Literature review and evaluation of the evidence - Essay Example

Literature review and evaluation of the evidence A well designed before-after study with a concurrent control group performed by Rose (1997) revealed that anesthesiologists' practice of pain management can be improved through education and feedback. The study was carried out in tertiary-care teaching institutions affiliated with the University of Toronto, each fully staffed by board-certified anesthesiologists. The study found significant increase in anesthesiologists' use of any preventive strategy in the study hospital whereas at the control hospital, there was a smaller but significant increase in anesthesiologists' use of any preventive measure. With the patient as the "unit of analysis," comparing the feedback-2 period with baseline, the proportion of patients who received any promoted strategy increased from 0.7% to 45.6% (P < 0.01) at the study hospital and from 8.5% to 31.3% at the control hospital (P < 0.01). This absolute increase at the study hospital was greater than at the control hospital (44.9% vs 22.8%, P < 0.0001). However, the study had several limitations. Rigid patient protocols, practice guidelines, and economic incentives were avoided in the study and allowed the anesthesiologists to choose the promoted strategies based only on the educational and feedback interventions. The avoidance of these additional approaches may have limited the ability to affect changes in practice and outcome. Pouzeratte et al (2001) reported that thoracic epidural analgesia was more effective with bupivacaine than with ropivacaine when these two local anesthetics are used in a mixture with sufentanil after major abdominal surgery and ropivacaine alone was less effective than ropivacaine in combination with sufentanil. Intensity of post-operative pain was assessed with a reliable and valid Visual Analogue Scale. The study was planned well with a prospective double blind design. In order to assess the tolerability and efficacy of a single dose of paracetamol solution infused intravenously (1g) compared with those of a single dose of Propacetamol (2g) in patients with moderate to severe pain after minor gynecologic surgery, a randomized, double blind, active controlled, 2-parallel group study was performed by Marty et al (2005). The study concluded that a single dose of IV-Paracetamol infusion was associated with better local tolerability, simlar analgesic efficacy, and greater patient satisfaction compared with a single bioequivalent dose of Propacetamol in patients with moderate to severe pain after minor gynecologic surgery. Charghi et al (2003) examined the hypothesis that pain treatment with patient controlled analgesia (PCA) using iv morphine is a suitable and safe alternative to epidural analgesia in morbidly obese patients undergoing gastric bypass surgery. They concluded that PCA with iv morphine is an acceptable strategy for pain management in obese patients undergoing gastric bypass surgery. Mujadi (2006) in a prospective, randomized, double-blind clinical trial reported that preoperative gabapentin decreased pain scores and postoperative morphine consumption in patients following thyroid surgery. Reuben (2000) evaluated the analgesic efficacy of administering a single preoperative dose of celecoxib or rofecoxib for spinal fusion surgery. The study found that rofecoxib demonstrated an extended analgesic effect that lasted throughout the 24-h study. The morphine dose required was significantly less in five of the six time intervals in the rofecoxib group compared with the celecoxib group. Rockeymann (1997)compared the costs, quality of analgesia, and side effects of postoperative patient-controlled epidural analgesia (PCEA) with bupivacaine/ sufentanil versus an epidural bolus (BOLUS) of clonidine/morphine in 68 patients with pancreatic surgery. An epidural clonidine/ morphine bolus technique resulted in inferior analgesia, more side effects, and comparable costs compared with a bupivacaine / sufentanil patient controlled regimen. Broekema (1998) assessed the efficacy and side effects of postoperative analgesia with three different pain regimens in 90 patients undergoing major abdominal surgery. Postoperative analgesia with epidural sufentanil or morphine and bupivacaine after major abdominal surgery seemed to be better than the conventional method