Preemptive analgesia in the relief of postoperative pain

Preemptive analgesia is the idea that postoperative pain may be significantly attenuated using local anesthetics or opiates as a supplement to anesthesia, just prior to surgical incision. Basic research has shown that noxious inputs may trigger a state of spinal “central sensitization.” In this state innocuous stimuli are felt as painful. Central sensitization arises despite surgical anesthesia. Hence, by blocking the noxious inputs generated during surgery, central sensitization might be “preempted.” Clinical trials of this idea clearly have a favorable effect on postoperative pain. However, only a few studies have obtained evidence of preemption,ie, that it is essential to provide the analgesia immediately prior to surgery. Here we present the scientific rationale of preemptive analgesia, summarize the outcomes of clinical trials, and draw conclusions from the less-than-spectacular results obtained to date.     

Improving postoperative pain management: Continuous wound infusion and postoperative pain

Despite various analgesic drugs and techniques, relieving acute postoperative pain remains a challenge. An actual state of the question indicates that there is imperative need for further improvements. After a surgical incision, nociceptive inputs originating from the wound play a major role in both the initiation and the maintenance of postoperative pain. Continuous infiltration of analgesics into the surgical wound is a rational approach, a simple and safe technique which has gained in popularity. Local intrawound analgesics are mainly local anesthetics which block the nociceptive transmission. Non-steroidal anti-inflammatory drugs which modulate the local inflammatory reaction sensitizing the peripheral nociceptors represent an interesting alternative. Moreover, both local anesthetics and anti-inflammatory drugs possess a variety of modes of action, beside those which are conventionally recognized, mechanisms which may participate to their local analgesic effect. However, clinical reports published to date have brought conflicting results regarding the efficacy of intrawound analgesic techniques. These studies have pointed out several important issues like the place of the catheter, choice and dose of the analgesic drug, potential local toxicity. These issues need to be solved to better determine the right place of the technique in postoperative multimodal analgesia.     

Transcutaneous electrical nerve stimulation for the relief of postoperative pain.

The pain-killing abilities of electricity were known as far back as the ancient Egyptians and Hippocrates, but it was not until 1965 when Melzack and Wall [10] proposed the “gate theory of pain” that clinical interest was re-awakened. This theory postulated that a “gate” for pain existed in the substantia gelatinosa of the posterior spinal horns and that modification of the perception of pain might be possible by blocking the “gate” with non-painful stimuli. They suggested that selective stimulation of large diameter myelinated cutaneous afferent nerve fibers could set a process in motion which would close the “gate” to information coming over smaller pain-carrying fibers.The first clinical application of this theory centered around the relief of chronic pain by surgical placement of dorsal column stimulators [1] and implantation of stimulating devices around large peripheral nerves to block pain sensations. Transcutaneous electrical nerve stimulation was first employed in an attempt to select patients for implantable devices and then as a therapeutic device to alleviate chronic pain [2,4,6,9,11].The next logical step was to apply this modality to patients in the immediate postoperative period to decrease incisional pain. Hymes et al. [8] noted a decrease in atelectasis, ileus, postoperative pain and days spent in intensive care in patients using transcutaneous electrical stimulation. Vanderank and McGrath [9] reported that 77% of their patients treated with stimulators experienced some relief of postoperative pain.     

Spinal opioids in postoperative pain relief 1: pharmacology

This is a two-part unit on using spinal opioids to manage postoperative pain. Part 1 outlines the pharmacology and adverse effects. For details on spinal anatomy and dose levels, plus a table that outlines the differences between spinal anaesthesia and analgesia, and epidural analgesia, see Portfolio Pages at nursingtimes.net.     

Anesthesia-based pain services improve the quality of postoperative pain management

Anesthesia-based pain services are facilitating improvements in the quality of care of surgical patients by developing and directing institution-wide perioperative analgesia programs that include interdisciplinary collaborations. However, the impact of anesthesia-based pain services has not been evaluated in a systematic fashion. This prospective multisite study (n = 23 hospitals) utilized a standardized approach to evaluate the quality of pain care provided to patients who were and who were not cared for by an anesthesia-based pain service. A total of 5837 patients were evaluated using a standardized survey that consisted of a medical record review and a patient interview. The data were collected as part of the hospitals' quality improvement activities. Forty-nine percent of the patients were cared for by an anesthesia-based pain service. Patients who received pain service care reported significantly lower pain intensity scores; had lower levels of pain in the postoperative period; had a lower incidence of pruritus, sedation, and nausea; and experienced significantly less pain than expected. In addition, these patients were more likely to receive patient education about postoperative pain management; were more satisfied with their postoperative pain management; and were discharged sooner from the hospital. The findings from this study demonstrate that the care provided by anesthesia-based pain services has a significant impact on patient outcomes.     

