Postoperative Pain Treatment - Essay Example

Research Evidence and Clinical Practice Introduction Postoperative pain is the frequent operational-related pain, which is often referred to as aching and occurs normally near the operated site. The pain that patients experience after going through a surgery is usually unrelieved, unhealthy and can be prevented or controlled. This is why we have recently witnessed an increasing interest in postoperative pain management. Most hospitals have implemented Acute Pain Services to offer 24 hours pain care in a day. Numerous advanced pain management devices have been also been implemented such as Patient-controlled analgesia (PCA), epidural and plexus infusion among others (Mann 2005). The main purpose for postoperative pain management is to offer subjective comfort apart from inhibiting trauma-induced nocioceptive impulses. Postoperative pain management is aimed at directing autonomic and somatic reflex reactions to pain and consequently to improve restoration of function by permitting patient to cough, breathe and move without difficulties. Pain management also improves clinical outcomes by minimizing incidences of postoperative complications such as impaired wound healing and metabolic acidosis (Wu 2005). PCA is a method whereby the patients are involved in management of their own pain. In this paper, I will examine the effectiveness of using patient-controlled analgesia as opposed to thoracic analgesia in patients who have gone through thoracic surgical procedures in the postoperative setting. To be able to identify relevant articles to be used, I will use PICO. In this case, P means population and the population I am dealing with is patients who have gone through thoracic surgical procedures, I mean interventions and they will the use of patient-controlled analgesia, C stands for counter interventions which will involves the use of thoracic analgesia, while O means outcomes which will include pain scores or use of analgesia. To do this, I will examine three relevant research articles as follows; Article Name: Is intravenous patient controlled analgesia enough for pain control in patients who underwent thoracoscopy? Authors: Kim J., Tae K.H., Mikyung Y and Hyun S. Publication details: A Journal of Korean Medical Science, 2009 This study was conducted to assess the efficacy of two types of analgesic methods of pain management, intravenous patient-controlled and thoracic epidural patient-controlled analgesia in patient suffering from lung cancer and scheduled to go through a lobectomy. The validity and reliability of this study can be determined by assessing the target of the research and the way it is achieved. This will involve evaluating the research participated in the research process as an observer and experimenter increasing the validity of the research. The study consisted of 52 patients aged below 75 years and who were randomly allocated to two groups, an Epidural PCA group and the Intravenous PCA group, using a computer-generated table. The patients in the Epidural group were inserted an epidural catheter between the 5th and 6th thoracic vertebra before being induced with an anesthesia. All the patients were operated by the same surgeon using the same method. Immediately after the patients were induced with an anesthesia, they were given the first dose of analgesia (Kim 2009). The results of this study were produced using valid research techniques. Standards protocols were developed to aid the research assistants so that the instrumentation could be done in a standard way. Throughout the study period, data was collected using the same research assistants increasing the validity and reliability of the study. A validated 10cm non-graduated visual analogue scale was used to measure the intensity of pain in patients. The first measurement was taken one hour after the operation and then each day for five days after the surgery. If the pain intensity was high, 4 gm of morphine was administered to the affected patients. Records were taken of the total amount of morphine administered, together with the prevalence of faintness, pruritus, vomiting, respiratory depression, pneumonia and somnolence (Dolin and Cashman (2005). Both the experiment and control group were regularly monitored by use of surveillance and feedback undertaken by the research assistants. Throughout the study period, a log book was maintained in order to evaluate and maintain data compared to the baseline. The patients were asked if they were contented with their method of pain management. The research assistants who performed all the postoperative assessments were blinded as regards the purpose of the study; however, the physicians were not blinded. To determine the patient characteristics between the two groups, a student’s t-test was used while as the Chi-square test was used to compare the differences in the incidences of side-effects. Holm-Sidak test was used to compare the differences in the two groups. A probability of 0.05 was applied to establish the significance of the analysis. The patient’s characteristics, pain scores, the need for rescue analgesics, patient’s satisfaction levels and operation data did not differ in the two groups. Moreover, the prevalence of faintness, vomiting