Infant Behaviors as Indicators of Established Acute Pain

ISSUES AND PURPOSE. Many infant pain assessment tools use infant behaviors indicative of increased arousal. These tools were developed and tested using clinical situations involving acute immediate pain responses. Are these behaviors valid, clinical indicators of acute established pain (non‐procedurally caused) pain? Can these tools be used to assess acute established infant pain? This article explores research findings to answer these questions. CONCLUSIONS. Findings suggest that behaviors indicative of increased arousal (e.g., crying, facial expressions that accompany crying) are nonspecific indicators of distress rather than independent indicators of established acute pain. Thus, the use of behaviors representing acute immediate pain responses to assess acute established pain, or the use of tools that incorporate these behaviors, can be misleading. PRACTICE IMPLICATIONS. Always use acute immediate pain behavioral responses (behaviors indicative of increased arousal) in conjunction with clinical data concerning “likelihood of pain“ and consolability.     

Validation Study of the Strategic and Clinical Quality Indicators in Postoperative Pain Management Questionnaire in Turkish Surgery Patients

Determining patient satisfaction with postoperative pain management is an important intervention to improve strategies for effective pain control. The aim of this study was to validate an English version of the 14-item Strategic and Clinical Quality Indicators in Postoperative Pain Management questionnaire in Turkish language. The study included 113 patients who underwent elective surgeries at a university hospital in Bursa, Turkey. The data were collected after translation procedures and final adjustments were done on the original instrument. For the total scale, Cronbach’s coefficient α was 0.81 and the main score obtained from the scale was 45.8 ± 10.8. Included were three subscales: nursing interventions, pain management, and environments. Of the patients, 40.7% reported more pain than expected in the postoperative period and their satisfaction with pain relief was 7.4 ± 2.5. This instrument is a reliable and valid instrument in Turkish language and can be used to evaluate the effectiveness of postoperative pain management.     

AAAPT Diagnostic Criteria for Acute Thoracic Surgery Pain

Patients undergoing thoracic surgery experience particular challenges for acute pain management. Availability of standardized diagnostic criteria for identification of acute pain after thoracotomy and video assisted thoracic surgery (VATS) would provide a foundation for evidence-based management and facilitate future research. The Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership with the United States Food and Drug Administration, the American Pain Society (APS), and the American Academy of Pain Medicine (AAPM) formed the ACTTION-APS-AAPM Pain Taxonomy (AAAPT) initiative to address absence of acute pain diagnostic criteria. A multidisciplinary working group of pain experts was invited to develop diagnostic criteria for acute thoracotomy and VATS pain. The working group used available studies and expert opinion to characterize acute pain after thoracotomy and VATS using the 5-dimension taxonomical structure proposed by AAAPT (i.e., core diagnostic criteria, common features, modulating factors, impact/functional consequences, and putative mechanisms). The resulting diagnostic criteria will serve as the starting point for subsequent empirically validated criteria.Perspective ItemThis article characterizes acute pain after thoracotomy and VATS using the 5-dimension taxonomical structure proposed by AAAPT (ie, core diagnostic criteria, common features, modulating factors, impact and/or functional consequences, and putative mechanisms).     

超前镇痛对腰椎术后患者疼痛及睡眠质量的影响

目的:探讨超前镇痛对腰椎术后患者疼痛及睡眠质量的影响。方法:选取2019年7月至2020年6月谷城县人民医院收治的腰椎手术患者78例作为研究对象,随机分为对照组和观察组,每组39例,对照组应用常规镇痛干预,观察组应用超前镇痛干预。结果:观察组术后在3 h、6 h及12 h的评分均明显低于对照组(P<0.05),而术后24 h后的疼痛评分2组为比较差异有统计学意义(P>0.05)。观察组的入睡潜伏期为(31.1±1.5)min短于对照组的(54.9±1.8)min(P<0.05);观察组的实际睡眠时间(6.4±1.2)h长于对照组的(4.1±0.9)h(P<0.05);观察组的睡眠效率为(73.1±1.9)%好于对照组的(53.2±1.7)%(P<0.05)。结论:应用超前镇痛对腰椎术患者进行干预,患者的疼痛获得极大的减轻,提升了患者的睡眠效率,可应用推广。     

Initial validation of the Behavioral Indicators of Infant Pain (BIIP)

