Assessment of postoperative pain: impact of clinical experience and professional role

Background: Unrelieved postoperative pain is still reported to be a rather common clinical problem which may be related to inadequate routines for pain assessment. Therefore, the aim of the study was to describe strategies used by experienced and less experienced nurses and physicians in their assessment of postoperative pain and to relate different approaches, clinical experience, and professional role to the accuracy of the pain ratings.
Methods: Data collection was based on repeated interviews with nurses (n=30) and physicians (n=30) in connection with clinical pain assessments (n=180) including VASscoring
Results: Commonly used strategies in the pain assessment were: - how the patient looks, - what the patient says, - the manner of talking, and - past experience of similar circumstances. The mean VAS-score given by the patients (6.1±21.1) was significantly (P<0.001) higher than that rated by the staff members (4.9±21.2). Nurses as well as physicians overestimated low and underestimated high levels of pain indicated by the patients. The accuracy of the ratings by nurses, especially by more experienced ones (≤10 years in nursing), was found to be less precise than that of physicians. The pain assessment of these very experienced nurses was characterized by a systematic underestimation.
Conclusions: The present study emphasizes a need for definition of more precise strategies for clinical postoperative pain assessment which better take into consideration the pain experiences and needs of individual patients     

An audit of the safety of an acute pain service

We audited and analysed the adverse effects and safety of postoperative pain management on 2509 consecutive patients under care of the Acute Pain Service at a tertiary referral teaching hospital over a 32-month period. Our standard respiratory monitoring consisted of continuous pulse oximetry, hourly respiratory rate counting, sedation scoring and intermittent arterial blood gas sampling. This protocol was reliable and detected six episodes of bradypnoea, 13 of hypercapnia and 23 of oxygen desaturation occurring in 39 patients (1.8% of all spontaneously breathing patients) . Two patients required naloxone injection and none had long-term sequelae. Hypotension due to epidural bupivacaine 0.0625% and fentanyl 3.3 μg.ml⁻¹ infusion occurred in four patients (1.2%), all with a sensory block higher than T₅. They readily responded to fluid infusion and ephedrine (two patients). Postoperative nausea or vomiting occurred in 723 (28.8%) and 380 (15.1%) patients, respectively. Odds ratio analysis showed that the risk factors for postoperative nausea and vomiting were: female gender, gynaecological operations, nongeriatric patients and systemic analgesia. Postoperative nausea and vomiting decreased analgesic efficacy by discouraging the use of patient-controlled analgesia and was regarded as equally distressing as pain. Other side-effects included: pruritus in 182 patients; dizziness in 333 and lower limb weakness in 73 (21.2% of patients receiving epidural local anaesthetics). It is concluded that a standard monitoring and management protocol, an experienced nursing team and reliable Acute Pain Service coverage is mandatory for the safe use of modern analgesic techniques.     

Thermoreceptive lamina I trigeminothalamic neurons project to the nucleus submedius in the cat

Summary The technique of antidromic mapping with a roving array of electrodes was used to demonstrate that lamina I trigeminothalamic cells responsive specifically to skin temperature project to the n. submedius (Sm) in the medial thalamus of the cat. This finding indicates that Sm receives thermoreceptive in addition to nociceptive information.     

Prostaglandins and CGRP release from cardiac sensory nerves

Summary (1) The possible influence of Prostaglandins (PG) E₁ and I₂ as well as ischaemia, ouabain and bradykinin on the outflow of calcitonin gene-related peptide (CGRP)- and neuropeptide Y (NPY)-like immunoreactivity (LI) from the guinea-pig heart was studied in vitro. (2) Exposure to PGE₁ (10^–5 M), but not PGI₂ (10^–5 M), induced an increased outflow, suggesting release of CGRP-LI. PGE₁ simultaneously increased the contractile force and heart rate while no effects were observed on perfusate volume or outflow of NPY-LI. PGI₂ had no effect on contractile parameters or coronary flow. In separate experiments on capsaicin-pretreated animals, the stimulatory effects of PGE₁ on heart rate and contractile force remained unchanged while no increased CGRP-LI outflow was detectable. (3) Ouabain, bradykinin and reperfusion after total stop-flow ischaemia was associated with an indomethacin-resistant increase in perfusate levels of CGRP-LI but not of NPY-LI. While ouabain markedly increased the contractile force, exposure to bradykinin or ischaemia did not induce any clear-cut changes in contractile force or heart rate. (4) Capsaicin-exposure evoked a markedly increased outflow of CGRP-LI but not of NPY-LI in combination with an increase in heart rate and a decrease in contractile force. Repeated administration of capsaicin induced tachyphylaxis. The stimulatory effects of capsaicin on CGRP-LI outflow and heart rate, but not the negative inotropic effect, did not occur in capsaicin-pretreated animals. (5) It is concluded that PGE₁, but not PGI₂, can activate cardiac capsaicin-sensitive fibres as revealed by increased outflow of CGRP-LI. The cardiostimulatory effects induced by PGE₁ are not related to CGRP release, however. A possible prostaglandin link in the CGRP-LI released by ouabain, bradykinin or ischaemia seems unlikely. Send offprint requests to: A. Franco-Cereceda at the above address     

外周伤害性刺激及吗啡对大鼠丘脑束旁核痛抑制-兴奋神经元电活动的影响

应用细胞外微电极技术,观察和记录了Pf痛反应神经元对伤害性夹尾、伤害性电刺激坐骨神经和检验性刺激及脑内微量注射吗啡前后电活动变化的情况。在67只Wistar大鼠右侧Pf内记录了309个痛反应神经元,其中PI-EN64个,占神经元总数的20.71%。PI-EN对伤害性夹尾和电刺激坐骨神经均发生特异性的抑制-兴奋反应,对非伤害性刺激则不发生反应。伤害性刺激诱发放电之前有     