pneumonia, respiratory depression and pruritus did not differ in the two groups. We can therefore conclude that the benefits of using Intravenous PCA in pain management are equal to those of using epidural PCA and hence intravenous PCA can replace epidural PCA in patients undergoing lobectomy (Yoshioka 2006). Article Name: Thoracic epidural versus morphine patient-controlled analgesia after laparoscopic colectomy Authors: Dennis RJ. And Mills P Publication details: World Journal of Laparoscopic surgery, Dec 2008, 1(3):49-52 This study was conducted to find out the benefit of using morphine patient-controlled analgesia as opposed to thoracic epidural in pain management after laparoscopic colorectal operation. The study sample consisted of 16 patients who had undergone laparoscopic colectomy operation. The study sample was randomized into two groups, that which was given morphine PCA and that which received thoracic epidural analgesia (TEA) for post-operative pain management. The bowels for both groups were mechanically prepared, where as, prophylactic cefuroxime and metronidazole were administered intravenously in both groups at the induction of anesthesia. A catheter was introduced in all patients during operation and given clear fluids immediately after the operation. Once the patient could tolerate a normal diet and pain was well managed by oral analgesics, they were discharged from the hospital (Dennis and Mills 2008). Before operation, the patients were visited by members of the acute pain service and given verbal and written information as regards pain scores rating and techniques of postoperative analgesia that would be offered. The catheter was placed at the mid-thoracic dermatomal level of T7/8 for all the patients in the TEA group before anesthesia. After the operation, they were infused with 0.125 % bupivacaine and 4mcg/ml of fentanyl at an hourly basis, while those in the PCA were given a prescription of 1mg bolus of morphine until they were able to take oral analgesia. The patients were observed on a daily basis by the acute pain service members. A verbal rating score of 0-10 was used to assess the post-operative pain starting one hour after the operation and then at an interval of 6, 12, 18 and 24 hours. Data was collected from medical notes, observation charts and anesthetic records (Werawatganon and Charuluxanun 2005). Demographic data was analyzed using Mann-Whitney u-test, where as pain scores were analyzed using paired t-test and 95% confidence level used to determine any significant differences in pain scores between the two groups. There was significant differences in pain scores between the two groups in recovery and at 6, 12, 24 hours after surgery. However, there was no important difference in pain scores 48 hours after the operation. The duration of stay in hospital did not differ between the two groups. Some patients in both the groups experienced negative effects from analgesia such a vomiting and nausea. We can therefore conclude that PCA is an improved pain control as compared to morphine TEA for the first 24 hours after operation. This study agrees with other previous studies on the benefit of using PCA in pain management in the post-operative setting. This study would be subject to bias since it is not possible to blind the patients and the staff as regards analgesic technique. However, the staff taking care of these patients was not ware of this study when they were recording pain scores (Taqi 2007). Article Name: Thoracic epidural versus intravenous patient-controlled analgesia after cardiac surgery: a randomized controlled trial on length of hospital stay and patient-perceived quality of recovery. Authors: Hansdottir V., Phillip J., Olsen MF and Eduard C. Publication details: Anesthesiology, 2006, 105:854-5. This study was conducted to compare the effectiveness of using thoracic epidural analgesia with patient-controlled analgesia in postoperative pain management. The study population consisted of 113 patients who had undergone elective cardiac surgery who were randomly allocated to thoracic epidural analgesia and the patient-controlled analgesia group. The PCA group was the control group, while the TEA group formed the experimental group. Patients were concealed as regard the group to which they belonged. To determine the effectiveness on each of the technique, postoperative length of hospital stay, pain and sedation scores, lung volume, organ morbidities, time to eligibility for hospital discharge and degree of ambulation were evaluated. Patients’ and medical records were used to obtain demographic data, preoperative medication and surgical and clinical history (Christie and McCabe 2007). Patients in the PCA group were given general anesthesia followed by postoperative PCA with intravenous morphine. The experimental group was given general analgesia and intra-operative thoracic epidural anesthesia followed by postoperative TEA. Both groups were treated for three consecutives days after the surgery. They were also given preoperative written and oral instructions for use of PCA or TEA. Patients in the TEA group were inserted with an epidural catheter in the thoracic area between T2 and T5 the day before they were operated and were removed on the fourth postoperative