Epidural fentanyl by continuous infusion for relief of postoperative pain

Data from the charts of 40 patients in whom a continuous epidural infusion of fentanyl had been used to effect postoperative pain relief were retrospectively reviewed. Of these patients, 39 out of 40 (97.5%) reported adequate analgesia at an average fentanyl infusion rate of 1.3 micrograms/kg/h. After discharge from the postanesthesia recovery room, each patient was sent to a general medical-surgical nursing floor with standard orders for medications to be administered as required. The overall incidence of side effects was low, and, in particular, respiratory depression was not noted. In our experience, this analgesia technique is safe, effective, and could be readily introduced into most community hospital settings.     

对非药物方法减轻儿童术后疼痛的调查研究

采用芬兰Tarja Polkki博士设计的问卷对福建省5所省级医院178名护士进行调查,了解护士使用非药物方法减轻学龄儿童术后疼痛情况,探讨减轻儿童术后疼痛的最佳护理方法.结果提示护士常用的方法有提供术前准备知识、安慰、创造舒适环境、转移注意力和改变体位.护士的年龄、受教育程度、职称、护理经验、有无子女、有无陪伴子女住院经历以及所在医院和科室注重减轻儿童术后疼痛护理的程度,均与某些非药物方法的使用存在显著相关.因此,应加强护士对使用非药物方法减轻儿童术后疼痛重要性和必要性的认识,使用多种非药物方法减轻学龄儿童术后疼痛.     

Chinese parent's use of nonpharmacological methods in children's postoperative pain relief

Parental participation in paediatric postoperative care is common in China. However, the knowledge is limited on what methods parents use to relieve their children's postoperative pain in hospital. The purpose of this study was to describe what nonpharmacological methods parents use to relieve their children's postoperative pain and factors related to this. A previously validated Scandinavian questionnaire survey was conducted in five provincial hospitals in Fujian, China, in 2004. Parents (n = 206) whose children had undergone operation were asked to complete questionnaires concerning nonpharmacological methods for children's pain relief. The response rate was 88%. Results show that the most commonly used methods by parents were emotional support strategies, helping with daily activities, distraction and imagery. Breathing technique was the method used least frequently. Fathers and parents who were older, more educated, employed and with earlier hospitalization experience with their children used pain alleviation methods more frequently than mothers and parents without these characteristics. Moreover, parents used some methods more frequently with boys, younger children, as well as children admitted for selective operations, with longer duration of hospitalization and with moderate or severe pain. Parents utilized various nonpharmacological methods for children's pain relief, especially those easy to use. This study may serve to focus healthcare providers' efforts on educating parents with respect to various nonpharmacological pain alleviation methods available for postoperative pain. Furthermore, this study provides parents an opportunity to be aware of their role in their children's pain management.     

Spinal opioids in postoperative pain relief. 2: Adverse effects

This is a two-part unit on using spinal opioids to manage postoperative pain. Part 1 outlined the pharmacology of spinal opioids. Part 2 discusses the selection of patients and their nursing care. It also focuses on the incidence of and response to adverse effects. For further information on contraindications, nursing care and patients' clinical requirements, see Portfolio Pages on nursingtimes.net.     

Imagery-induced relaxation in children's postoperative pain relief: a randomized pilot study

This study aimed to test the efficacy of imagery and relaxation in hospitalized children's postoperative pain relief. Sixty children aged 8-12 years who had undergone appendectomy or upper/lower limb surgery and had been randomly assigned to the experimental group (n(1) = 30) listened to an imagery trip CD, whereas those in the control group (n(2) = 30) received standard care. An investigator-developed questionnaire was used, and the intensity of pain was assessed using a visual analogue scale: before (Phase 1), immediately after (Phase 2), and 1 hour after (Phase 3) intervention or standard care. The children in the experimental group reported having significantly less pain (p < .001) than the control children based on a comparison of VAS pain scores in Phases 1 and 2. There were no significant differences in nurse-assessed pain scores. The type and time of operation were related to pain intensity in children. The nurses underestimated the pain of pediatric patients. The imagery trip CD can be used to reduce children's postoperative pain in a hospital setting, although its effect is short-lasting.     