of IM morphine treatment, despite optimal administration, i.e., fixed doses at fixed intervals with regular adjustments and analgesic efficacy and side effects of epidural sufentanil and morphine were similar. Angle (2002) in a randomized controlled trial examining the effect of naproxen on analgesia during the second day after cesarean delivery reported that the addition of regular doses of naproxen to conventional oral pain therapy after cesarean delivery leads to reductions in incision pain on sitting at 36 h and pain over day 2 but did not reduce the incidence of inadequate analgesia. Sarvela (2002) reported that after cesarean delivery in women who are receiving ketoprofen, although rescue analgesics may be required, IT morphine 100mcg is superior for post-operative analgesia. Worksheet to Critique Quality of Evidence using Rosswurm's Method Rose, DK., Marsha, MC., and Doreen AY. (1997). Changing the Practice of Pain Management. Anesth Analg. 84,764-72. Purpose/Research Questions/Hypotheses Research Variables Design Major Findings and Limitations Purpose of Study: The primary objective of this study was to change anesthesiologists' practice of pain management by introducing directed interventions based on the principles of academic detailing combined with personalized feedback profiles. Secondary objectives were to determine whether there was any effect on the rate of early postoperative pain (either in the postanesthesia care unit [PACU] or within the first six-hour interval after PACU ischarge) or on other indicators of morbidity (postoperative respiratory problems) and resource use (length of PACU and hospital stay). Research Questions/Hypotheses: Anesthetic strategies which reduce postoperative pain, if routinely used, could enhance overall patient care. Independent: Hospital and a specific time period. Dependent: Use of PCA, NSAIDs, EPIMORPHs and regional nerve blocks initiated by anesthesiologists (either preoperatively, intraoperatively or as preventive strategy in PACU, Patients' experience of pain during the first 6 h after PACU discharge, drugs and doses used in this early postoperative interval and any additional patient problems. Level 1: Exploratory or Descriptive (A before-after study design with a concurrent control group) Findings:1. At the study hospital over the 2-yr study period, there was a significant increase in anesthesiologists' use of any preventive strategy whereas at the control hospital, there was a smaller but significant increase in anesthesiologists' use of any preventive measure. 2. With the patient as the "unit of analysis," comparing the feedback-2 period with baseline, the proportion of patients who received any promoted strategy increased from 0.7% to 45.6% (P < 0.01) at the study hospital and from 8.5% to 31.3% at the control hospital (P < 0.01). This absolute increase at the study hospital was greater than at the control hospital (44.9% vs 22.8%, P < 0.0001). 3. At the study hospital increases were found in the percentage of each anesthesiologists' patients (mean value) who received PCA during all time periods compared with baseline and a further increase compared with the education period (P < 0.01) (Figure 2). In contrast, at the control hospital anesthesiologists' use of PCA was increased only in the feedback-2 period. 4. Anesthesiologists' use of NSAIDs also increased at the study hospital, specifically compared to the baseline period ;there was no increase at the control hospital. The use of any strategy as well as PCA and NSAIDs by anesthesiologists was maintained at the study hospital for the follow-up period. 5. From the baseline to the feedback period, the absolute increase in the proportion of patients receiving at least one promoted strategy was greater at the study hospital than at the control hospital (44.9% vs 22.8% P < 0.0001). 6.Mean pain scores with activity decreased at both hospitals; study hospital 7.6 (7.3-7.B1 99% confidence interval) to 6.2 (5.9-6.5); control hospital 7.3 (6.9-7.6) to 6.1 (5.7-6.4). 