day. Intravenous PCA morphine was used to control pain in PCA group (Hansdottir 2006). The neurosurgeons and the neuroradiologist were not blinded as regard the purpose of the study from the beginning. A validate quality of recovery scores was designed to assess the patient-perceived quality of recovery. One of the authors was used to assess analgesia for 3 postoperative days, using a validated 100mm visual analog scale. A four-point sedation scale was used by one of the researchers to assess the level of sedation. The surgical team responsible for hospital discharge was not blinded of the group treatment. The investigators who were used to assess the level of mobilization, pain, degree of discharge, hospital discharge and ling function were blinded of the group allocation and treatment. The nursing team was not blinded to the group treatment and hence was not used in assessing the patients. Blinded investigators were also not involved in nursing of the patients. However, 5% of the TEA group patients revealed by mistake the presence of the epidural catheter to the blinded investigators (Liu 2004). Student unpaired t-test and Pearson chi-square test were used to compare the baseline and outcome variables between the two groups. A two-way analysis of various repeated measurements was used to assess the effect of the treatment. The Kaplan-Meier method was used to plot the time for hospital discharge and eligibility to hospital discharge. The log rank test was used to determine the differences between the two groups. All analyses were carried put with the intention to treat. A significant level of 0.05 was used to determine any significant correlation between the variables. There were no significant differences between the two groups in time of hospital discharge, eligibility for hospital discharge and mobility scores (Fernandez 2005). However, a large number of the patients in the TEA group experienced off-pump CABG as compared to the PCA group. This study found out that the use of TEA in managing postoperative pain does not offer any major advantage when compared to the use of PCA. We can therefore conclude that PCA can replace TEA in the management of postoperative pain in patients who have gone through an operation (Priestley 2002). Recommendations Patient-controlled analgesia: Patient-controlled analgesia is an effective technique for the management of pain in the postoperative setting as the patients can get the medicine when they need it without having to wait for nurses. From the above articles analyses, it is evident that patients who used PCA techniques reported lower pain scores and experienced less side-effect as compared to those who used other methods. Involving patients in their own care also resulted to higher patient’s satisfaction level and better outcomes. PCA also reduces nurses’ workload as the amount of drug administered using the PCA is enough for multiple doses. It also reduces chances for medication errors as the PCA is programmed as per the clinician’s orders and it ‘locks out’ if the patient attempt to overdose (Lehmann 2005). Regular Staff training: All staff concerned with the delivery of postoperative pain management should be regularly trained while emphasizing the need for team-working and collaboration. They should be trained on the locally available methods of treatment, monitoring routines as regards pain treatment, regularly documenting treatment and pain assessments, physiology and pathophysiology of pain and pharmacology of analgesia (Fischer HBJ and Simanski CJP. (2005). Patient education: The success of the pain management process depends on the knowledge and beliefs of patients. It is therefore imperative to provide patients with detailed information as regards postoperative pain and treatment techniques. This gives the patient a clear depiction of what to look forward to. The patients need to be told why it is important to treat postoperative pain, the various methods of pain treatment, pain assessment routine and why it is important for them to participate in the management of their own pain treatment. This can be done orally or through written and audiovisual information such as brochures, wall posters, video films and web pages. The patients can be involved in the management of their own pain by involving them in the development of a pain assessment plan (Australian and New Zealand College of Anesthetists and Faculty of Pain Medicine 2005). Audit and quality control: It is imperative to review the efficacy of a new pain management system in the hospital before introducing it into the acute pain service for the first time. This will make it possible to compare the benefits of using a current pain management system as opposed to a former pain management system. This can be done by assessing the patient satisfaction level within each group, side effects experienced, length of hospital stay, number of major and complex cases treated and the type and amount of analgesic drug administered (Kehlet 2005). Regular pain assessment using specific assessment tools: A specific pain assessment scale should be used in the hospital by all the staff to ensure that they ‘speak’ the same language when it comes to pain intensity. The most useful pain assessment tool is the patient’s own