Accurate pain assessment in preterm infants in the neonatal intensive care unit (NICU) is complex. Infants who are born at early gestational ages (GA), and who have had greater early pain exposure, have dampened facial responses which may lead to under-treatment. Since behavioral and physiological responses to pain in infants are often dissociated, using multidimensional scales which combine these indicators into a single score may limit our ability to determine the effects of interventions on each system. Our aim was to design a unidimensional scale which would combine the relatively most specific, individual, behavioral indicators for assessing acute pain in this population. The Behavioral Indicators of Infant Pain (BIIP) combines sleep/wake states, 5 facial actions and 2 hand actions. Ninety-two infants born between 23 and 32 weeks GA were assessed during 3, 1 min Phases of blood collection. Outcome measures included changes in BIIP and in Neonatal Infant Pain Scale (NIPS) scores coded in real time from continuous bedside video recordings; changes in heart rate (HR) were obtained using custom physiological processing software. Scores on the BIIP changed significantly across Phases of blood collection (p<0.01). Internal consistency (0.82) and inter-rater reliability (0.80-0.92) were high. Correlations between the BIIP and NIPS were modest (r=0.64, p<0.01) as were correlations between the BIIP and mean heart rate (r=0.45, p<0.01). In this initial study, the BIIP has been shown to be a reliable, valid scale for assessing acute pain in preterm infants in the NICU.     

AAAPT Diagnostic Criteria for Acute Pain Following Breast Surgery

Acute pain after breast surgery decreases the quality of life of cancer survivors. Previous studies using a variety of definitions and methods report prevalence rates between 10% and 80%, which suggests the need for a comprehensive framework that can be used to guide assessment of acute pain and pain-related outcomes after breast surgery. A multidisciplinary task force with clinical and research expertise performed a focused review and synthesis and applied the 5 dimensional framework of the AAAPT (Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks [ACTTION], American Academy of Pain Medicine [AAPM], American Pain Society [APS] Pain Taxonomy) to acute pain after breast surgery. Application of the AAAPT taxonomy yielded the following: 1) Core Criteria: Location, timing, severity, and impact of breast surgery pain were defined; 2) Common Features: Character and expected trajectories were established in relevant surgical subgroups, and common pain assessment tools for acute breast surgery pain identified; 3) Modulating Factors: Biological, psychological, and social factors that modulate interindividual variability were delineated; 4) Impact/Functional Consequences: Domains of impact were outlined and defined; 5) Neurobiologic Mechanisms: Putative mechanisms were specified ranging from nerve injury, inflammation, peripheral and central sensitization, to affective and social processing of pain.PerspectiveThe AAAPT provides a framework to define and guide improved assessment of acute pain after breast surgery, which will enhance generalizability of results across studies and facilitate meta-analyses and studies of interindividual variation, and underlying mechanism. It will allow researchers and clinicians to better compare between treatments, across institutions, and with other types of acute pain.     

Postoperative Pain Trajectories in Chronic Pain Patients Undergoing Surgery: The Effects of Chronic Opioid Pharmacotherapy on Acute Pain

For 2 weeks following surgery, 55 patients with preexisting chronic pain (CP) reported daily postoperative pain with movement and at rest. Of these, 30 CP patients used opioid pharmacotherapy for CP management and 25 did not. We modeled pain resolution in each patient using a linear fit so that each patient yielded 2 scores for each pain rating: 1) an intercept, or initial level of pain, immediately after surgery; and 2) a slope, or rate of pain resolution. The patients not using opioid pharmacotherapy had a mean pain with movement intercept of 5.4 and a slope of −.20, while the patients using opioid pharmacotherapy had a significantly higher mean intercept of 7.68 (P = .001) and a slope of −.21, sustaining higher pain levels over days. The opioid pharmacotherapy patients had the same rate of pain resolution as the other CP patients, and both groups resolved their pain more slowly than normal surgery patients. Preexisting CP may predispose a patient undergoing surgery to a slower rate of postoperative pain resolution. Chronic pain patients who use opioids share this predisposition but in addition, they are at risk for markedly higher postoperative pain across the entire pain resolution trajectory.

Perspective

This is an observational rather than a randomized controlled study, and as such is less definitive. Nonetheless, these findings are consistent with those of animal studies showing that prolonged exposure to opioids can produce opioid-induced hyperalgesia. Patients with opioid pharmacotherapy for chronic pain who undergo surgery merit special attention for acute pain management.     