7. The modest change in patient outcome was unlikely related to directed interventions. Limitations: The study avoided rigid patient protocols, practice guidelines, and economic incentives and allowed the anesthesiologists to choose the promoted strategies based only on the educational and feedback interventions. The avoidance of these additional approaches may have limited the ability to affect changes in practice and outcome. There were limitations to the study related to the directed interventions. Perhaps if more opinion leaders had been designated, the daily promotion of the strategies could have been even more successful. Several anesthesiologists questioned the strategies promoted during the educational period. They were reluctant to use new strategies when the efficacies were not fully documented and there was a potential for increased patient risk. Several anesthesiologists did not attend the educational seminars due to scheduling conflicts and holidays. The increased costs (capital and operating) required for the promoted interventions were not computed. Similarly, the determination of costs for nursing and patient education was not a part of the study protocol. Sample Setting Major Tools Quality of Evidence Number: 3413 patients at the study hospital and 1753 at the control hospital. An equal number of anesthesiologists were involved in critical care, 25% at the study hospital and 20% at the control hospital. Type: operating theaters Age: The age groups of anesthesiologists were distributed as follows: 16% were less than 40 yr and 13% older than 60 yr at the study hospital compared to the control hospital where 45% were less than 40 yr, and 10% older than 60 yr. An equal number of anesthesiologists were involved in critical care, 25% at the study hospital and 20% at the control hospital. At the study hospital,68% of the patients were more than 40 yr old, Gender: At the study hospital 67% of patients were female Data were not presented in case of control hospital. Health Status: 40% had gynecological procedures, 32% orthopedic procedures, and 22% open abdominal procedures. Diagnosis: gynecological, joint replacement or repair, limb amputation, and invasive renal and abdominal procedures requiring laparotomy Type: Tertiary-care teaching institutions affiliated with the University of Toronto, each fully staffed by board-certified anesthesiologists. Location: University of Toronto Urban Name(s): 1# assessment of postoperative pain using the Visual Analogue Scale. Reliability: #1_Reliable______________________ Validity: #1___Valid____________________ Evidence Rating: II. a. One well-designed controlled study without randomization (before-after study design with a concurrent control group) Feasibility: Could this practice change be implemented easily in your organization and with minimal resources Yes Benefit/Risk: Would the benefits of this practice change/outweigh the risk to patients Yes Rosswurm, M & Larabee, J. (1999). A model for change to evidence-based practice. Image: Journal of Nursing Scholarship, 31(4), 317-322. Worksheet to Critique Quality of Evidence using Rosswurm's Method Pouzeratte, Y., Jean, M., Georges, B., Gilles, B., Christine, V., Samir, J., Jean, M. F., Pascal, C., and Claude, M. (2001), Patient-Controlled Epidural Analgesia After Abdominal Surgery: Ropivacaine Versus Bupivacaine. Anesth Analg, 93, 1587-92. Purpose/Research Questions/Hypotheses Research Variables Design Major Findings and Limitations Purpose of Study: To assess the analgesic efficacy of ropivacaine and bupivacaine in combination with sufentanil and the efficacy of ropivacaine alone after major abdominal surgery. Research Questions/Hypotheses: Not stated in the study Independent: Hospital. Dependent: Local anesthetic consumption, Intensity of postoperative pain, VAS scores on coughing, Time of the first flatus, the first feces and oral nutrition without discomfort and the duration of PCEA (Patient -Controlled epidural analgesia). Level 1: Exploratory or Descriptive (prospective double-blinded study) Findings: VAS scores on coughing were significantly greater in the R and RS groups compared with the BS group (P _ 0.001 and P_ 0.01, respectively) (B _ bupivacaine; S _ sufentanil; R _ ropivacaine). Local anesthetic consumption (milligrams per day) was less in the BS than in the RS and R groups (P _ 0.0003 and P _ 0.0003, respectively) and was less in the RS than in the R group (P _ 0.03) during the first three postoperative days. Patients required more administration of propacetamol in the R group than in the RS and BS groups during the first two postoperative days (P _ 0.04). After major abdominal surgery, thoracic epidural analgesia was more effective with bupivacaine than with ropivacaine when these two local anesthetics are used in a mixture with sufentanil. Ropivacaine alone was less effective than ropivacaine in combination with sufentanil. Limitations: There was no prospective recovery program or discharge criteria in the institution, and 2) the power analysis of the study was performed with postoperative pain as the primary variable, meaning that the authors could not reach a conclusion on the incidence of side effects or rate of recovery. Sample Setting Major Tools Quality of Evidence Number: Total number = 60. 