report. Hence, the patients should be allowed to assess their own pain scores as long as they are able to communicate and express the pain they are feeling. It is imperative to pay attention and trust what the patients are saying. The nurses should regularly monitor patients’ pain scores and side effects of the treatment. These information by be easily obtained by use of a patient questionnaire (Rawal 2005). Recommendations for further research 1. Patient-controlled analgesia is a new technique that is being widely used in the management of pain in the postoperative setting. However, there are limited studies which have been carried out as regards the effective use of patient-controlled analgesia in the postoperative setting. It is therefore imperative to carry out more research studies on PCA to find out whether it can be an effective alternative to the other techniques commonly used in postoperative pain management (Grass 2005). 2. Further research studies need to be conducted as regards the effect of patients’ knowledge in pain management in the postoperative setting as only limited research studies have been conducted in this area. Drivers, barriers and strategies for practice change The drivers, barriers and strategies for Patients pain management in the postoperative setting are as outlined in the table below; Drivers for Practice change Strategies to maximize drivers for change Drivers for practice change High rates of death in the postoperative setting Postoperative complications Impaired healing Metabolic acidosis Prolonged hospitals stay after operation leading to ward congestion. Burdensome health care costs Deprived quality of life Barriers for practical change and strategies to overcome these barriers Barriers for practice change Strategies for practice change Patients Factors 1. patients’ fear and anxiety 2. Patients lack of knowledge of the site, nature and purpose of the operation. 3. Side-effects of PCA 4. Noncompliance with medications Patient education campaigns and training programs Providing culturally sensitive education Providing alternative PCA Clinical Factors 1.Unsuitable site of operation 2. Lack of advanced pain-relieving techniques 3. Drugs unavailability 4. clinician lack of knowledge of the various methods of analgesia 5. Lack of trained and expertise staff on pain management in the postoperative setting 6. Inaccurate measurement of patients’ pain scores a) not giving the patient time to relax before taking pain scores b) Failure to take at least two pain scores measurement in each patient. c) unreliable pain intensity scales devices 7. poor patient-clinician communication strategies Systematic physician education and training programs Make sure the operation site is environmentally conducive Invent new pain-relieving techniques Providing new nursing protocol and checklist for accurate pain scores measurements Providing appropriate pain intensity scales devices Effective patient-physician communication strategies Patient-centered care Local Factors 1. lack of availability of certain drugs such as morphine 2. PCA devices such as catheters are quite expensive The government should provide PCA devices and drugs to all public hospitals and to private hospitals at an affordable prices References Australian and New Zealand College of Anesthetists and Faculty of Pain Medicine (2005). Acute pain management: scientific evidence. Christie IW. And McCabe S. (2007). Chief complications of epidural analgesia after operation: findings of a six-year survey. Anesthesia, 62: 335-341. Dennis RJ. and Mills P. (2008). Thoracic epidural versus morphine patient-controlled analgesia after laparoscopic colectomy. World Journal of Laparoscopic surgery, 1(3):49-52 Dolin SJ. and Cashman JN. (2005). Permissibility of acute postoperative pain control: nausea, vomiting, sedation, pruritis and urinary maintenance. Evidence from published data. British Journal of Anesthesia, 95: 584-591. Fernandez MI. et al. (2005). Does a thoracic epidural present any extra benefit after video-assisted thoracoscopic pleurectomy for principal spontaneous pneumothorax? European Journal of Cardiothoracic Surgery, 27:671–674. Fischer HBJ and Simanski CJP. (2005). A procedure-specific review and consensus recommendations for analgesia after total hip replacement. Anesthesia, 60:1189-1202. Grass JA. (2005). Patient-controlled analgesia. Anesthesia Analgesia, 101: 544-561. Hansdottir V. et al. (2006). Thoracic epidural versus intravenous patient-controlled analgesia after cardiac surgery: a randomized controlled trial on length of hospital stay. Anesthesiology, 105:854-5. Kehlet H. et al. (2005). A specific method for organized review and consent recommendations for postoperative analgesia after laparoscopic cholecystectomy. Surgery Endoscope, 19:1396-1415. Kehlet H. (2005). Procedure specific postoperative pain management. Anesthesiology Clinical Journal, 23:209-210. Kim J. et al. (2009). Is intravenous patient controlled analgesia sufficient for pain management in patients who go through thoracoscopy? A Journal of Korean Medical Science. Lehmann KA. (2005). Recent development in patient-controlled analgesia. British Journal of Anesthesia, 29: 572-589. Liu SS. et al. (2004). 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