patient-controlled analgesia (PCA) has often been shown to be better than the intermittent delivery of intramuscular opioids. Patient-controlled analgesia is a process where the patients can determine the pain relief process. It is an evidence based medical practice that works by providing a safe framework in which medical professionals and patients can make tough decisions by safe guarding their concerns by a fair and scientifically sound process together. THE LITERATURE REVIEW A review of literature gives us insight on the need for evidence-based practice in pain management. A recent research to compare outcomes during conventional analgesia in the form of intramuscular dosing and patient-controlled analgesia (PCA) in postoperative patients by analyzing data from published comparative trials the meta-analyses of 15 randomized control trials with seven hundred eighty-seven adult patients aged between 16 to 65 undergoing various operative procedures gave the following results. Data on analgesic efficacy, analgesic use, patient satisfaction, length of hospital stay, and side effects were recorded. Meta-analyses of the data showed greater analgesic efficacy when PCA was used, with a mean additional benefit of 5.6 on a scale of 0 to 100 and a 42% difference in the proportion of patients expressing satisfaction over PCA.No significant differences were observed in the occurrence of any side effect. This leads us to the conclusion that Patient preference strongly favors PCA over conventional analgesia with better pain relief than those using conventional analgesia, without an increase in side effects (Ballantyne JC, et.al, 1993). In a double-blinded, randomized controlled trial Mark Reeves et.al have tested if the addition of ketamine to morphine for patient-controlled analgesia (PCA) resulted in improved analgesic efficacy and lower pain scores compared with morphine PCA alone after a major abdominal surgery. In the study seventy-one patients were allocated to receive morphine 1 mg/mL or morphine 1 mg/mL plus ketamine 1 mg/mL delivered via PCA after surgery. No other analgesics or regional blocks were permitted during the 48-h study period. Study results proved that small-dose ketamine combined with PCA morphine provides no benefit to patients undergoing major abdominal surgery. This study shows the efficiency of morphine in PCA and the increased side effects of. Ketamine. (Mark Reeves et.al, 2001). Patient-controlled analgesia (PCA) with intravenous morphine and patient-controlled epidural analgesia (PCEA), using an opioid either alone or in combination with a local anesthetic, have been two major advances in the management of pain after a major surgery. Since these techniques have not been evaluated in elderly people, a prospective, randomized study was done to compare the effectiveness on postoperative pain and safety of PCEA and PCA after major abdominal surgery in the elderly patient. The study was conducted with seventy patients older than 70 yr of age undergoing a major abdominal surgery and were assigned randomly to receive either combined epidural analgesia and general anesthesia followed by postoperative PCEA, using a mixture of 0.125% bupivacaine and sufentanil (PCEA group), or general anesthesia followed by PCA with intravenous morphine (PCA group). Pain intensity was tested using a visual analog scale. The study showed that patient-controlled analgesia, regardless of the route (epidural or parenteral), is effective after a major abdominal surgery in the elderly patient (Mann et.al, 2000). Postoperative use of intramuscular narcotics has been found to be potentially hazardous in frail elderly patients. Patient-controlled analgesia (PCA), on the other hand, allows patients to self-administer small doses of narcotic, allowing better dose titration, enhanced responsiveness to variability in narcotic requirements, and reduction in serum narcotic level fluctuation (Egbert et.al, 1990). A prospective controlled trial was carried out with 83 higher-risk elderly men after major elective surgery to assess PCA containing morphine sulfate with intramuscular morphine injections as needed .The patient case history included a variety of medical illnesses, chronic lung disease, coronary artery disease, heart failure, and liver disease. Preoperative and postoperative assessments included chest roentgenograms; daily mental status and pulmonary function testing; twice-daily serum morphine levels; and oxygen saturation values, linear analogue pain and sedation scores, and vital signs every 2 hours. Care was taken to optimize narcotic administration in control subjects as well as PCA subjects. The study found that Analgesia was significantly improved by PCA without an increase in sedation and Patient-controlled analgesia was adapted by most patients with no major problems referable to its use. Patients who had previously received intramuscular injections reported that PCA was easier to use and provided better analgesia (Egbert et.al, 1990). With Serum morphine levels showing significantly less variability on postoperative day 1 with PCA, compared with intramuscular injections, it can be concluded that PCA is an improved method of postoperative analgesia in high-risk elderly men with normal mental status, compared with as-needed intramuscular injections. But in a study by Singelyn et.al, the influence of three analgesic techniques on postoperative knee rehabilitation after total knee arthroplasty (TKA) were assessed. In this research study, forty-five patients scheduled for elective TKA under general anesthesia were randomly divided into three groups. For Group A patients Postoperative analgesia was provided with i.v. Patient-controlled analgesia (PCA) with morphine, For Group B continuous 3-in-1 block was given and epidural analgesia for Group C patients. For all the three groups, Pain scores, supplemental analgesia, side effects, degree of maximal knee flexion, day of first walk, and duration of hospital stay were recorded. Patients in Groups B and C in the study reported significantly lower pain scores than those in Group A. This study shows that, after TKA, continuous 3- in-1 block and epidural analgesia provide better pain relief and faster knee rehabilitation than i.v. PCA with morphine (FJ Singelyn, 1992). Thus, there is need for an Evidence based practice approach towards pain management in postoperative patients. STRATEGY FOR CHANGE Patient-controlled analgesia is a process where the patients can determine the pain relief process. This forms the basis of the pain management today and depends largely on individual clinical expertise, the proficiency and judgment that nurses acquire through clinical experience and practice. External clinical expertise is the relevant patient centered clinical research nurses acquire from the science of medicine. This includes the accuracy and precision of diagnostic tests, prognostic