20 no. in group Type: 18 to 70 yr, ASA status I or II, elective major abdominal surgery for cancer via midline or bisubcostal incision, absence of contraindication to epidural anesthesia (e.g., preoperative coagulopathy or localized infection), and absence of extreme malnutrition or cerebral vascular insufficiency. Age: 55 12 , 54 11 and 57 10 yrs. for the BS group, RS group and R group respectively. (B _ bupivacaine; S _ sufentanil; R _ ropivacaine). Gender: 9F/11M 8F/12M 11F/9M in the BS group, RS group and R group respectively. Health Status: elective major abdominal surgery for cancer Diagnosis: cancer Type: not mentioned Location: Montpellier Hospital, France. Name(s):1. To quantify the intensity of postoperative pain 100-mm VAS Reliability:Relaible Validity: Valid 2. Sedation scale Relaibility: Reliable Validity: Valid 3. Motor blockade was evaluated in terms of a modified four-grade Bromage scale. Reliability: Reliable Validity: Valid Evidence Rating: III. Comparative, correlational, and other descriptive studies Feasibility: Could this practice change be implemented easily in your organization and with minimal resources Yes Benefit/Risk: Would the benefits of this practice change/outweigh the risk to patients Yes Rosswurm, M & Larabee, J. (1999). A model for change to evidence-based practice. Image: Journal of Nursing Scholarship, 31(4), 317-322. Worksheet to Critique Quality of Evidence using Rosswurm's Method Marty, J., Dan, B., Dominique, C., Nicole, E., Alain, R., Annick, M., Dominique, H., Xavior, B., and Odile, H.P. ( 2005). Effects of single dose injectable paracetamol versus Propacetamol in pain management after Minor gynecologic surgery: A multicentre, randomized, double-blind, active-controlled Two-parallel group study.Current TherapeuticRresearch,66( 4), 294-306. Purpose/Research Questions/Hypotheses Research Variables Design Major Findings and Limitations Purpose of Study:To assess the tolerability and efficacy of a single dose of paracetamol solution infused intravenously(1g) compared with those of a single dose of Propacetamol (2g) in patients with moderate to severe pain after minor gynecologic surgery. Research Questions/Hypotheses: A stable, ready-to-use formulation of paracetamol solution infused intravenously might be associated with less pain at the injection site compared with Propacetamol. Independent: Hospitals and clinics. Dependent: Adverse events, Pain intensity at 0, 1, 2, 4 and 6 hours, median time to rescue medication, patients' rating of acceptability of infusion, and patients' satisfaction with the study drugs Level 1: Exploratory or Descriptive (Randomized, double blind, active controlled, 2-parallel group study) Findings: The incidence of local treatment -emergent AEs was significantly lower in the IV-APAP group compared with that in the ProAPAP group. The percentage of patients in the IV-APAP and pro-APAP groups who rated the study medication as good or excellent on the Patient's Global Evaluation scale and who were willing to receive the same treatment again were significantly higher with IV-APAP compared with Pro-APAP. Limitations:No study limitations are mentioned. Sample Setting Major Tools Quality of Evidence Number: Total : 161 patients. IV-APAP group comprised of 80 patients and Pro-APAP group comprised of 81patients. Type: Hysteroscopy, elective abortion, ceileoscopy, curettage, Conization, aspiration, Hysterectomy, laser treatment for condyloma, Age: 38.3 12.8 in IV-APAP group (range 18-69 yrs) 33.9 12.0 ( range 18-67 yrs) in Pro-APAP group. Gender: All female patients (n=161). Health Status: Patients scheduled for elective minor gynecologic surgery Diagnosis: not mentioned in the study Type: Not mentioned in the study Location:23 hospitals and out patient clinics in France Name(s): #1-100 mm visual analogue scale_to rate pain