Background
The leading principle in peri‐operative pain management is multimodal analgesia, which reduces opioid requirements and associated adverse effects. Pragmatic pain trials should optimally ...test interventions in addition to multimodal non‐opioid analgesics and interventions to ensure clinical relevance and baseline levels of opioid consumption that reflect clinical settings. We aimed to investigate opioid consumption and use of non‐opioid analgesics administered adjunct to interventions in post‐operative pain trials after total hip and knee arthroplasty.
Methods
A systematic literature search was conducted 7 January 2020 in The Cochrane Library's CENTRAL, PubMed, and EMBASE. Trials investigating analgesic interventions for post‐operative pain in adults undergoing total hip or knee arthroplasty were included. The primary outcome was the aggregated median 0–24 h post‐operative opioid consumption. Further, we assessed the use of paracetamol, non‐steroidal anti‐inflammatory drugs, gabapentinoids, high‐dose glucocorticoids, local infiltration analgesia and nerve blocks administered as co‐interventions equally to all participants. We assessed trends over time for all outcomes.
Results
Of 14,200 records, 570 trials were included. Median 0–24 h opioid consumption was 21 and 22 mg iv morphine equivalents in hip and knee arthroplasty trials, respectively. Meta‐regression showed no overall linear correlation between opioid consumption and publication year. The use of multimodal non‐opioid analgesia increased over time, though only 48% of trials published from 2010 to 2020 administered two or more non‐opioid analgesics. Applying more non‐opioid analgesics was associated with lower opioid consumption in intervention groups.
Conclusion
Post‐operative 0–24 h morphine consumption was median 21–22 mg. The demonstrated differences in non‐opioid multimodal analgesic regimens between research and clinical settings, can potentially diminish the demonstrated opioid‐sparing effects of trial interventions when such are implemented in a clinical context.
This narrative review is an updated summary of the value of regional anesthesia and analgesia for trauma and the special considerations when optimizing pain management and utilizing regional ...analgesia for acute traumatic pain.
In the setting of the opioid epidemic, the need for multimodal analgesia in trauma is imperative. It has been proposed that inadequately treated acute pain predisposes a patient to increased risk of developing chronic pain and continued opioid use. Enhanced Regional Anesthesia techniques along with multimodal pain therapies is thought to reduce the stress response and improve patient's short- and long-term outcomes.
Our ability to save life and limb has improved, but our ability to manage acute traumatic pain continues to lag. Understanding trauma-specific concerns and tailoring the analgesia to a patient's specific injuries can increase a patient's immediate comfort and long-term outcome as well.
Aims and objectives
To describe patients' and nurses' knowledge and beliefs regarding pain management. Moreover, to explore the effect of information and education on patients' and nurses’ knowledge ...and beliefs regarding pain management.
Background
In the treatment of postoperative pain, patients' and nurses' inadequate knowledge and erroneous beliefs may hamper the appropriate use of analgesics.
Design
A randomised controlled trial and a cross‐sectional study.
Methods
In 2013, half of 760 preoperative patients were allocated to the intervention group and received written information about the complications of postoperative pain. The knowledge and beliefs of 1184 nurses were studied in 2014 in a cross‐sectional study. All data were collected with the same questionnaires.
Results
In the intervention group, patients' knowledge level was significant higher than in the control group, while no differences were found in beliefs. Nurses had higher knowledge and more positive beliefs towards pain management compared with both patient groups. Nurses with additional pain education scored better than nurses without additional pain education. Nurses were also asked what percentage of pain scores matched their impression of the patient's pain, and the mean was found to be 63%.
Conclusions
Written information was effective for increasing patients' knowledge. However, it was not effective for changing beliefs about analgesics and patients and nurses had erroneous beliefs about analgesics.
Relevance to clinical practice
It is necessary to continue to inform patients and nurses about the need for analgesics after surgery. Such education could also emphasise that a discrepancy between a patient's reported pain score and the nurse's own assessment of the patient's pain should prompt a discussion with the patient about his/her pain.
Aims and objectives
To explore emergency nurses’ perceptions of the feasibility and utility of Pain Assessment in Advanced Dementia tool in people over 65 with cognitive impairment. The Pain ...Assessment in Advanced Dementia tool was then compared with The Abbey Pain Scale, Doloplus‐2 and PACSLAC. The objective was to determine which observational pain assessment tool was the most appropriate for the emergency department context and the cognitively impaired older person.
Background
The number of older people with cognitive impairment conditions, such as dementia, presenting to the emergency department is increasing. Approximately 28% of people over 65 years who present will have cognitive impairment. Older people with cognitive impairment often receive suboptimal pain management in the ED. There is limited evidence of the use and/or appropriateness of dementia‐specific pain observation assessment tools in the ED.