Diagnosis of thoracic outlet syndrome Relative value of electrophysiological studies

The diagnostic utility of various electrophysiological techniques was evaluated in patients with thoracic outlet compression syndrome (TOCS). Our results suggest that in true neurogenic TOCS, there is no standard electrophysiological picture, but that this evolves with the severity of the syndrome. The first changes observed are electromyographic, followed by changes in F-wave and SEPs, followed finally by changes in nerve conduction parameters. EMG study was certainly more informative, showing neurogenic damage not only in limbs with neurological signs but also in about 1/4 of limbs with only subjective symptoms. The study of F-wave and SEPs does not seem to be particularly helpful, however, in view of the peculiar changes found in these patients, SEPs may be a useful complement to EMG. Nerve conduction studies were of little utility since changes in these parameters are only found in patients with long-standing anomalies and severe atrophy.     

Analgesic actions of dynorphin A(1–13) antiserum in the rat brain stem

This study was performed to evaluate the effects of dynorphin A(1–13) antiserum when microinjected into an active hyperalgesic region within the rat brain stem. When administered within the dorsal posterior mesencephalic tegmentum (DPMT) of intact conscious rats, dynorphin A(1–13) antiserum produced rapid onset and persistent prolongation of a low intensity thermally evoked tail avoidance response (LITETAR). These analgesic actions of the dynorphin A(1–13) antiserum appeared to be dose dependent. These studies support previous hypotheses about the existence of tonically active brain stem opioid hyperalgesic processes. Further, the results provide indirect evidence for a potential role of brain stem dynorphin(s) in facilitating pain.     

Area 3a in the cat. I. A reevaluation of its location and architecture on the basis of Nissl, myelin, acetylcholinesterase, and cytochrome oxidase staining.

Current knowledge on the anatomy of area 3a of the cat mainly derives from the cyto- and myeloarchitectonic study of Hassler and Muhs-Clement (J Hirnforsch 6:377, 1964). Previous investigations in the cat had failed to identify a cortical region comparable to monkey's area 3a. In the present study, Nissl, myelin, acetylcholinesterase, and cytochrome oxidase staining techniques were applied to coronal and sagittal serial sections of the cat brain. Area 3a appears as a slender band of cortex between areas 4 and 3b, and in Nissl-stained sections it is mainly characterized by an attenuated granular layer IV, overlying a thin layer V with pyramidal cells of various sizes, including a few large ones. These cytoarchitectonic features are sufficient to differentiate area 3a from neighboring areas, although the borders between them are not sharp in many cases. After the Nissl staining, the acetylcholinesterase staining proved to be the most helpful in defining the structure and borders of area 3a. Acetylcholinesterase staining was dense in layer I (in contrast with a lighter staining of outer layer I in area 4), and light in layers II and IIIa, changing to moderate in IIIc and IV (a pattern which is accentuated in area 3b). Myelin and cytochrome oxidase techniques also yielded differential staining patterns of area 3a and neighboring areas 4 and 3b, although the borders were not easily drawn with these techniques. Whereas our cyto- and myeloarchitectonic findings were comparable to those of Hassler and Muhs-Clement ('64) and applied well to area 3a in the convexity of the hemisphere, we found that most of the area 3a described by these authors in the medial face of the hemisphere had a number of distinguishing architectonic (as well as connectional and physiological) features which enabled us to define it as a separate area (7m). The techniques we used to delineate area 3a are compatible with most current procedures of histo- and immunohistochemical staining of the brain, and may also provide valuable supporting data for electrophysiological studies.     

APPLICATION OF ACUPOINT-INJECTION THERAPY TO PAIN SYNDROME: CLINICAL ANALYSIS OF 250 CASES

In this paper,250 cases of headache,shoulder pain,lumbago and leg pain weretreated with 20％Angelicae Sinensis mixed with Vitamine B_(12) point-injection therapy.The total effective rate was 95.2％and in which the cure rate was 53.6％.Authors have found a close correlation between the effectiveness and the duration of disease.     

Distribution of input synapses from processes exhibiting GABA- or glutamate-like immunoreactivity onto terminals of prosternal filiform afferents in the locust

The locust prosternum carries a population of long filiform hairs that are very sensitive to air currents. The sensory afferent neurons that innervate the hairs make strong monosynaptic connections with an identified intersegmental interneuron (A4I1) which is known to contact motor neurons that supply muscles controlling wing angle during flight. In order discover how the synapse between the afferents and interneuron A4I1 might be modulated, the afferents were labelled intracellularly by backfilling with horseradish peroxidase to reveal their central terminals which lie in the prothoracic ganglion. A postembedding immunogold method was used to make a quantitative assessment of the prevalence of immunoreactivity for GABA and glutamate in processes presynaptic to the afferent terminals. In one afferent neuron, where 77 synapses were examined, 40 (52%) of the presynaptic processes were immunoreactive for GABA. When adjacent sections through the same terminal branches were labelled with the two antibodies, it was demonstrated that GABA- and glutamate-like immunoreactivity was present in different populations of presynaptic processes. A series of 110 ultrathin sections was cut through one set of afferent terminal branches and alternate grids were stained with GABA and glutamate antibodies. From these sections, the terminals were reconstructed and the position of 35 input and 21 output synapses mapped. Of the 35 input synapses, 18 (51%) were immunoreactive for GABA, 14 (40%) were immunoreactive for glutamate and 3 (9%) were unlabelled by either antibody. On these terminals, the different classes of input synapses appeared to be intermingled at random with the output synapses made by the afferent, and no pattern govering synapse distribution could be discerned. © 1994 Wiley-Liss, Inc.