markers, and therapeutic, rehabilitative and preventive regimens. External expertise sometimes replaces previously accepted treatments by virtue of accuracy and safety. Nursing care should take patient's perspective also into account. Hence, nurse care should involve a big process of question building and this process of question building should take into account Clinical findings, Aeotiology, Diagnosis, Prognosis, Therapy and Prevention of diseases. This question building process will thus give the idea on the most important question, the question which is encountered very often in practice and the question's relevance very often in practice and the question's relevance to the patient situation. Thus, Nurse care should be based on a framework that facilitates complex decisions across different and sometimes conflicting groups. It involves considering research and other forms of data on a routine basis when making health care decisions. Such decisions include choice of treatment, tests or risk management for individual patients, as well as policy decisions for large groups and populations (Baum, 2003). In such a process, unlike the past, pain assessment is vital before the start of the treatment for pain. Pain assessment aids the identification of the problems, overall understanding of the etiology, location, severity, frequency and duration of the pain. Pain assessment also helps to understand the associated debility, factors that enhances or relieves pain and the mode of treatment. Pain assessment is also useful to adjust the drug dosage and detect the possible side effects. For instance, the Opioid Therapy Documentation Kit, created by pain authority Elizabeth J. Narcessian provides tools to help nurses evaluate and select patients appropriate for opioid therapy for pain. (www.partnersagainstpain.com). The Kit includes forms to take a general medical history, to record an initial pain assessment, and to allow patients to perform ongoing assessment. The first step towards pain assessment using tools like 'The Opioid Therapy Documentation kit' should be the documentation of patient selection and evaluation report, which records the patient's past medical or surgical history and is very useful in tracing the etiology of the pain. The report should further document the symptoms, medical allergies and side effects. The report should contain also documents of substance abuse if any and patient behaviour patterns. The initial pain assessment should be done on pain history with the following questionnaire; 1.When and how did your pain problem start 2. As far as you know, what is the cause of your pain 3. What doctors have you seen, when did you see them, what did they do 4.What tests and studies have been done The next step involves probing the pain locations and the previous treatments. Pain location can be done by diagrammatic mode. The patient is shown four diagrammatic representations depicting human morphology and asked to shade the pain location /locations on the diagrams. Areas of severe pain are marked X. Evaluation of the previous treatments is done by using a series of numerical pain scales in which the numbers corresponding to the pain relief starting from 'no relief' to 'complete relief' is circled and marked for each of the treatment received. The patient is asked to mark the treatment mode if he is still receiving the treatment. This includes the history of pain medications and physiotherapy. This gives a clear idea on previous treatments and their effectiveness. The next step involves the description of the pain; details on the pain intensity and patterns; aggravating and relieving factors. Description provides clues on pain etiology. Pain intensity and patterns substantiates drug regimen and the pain aggravating or relieving factors helps the treatment plan. To describe the pain, the patient is asked to describe the body sites where he experiences the pain and circle the words provided that best describe his pain such as aching, throbbing, stabbing, gnawing, intermittent, sharp, tender, burning, exhausting, tiring, continuous, penetrating, nagging, numb miserable, unbearable, shooting etc. The patient is also asked to indicate the intensity of the pain and factors like walking, standing or medications that increased or relieved the pain over a period of time. The patient is also asked to indicate his pain condition from "no pain" to "worst pain imaginable" from the time of interview towards the past on the clauses of 'right now', 'on average during the last month', 'least during the last month' and 'worst during the last month' on a 0 -10 numeric pain intensity scale with 0 indicating 'no pain' and 10 indicating 'worst imaginable pain'. The effect of pain on the physical and psychosocial functions is then evaluated using the 0-10 numerical scale. The patient is asked to choose the number that suits his condition best. The activities evaluated includes the effect of pain on patient's activity, mood, walking ability, normal work, personal relations, sleep, appetite, enjoyment of life, concentration ability etc. The lower end of the scale value indicates no interference and the higher end value indicates complete interference of the pain in activity. The patient is also evaluated for the level of pain with which he can carry on his socio psychological functions on the 0-10 numerical function scale, with the value 0 indicating no pain and value 10 representing unimaginable pain. The next step in pain assessment involves the recording of 'Pain diary', which helps to assess how well the pain therapy is working with the patient. The pain level is recorded thrice a day from morning, midday through night on a weekly basis. This record also clearly indicates the effect of pain on daily activities. The Pain Diary also has a 0-10 numerical pain intensity scale with 0 indicating 'no pain' and 10 indicating 'worst imaginable pain'. The diary records the current regimen, rescue doses needed and dosage adjustments. The side effects if any is also recorded with the remedial steps taken. This is followed by the physical and psychosocial functions on weekly basis. The physical and psychosocial evaluation includes general activity, mood, walking ability; work routine, personal relations, sleep, enjoyment, concentration ability and appetite. This is done on the same 0-10 numerical pain intensity scale with 0 indicating no interference and 10 indicating complete interference. Pain management is dynamic and pain medications need to be altered accordingly. There is a need for such pain assessment training for nurses at the curriculum level. CONCLUSION Patient controlled analgesia is an effective method for pain management as evidenced by the research studies. It has been proved more effective and patient centered than other practice methods in pain control. 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