Design
This was a multicentre exploratory qualitative study, which was conducted within a constructivist paradigm.
Methods
Focus group interviews were conducted with nurses across three hospital emergency departments. Data were subject to thematic analysis.
Results
Six focus groups were conducted with 36 nurses over a 12‐week period. Four themes emerged from the analysis: 1) cognitive impairment is a barrier to pain management; 2) PAINAD gives structure to pain assessment; 3) PAINAD assists to convey pain intensity; and 4) selection of an appropriate observational pain assessment tool.
Conclusions
This study identified that emergency nurses find it challenging to detect, assess and manage pain in cognitively impaired people. While the use of the PAINAD helped to address these challenges compared to other tools, nurses also identified the important role that family and carers can play in pain assessment and management for older people with cognitive impairment.
Relevance to clinical practice
This study has generated new knowledge that has broad application across clinical settings, which can assist to transform pain management practice and reduce human suffering. The use of an observational pain assessment tool can provide for greater practice consistency for patients with communication difficulties. Pain management for older people with cognitive impairment is best achieved by the use an appropriate observational pain assessment tool and with a multidisciplinary approach that includes the person and their family/carer.
Abstract
Objectives
To identify predictors of the specific (difference between treatment and placebo) and overall (change from baseline in treatment arm) treatment effects of topical NSAIDs in OA.
...Methods
Randomized controlled trials (RCTs) of topical NSAIDs in OA were identified through systematic literature searching and inquiry to pharmaceutical companies. The raw, de-identified data were analysed in one-stage individual patient data meta-analysis (IPD-MA). Negative values for treatment effects (0–100 scale) indicate pain reduction.
Results
Of 63 eligible RCTs, 15 provided IPD (n = 1951 on topical NSAID), including 11 placebo-controlled RCTs (n = 1587 on topical NSAIDs, 1553 on placebo). Seven potential predictors of response were examined. Topical NSAIDs were superior to placebo −6 (95% CI −9, −4), with a small, but statistically significant greater effect in women than men difference −4 (95% CI −8, −1). The overall treatment effect was 4-fold larger than the specific effect −25 (95% CI −31, −19) and increased with greater baseline pain severity (P < 0.001). No differences in efficacy were observed for age, BMI, features of inflammation, duration of complaints or radiographic OA severity.
Conclusion
Topical NSAIDs are effective for OA pain relief. Greater overall pain relief in individuals with more baseline pain might be due to contextual and non-specific effects, including regression to the mean. Additional factors that have been linked either mechanistically or through empirical evidence to outcomes should be selected for inclusion across future RCTs in order to facilitate the identification of response predictors through IPD-MA.
Aims and objectives
To aggregate, interpret and synthesise findings from qualitative studies to further our knowledge regarding patients’ pre‐ and postoperative experiences when participating in an ...enhanced recovery after surgery.
Background
Numerous quantitative studies have documented benefits of participation in enhanced recovery after surgery programmes. Randomised control trials show that enhanced recovery after surgery reduce patient morbidity and shorten hospital length of stay. However, we presently have only sparse knowledge regarding patients’ experiences of participating in these programmes.
Design
A qualitative systematic review and meta‐synthesis.
Methods
A systematic literature search of databases (Cinahl, Medline, PsycINFO, Ovid Nursing, and EMBASE) for qualitative studies published between 2000–2014 were undertaken. The identified studies were critically evaluated using the Critical Appraisal Skills Program, and patient experiences were synthesised into new themes by a team of researchers, using qualitative content analysis.
Results
Eleven studies were included. Upon analysis, four main themes emerged: information transfer, individualised treatment vs. standardised care, balancing burdensome symptoms and expectations for rapid recovery, and sense of security at discharge. Information helped patients feel secure and prepared for surgery. Patients reported being motivated to participate in their recovery process. However, this became challenging when they faced symptoms such as pain, nausea, and weakness. Professional support fostered a feeling of security that was important in helping patients continue their regimen, recover, and be discharged as early as planned.
Conclusions
Patients in enhanced recovery after surgery programmes desired more consistency between pre‐ and postoperative information. Important opportunities exist to improve symptom management and help patients feel more secure about recovery postoperatively.
Relevance to clinical practice
Nurses are in a unique position to improve communication of standardised regimens and enhance symptom management across the perioperative period. Clinical outreach, such as follow‐up visits or phone calls, could target older adults who need additional assistance to meet enhanced recovery after surgery programme goals and derive benefit.
Surgical pain is managed with multi-modal anaesthesia in total hip replacement (THR) and total knee replacement (TKR). It is unclear whether including local anaesthetic infiltration before wound ...closure provides additional pain control.