帕瑞昔布钠与氟比洛芬酯在腹腔镜胆囊切除术后的镇痛效应

目的 比较帕瑞昔布钠与氟比洛芬酯在腹腔镜胆囊切除术后的镇痛效应.方法 选择行择期腹腔镜胆囊切除术患者90例,ASA Ⅰ或Ⅱ级,年龄＞18岁,随机分为三组(n=30):P0为对照组,患者麻醉诱导前未使用帕瑞昔布钠或氟比洛芬酯;P1组,患者麻醉诱导前静脉予帕瑞昔布钠40 mg;P2组,患者麻醉诱导前静脉予氟比洛芬酯50 mg.所有患者均行常规麻醉诱导,采用视觉模拟评分,观察术后2、4、8、12、24 h疼痛评分.结果 P1、P2组在术后2、4、6、12、24 h的VAS评分都低于P0组,差异有统计学意义(t分别=4.48、-4.78、5.76、5.39、3.81、2.97、5.04、4.09、4.71、5.04,P均＜0.05),P1、P2组在术后各个时间点VAS评分比较,差异均无统计学意义(t分别=0.57、-5.71、-1.14、-1.79、0.33,P均＞0.05);三组应用吗啡用药病例数及24 h内需要更换敷料的病例数比较,差异均无统计学意义(x2分别=3.03、0.58,P均＞0.05).结论 帕瑞昔布钠40mg,氟比洛芬酯50mg静脉注射均可以减轻腹腔镜胆囊切除术后疼痛,减少术后24 h内吗啡用药.     

Epidural and intrathecal administration of alpha 2-adreno-ceptor agonists for postoperative pain relief

Spinal clonidine interacts with pre- and postsynaptic alpha(2)-adrenoceptors on afferent neurons in the superficial dorsal horn of the spinal cord: it causes analgesia by inhibition of the synaptic and electrotonic neurotransmission of nociceptive impulses. Epidural doses higher than 4 microg/kg have an analgesic onset time of less than 30 min, reduce pain by more than 70 %; these effects last for 4-5 h. Epidural clonidine analgesia is accompanied by a reduction in heart rate, cardiac output and blood pressure of approximately 20 % compared with baseline. The haemodynamic side effects mean close supervision is needed during the first hour after epidural application and limit the use of epidural clonidine to patients who are refractory to the analgesic effects of epidural opioid or local anaesthetics. In these patients excellent results can be achieved either with clonidine alone or with a combination of clonidine and an opioid or a local anaesthetic to exploit the additive or supra-additive interactions of these drugs.     

A survey of Chinese nurses' guidance to parents in children's postoperative pain relief

Aims and objectives. The aim of the study was to describe parental guidance provided by Chinese nurses regarding non‐pharmacological methods in children's surgical pain relief as well as factors related to this. Background. Parental involvement in children's pain management has been acknowledged and encouraged in recent years. However, parents’ lack of related information has been pointed out and little is known about how parents are guided to use non‐pharmacological methods to relieve the pain. Methods. A previously validated European questionnaire survey was conducted in 2002. Structured questionnaires were distributed to all 187 nurses working at 12 surgical wards in five hospitals of Fujian Province, China. The average response rate was 98%. Results. The results show that nurses informed parents of the majority of cognitive information. The most commonly guided non‐pharmacological methods were distraction, positive reinforcement, comforting/reassurance, positioning and relaxation. Nurses’ background factors, including age, education, nursing position, professional work experience, number of their own children and experiences of earlier hospitalizations of their children, were significantly related to their perceptions regarding parental guidance. Conclusions. Chinese nurses provided much guidance to parents on non‐pharmacological methods. However, the results show that sensory information and physical methods were poorly conveyed to parents, which needs future attention to reinforce parents’ active role in pain management. Relevance to clinical practice. This study provides new information on Chinese nurses’ guiding parents to use non‐pharmacological methods in pain alleviation, thereby contributing to the body of knowledge on this subject. Furthermore, the study makes the respondents aware of the importance of involving parents in their child's pain management.     

Acute pain relief

Pain is a multidimensional psychophysiologic phenomenon. Systematic multidimensional assessment is an essential first component of an effective plan to relieve the pain. Nurses are key to effective pain management because of the close, 24-hour-a-day relationship with the hospitalized patient. It is the nurse who is most critical to the adequate assessment of pain, to the implementation of the treatment plan, and to the evaluation of efficacy. Nurses should continue to develop a better knowledge base about pain and pain therapies and assessment skills, be assertive in obtaining effective treatment for their patients, and perceive themselves as responsible for pain relief.