intensity #2-Patient's global evaluation Scale to assess patients' satisfaction. Reliability: #1-Reliable #2-Reliable Validity: #1__Valid #2__Valid. Evidence Rating: I. b. One randomized controlled trial Feasibility: Could this practice change be implemented easily in your organization and with minimal resources Yes Benefit/Risk: Would the benefits of this practice change/outweigh the risk to patients Yes Rosswurm, M & Larabee, J. (1999). A model for change to evidence-based practice. Image: Journal of Nursing Scholarship, 31(4), 317-322. Worksheet to Critique Quality of Evidence using Rosswurm's Method Charghi, R., Steven, B., Nicolas, C., Fabrice, R., & Thomas, S. (2003). Patient controlled iv analgesia is an acceptable pain management strategy in morbidly obese patients undergoing gastric bypass surgery. A retrospective comparison with epidural analgesia. CAN J ANESTH, 50,. (7), 672-678. Purpose/Research Questions/Hypotheses Research Variables Design Major Findings and Limitations Purpose of Study: To examine the hypothesis that pain treatment with patient controlled analgesia (PCA) using iv morphine is a suitable and safe alternative to epidural analgesia in morbidly obese patients undergoing gastric bypass surgery. Research Questions/Hypotheses: The hypothesis of the present study was that pain treatment with PCA using iv morphine is a suitable and safe alternative to epidural analgesia in morbidly obese patients undergoing gastric bypass surgery. Independent: Hospital Dependent: quality of pain control, incidence of cardiovascular and respiratory complications, analgesia related side effects, time to ambulation and first flatus, length of hospital stay, and wound infections. Level 1: Exploratory or Descriptive Findings: 1.Patients in the PCA group had a wound infection rate of 15%, which was lower than in patients with epidural analgesia (39%). 2.Due to epidural catheter placement patients in the epidural group spent significantly more time (20 min) in the operating room than patients in the PCA group. 3. In grossly obese patients, undergoing gastric bypass surgery PCA with iv morphine is an acceptable strategy for pain management and may confer some advantages when compared to epidural analgesia. Limitations: 1. Pain levels on coughing and ambulation, which are better indicators of the quality of dynamic pain relief, could not be obtained in this retrospective analysis. 2.Relative small number of patients due to a time restricted observation period. Sample Setting Major Tools Quality of Evidence Number: PCA group 40 & Epidural group 46. Age: PCA group: 39 11 yrs. Epidural group : 38 9 yrs. Gender: Male/Female PCA group: 13/27. Epidural group 8/38. Health Status: Diabetes mellitus: 25% & 13% Hypaertension: 23% & 24% Asthma: 20% & 22% Sleep apnea: 18% and 20% in the PCA and epidural group respectively. Diagnosis: Obese patients undergoing gastric bypass surgery were included but their major diagnosis is not mentioned in the study. Type: not mentioned Location: Operating room and post operative ward of Royal Victoria Hospital. Name(s): Visual Analogue Scale (VAS) to score postoperative pain Reliability: Reliable Validity: Valid Evidence Rating: III. Comparative, correlational, and other descriptive studies Feasibility: Could this practice change be implemented easily in your organization and with minimal resources Yes Benefit/Risk: Would the benefits of this practice change/outweigh the risk to patients Yes Rosswurm, M & Larabee, J. (1999). A model for change to evidence-based practice. Image: Journal of Nursing Scholarship, 31(4), 317-322. Worksheet to Critique Quality of Evidence using Rosswurm's Method Reuben, S.S., and Neil, R.C. (2000). Postoperative Analgesic Effects of Celecoxib or Rofecoxib After Spinal Fusion Surgery. Anesth Analg,.91,1221-5. Purpose/Research Questions/Hypotheses Research Variables Design Major Findings and Limitations Purpose of Study: to evaluate the analgesic efficacy of administering a single preoperative dose of celecoxib or rofecoxib for spinal fusion surgery. Research Questions/Hypotheses: a preoperative dose of celecoxib or rofecoxib to patients who have undergone spinal stabilization would enhance analgesia when used in conjunction with PCA morphine after spinal fusion surgery. Independent: Time period and hospital Dependent: Pain intensity and 24-h morphine use at six times during the first 24 postoperative hour. Level 1: Exploratory or Descriptive (double-blinded randomized, controlled study) Findings: 1. The total dose of morphine and the cumulative doses for each of the six time periods were significantly more in the placebo group than in the other two groups. 