We performed a systematic review of randomised controlled trials of local anaesthetic infiltration in patients receiving THR or TKR. We searched MEDLINE, Embase and Cochrane CENTRAL to December 2012. Two reviewers screened abstracts, extracted data, and contacted authors for unpublished outcomes and data. Outcomes collected were post-operative pain at rest and during activity after 24 and 48 hours, opioid requirement, mobilisation, hospital stay and complications. When feasible, we estimated pooled treatment effects using random effects meta-analyses.
In 13 studies including 909 patients undergoing THR, patients receiving local anaesthetic infiltration experienced a greater reduction in pain at 24 hours at rest by standardised mean difference (SMD) -0.61 (95% CI -1.05, -0.16; p = 0.008) and by SMD -0.43 (95% CI -0.78 -0.09; p = 0.014) at 48 hours during activity.In TKR, diverse multi-modal regimens were reported. In 23 studies including 1439 patients undergoing TKR, local anaesthetic infiltration reduced pain on average by SMD -0.40 (95% CI -0.58, -0.22; p < 0.001) at 24 hours at rest and by SMD -0.27 (95% CI -0.50, -0.05; p = 0.018) at 48 hours during activity, compared with patients receiving no infiltration or placebo. There was evidence of a larger reduction in studies delivering additional local anaesthetic after wound closure. There was no evidence of pain control additional to that provided by femoral nerve block.Patients receiving local anaesthetic infiltration spent on average an estimated 0.83 (95% CI 1.54, 0.12; p = 0.022) and 0.87 (95% CI 1.62, 0.11; p = 0.025) fewer days in hospital after THR and TKR respectively, had reduced opioid consumption, earlier mobilisation, and lower incidence of vomiting.Few studies reported long-term outcomes.
Local anaesthetic infiltration is effective in reducing short-term pain and hospital stay in patients receiving THR and TKR. Studies should assess whether local anaesthetic infiltration can prevent long-term pain. Enhanced pain control with additional analgesia through a catheter should be weighed against a possible infection risk.
Objective
Given the risks of opioid medications, nonpharmacological strategies should be considered for total joint replacement patients. We investigated acupuncture as an adjunct therapy for ...postsurgical pain management in a total joint replacement program by examining which total hip and knee replacement patients elected to receive acupuncture and the effect of acupuncture on short‐term pain.
Design
A total joint replacement program using fast‐track physiotherapy offered elective postsurgical acupuncture to all patients, at no additional cost, as an adjunct therapy to opioids for pain management.
Setting
The Joint Replacement Center at Abbott Northwestern Hospital, a 630‐bed teaching and specialty hospital in Minneapolis, Minnesota from 2010 to 2012.
Subjects
Our sample included 2,500 admissions of total hip (THR) and total knee replacement (TKR) patients.
Methods
Self‐reported pain was assessed before and after acupuncture using a 0–10 scale and categorized as none/mild (0–4) and moderate/severe pain (5–10).
Results
Seventy‐five percent of admissions included acupuncture. Women (Odds Ratio: 1.48, 95% Confidence Interval (CI): 1.22, 1.81) had higher odds of receiving acupuncture compared to men, and nonwhite patients (Odds Ratio: 0.55, 95% CI: 0.39, 0.78) had lower odds of receiving acupuncture compared to white patients. Average short‐term pain reduction was 1.91 points (95% CI: 1.83, 1.99), a 45% reduction from the mean prepain score. Forty‐one percent of patients reported moderate/severe pain prior to receiving acupuncture, while only 15% indicated moderate/severe pain after acupuncture.
Conclusions
Acupuncture may be a viable adjunct to pharmacological approaches for pain management after THR or TKR.
To explore the effect of modular transitional nursing intervention on the improvement of self-management of the patients with cancer pain.
This study will be conducted from March 2021 to May 2022 at ...Affiliated Hospital of Beihua University. The experiment was granted through the Research Ethics Committee of Affiliated Hospital of Beihua University (4348-019). Eighty patients are analyzed in our study. The patients will be included if they are between 18 and 70 years old and are diagnosed with cancer, the pain intensity score on moderate level, the pain lasts for more than 3 days, and the patients who have signed the written informed consent. While the patients will be excluded if they have a documented history of drug or alcohol abuse, and patients with limited performance, and patients have a surgery in the past 3 days. The primary result mainly expresses as intergroup differences in self-management disorders (Barriers Questionnaire-II) associated with the cancer pain. And the secondary results include the quality of life (QOL) and pain intensity. All the analyses are implemented with SPSS for Windows Version 20.0.
Table 1 will show the clinical outcomes between the 2 groups.
A modular transitional nursing intervention appears to reduce pain in cancer patients.
researchregistry6262.
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