2.The morphine dose was significantly less in five of the six time intervals in the rofecoxib group compared with the celecoxib group. 3.The pain scores were significantly less in the rofecoxib group than in the other two groups at two of the six intervals, and less than the placebo group in an additional interval. 4. Although both rofecoxib and celecoxib produce similar analgesic effects in the first 4 h after surgery, rofecoxib demonstrated an extended analgesic effect that lasted throughout the 24-h study. Limitations: The authors have not mentioned study limitations. Sample Setting Major Tools Quality of Evidence Number: 60 (20 no. in each group) Type: patients scheduled to undergo elective decompressive lumbar laminectomy with spinal fusion by a single surgeon. Age: Control group: 41 7; Celecoxib group: 47 9; Rofecoxib group: 43 9 yrs. Gender: The study has not mentioned about gender distribution of patients included. Health Status: patients scheduled to undergo elective decompressive lumbar laminectomy. Diagnosis: Major diagnoses have not been mentioned in the study. Type: Did not mention the type of setting. Location: Location has not been mentioned in the study Name: To quantify pain, a verbal analog pain scale (VbAPS) was used. Reliability: Reliable Validity: Valid Evidence Rating: I.b. One randomized controlled trial Feasibility: Could this practice change be implemented easily in your organization and with minimal resources Yes Benefit/Risk: Would the benefits of this practice change/outweigh the risk to patients Yes Rosswurm, M & Larabee, J. (1999). A model for change to evidence-based practice. Image: Journal of Nursing Scholarship, 31(4), 317-322. References Angle P.J., Stephen, H. H, Barbara, L. L., Szalai, J.P., Gnanendran, K., and Jean, E. K. (2002). A Randomized Controlled Trial Examining the Effect of Naproxen on Analgesia During the Second Day AfterCesarean Delivery. Anesth Analg, 95, 741-5. Broekema, A.A., Alexander, V., VBclav, Fidler., Mathieu, J. M., Gielen and Pim, J. H. ( 1998). Postoperative Analgesia with Intramuscular Morphine atFixed Rate Versus Epidural Morphine or Sufentanil and Bupivacaine in Patients Undergoing Major Abdominal Surgery. Anesth Analg ,87,1346-53. Charghi, R., Steven, B., Nicolas, C., Fabrice, R., & Thomas, S. (2003). Patient controlled iv analgesia is an acceptable pain management strategy in morbidly obese patients undergoing gastric bypass surgery. A retrospective comparison with epidural analgesia. CAN J ANESTH, 50,. (7), 672-678. Marty, J., Dan, B., Dominique, C., Nicole, E., Alain, R., Annick, M., Dominique, H., Xavior, B., and Odile, H.P. ( 2005). Effects of single dose injectable paracetamol versus Propacetamol in pain management after Minor gynecologic surgery: A multicentre, randomized, double-blind, active-controlled Two-parallel group study.Current TherapeuticRresearch,66( 4), 294-306. Mujadi, H.A., Abdul, R., Mario, G.K., Najat, A.D., Yatindra, K.B., Abdul R.A. (2006). Preemptive gabapentin reduces postoperative pain and opioid demand following thyroid surgery. CAN J ANESTH, 53, ( 3), 268-273. Pouzeratte, Y., Jean, M., Georges, B., Gilles, B., Christine, V., Samir, J., Jean, M. F., Pascal, C., and Claude, M. (2001), Patient-Controlled Epidural Analgesia After Abdominal Surgery: Ropivacaine Versus Bupivacaine. Anesth Analg, 93, 1587-92. Reuben, S.S., and Neil, R.C. (2000). Postoperative Analgesic Effects of Celecoxib or Rofecoxib After Spinal Fusion Surgery. Anesth Analg,.91,1221-5. Rockemann M.G., Wulf ,S., Sonja, D., Helmut Reinelt,, Peter Steffen, and Michael Georgieff. (1997). Epidural Bolus Clonidine/Morphine Versus Epidural Patient- Controlled BupivacaineKufentanil: Quality of Postoperative Analgesia and Cost-Identification Analysis. Anesth Analg, 85, 864-9. Rose, DK., Marsha, MC., and Doreen AY. (1997). Changing the Practice of Pain Management. Anesth Analg. 84,764-72. Sarvela, J., Halonen, P., Soikkeli, A., Kortilla, K. (2002). A double-blinded randomized comparison of intrathecal and epidural morphine for elective cesarean delivery. Anesth Anallg, 95, 436-40. Read More