Validation and Scoring of the Greek Version of the Strategic and Clinical Quality Indicators in Postoperative Pain Management (SCQIPP) Questionnaire

PurposeThe aim of this study was to validate the Greek version of the Strategic and Clinical Quality Indicators in Postoperative Pain Management (SCQIPP) questionnaire.DesignThe study was designed as a prospective questionnaire survey.MethodsOverall, 210 elective surgical patients were included . SCQIPP consisted of 14 items that were scored on a five point scale. After the translation and linguistic adjustments, the tool was distributed to the surgical wards. Internal consistency reliability was assessed by Cronbach's alpha. The tool construct was generated by a principal axis factoring model with promax rotation.FindingsBase Cronbach's alpha was 0.814. Due to low inter-item and item-total correlations and the increase of Cronbach's alpha (0.834) when item two was deleted, 13 items were included in the current tool version. Factor analysis identified three district subscales: nursing care, pain management, and support. Subscale and convergent validity were confirmed. The mean score of the validated tool was 55.2 (Range: 44-63). A low level of care was highlighted in most items.ConclusionsThe Greek version of the SCQIPP questionnaire is a valid and efficient tool for the evaluation of the quality of care of postoperative pain management.     

鼻部术后疼痛控制的护理现状

疼痛是一种令人不快的主观感受和情绪体验,是临床上最常见的症状之一。鼻部术后疼痛集中在术后24～48h,主要是因麻醉药物效果的消失及填塞物对周围组织的压迫和刺激所致,常伴有头痛、头晕等其他不适,直接影响患者的睡眠、饮食、呼吸及情绪。因此,充分止痛是减轻鼻部手术患者痛苦、保证术后顺利恢复的重要环节。本文综述鼻部术后疼痛的程度和原因、疼痛控制的影响因素与现状,以期对提高专科护理质量有所帮助。     

氟比洛芬酯用于开胸术后静脉镇痛的临床研究

目的 观察开胸术后患者自控静脉镇痛中氟比洛芬酯镇痛效果与不良反应、及对凝血功能的影响.方法 选择行开胸手术患者60例均分为三组,A组术后镇痛给予舒芬太尼200μg稀释到盐水100mL;B组关胸前静脉注射氟比洛芬酯50mg,术后镇痛给予舒芬太尼200μg稀释到盐水100mL;C组灭胸前静脉注射氟比洛芬酯50mg,术后镇痛给予舒芬太尼200μg＋氟比洛芬酯100mg稀释到盐水100mL.三组PCIA泵的设置维持量1.2mL/h,单次负荷剂量1.2mL,锁定时间20min.观察三组术后24h,48h的镇痛评分（VAS评分）和不良反应的发生情况,并于术前、术后24h,48h采用Sonoclot凝血与血小板功能分析仪评定三组患者凝血功能.结果 三组镇痛效果均满意,而B组恶心,呕叶等药物不良反应发生率低于A、C组（P〈0.05）.B、C两组舒芬人尼用量及患者按压次数均低于A组（P〈0.05）.三组间镇痛治疗后凝血功能变化差异无统计学意义.结论 氟比洛芬酯联合舒芬太尼用于开胸术后的镇痛效果与单纯舒芬太尼相似,但不良反应明显降低,且对凝血功能无明显影响.     

Risk Indicators in Low Back Pain

Injuries leading to low back pain can occur by direct trauma, overexertion or repetitive trauma. Overexertion is claimed by 60% of low back pain patients as the cause of injury. Of these patients with overexertion injuries, 66% implicated lifting and 20% pushing or pulling. It is, however, difficult to relate the workplace to the complaint of low back pain in a specific worker, and low back pain is found quite often in those with sedentary occupations.

The incidence, severity and potential disability are all related to the demands on the individual in the workplace. Among the factors implicated are the requirements for lifting (particularly when compared to the worker's lifting capacity), pushing and pulling, posture, and cyclic loading. Drivers of heavy vehicles have two to four times the average incidence of serious low back pain. This is probably due to the cyclic loading environment.

The general psychosocial environment (including that at work) is an important risk factor. The first attack of low back pain occurs in the teens or twenties. Low back pain is as frequent in females as males, although women in manual materials handling jobs are at greater risk. Posture, anthropometry and mobility measures have limited prognostic value. Muscle strength and physical fitness probably have some value. Radiographic findings have little pragmatic value.     

Psychosocial Predictors of Acute and Chronic Pain in Adolescents Undergoing Major Musculoskeletal Surgery

Acute and chronic pain delay recovery and impair outcomes after major pediatric surgery. Understanding unique risk factors for acute and chronic pain is critical to developing effective treatments for youth at risk. We aimed to identify adolescent and family psychosocial predictors of acute and chronic postsurgical pain after major surgery in adolescents. Participants included 119 youth age 10 to 18 years (M_age = 14.9; 78.2% white) undergoing major musculoskeletal surgery and their parents. Participants completed presurgery baseline questionnaires, with youth reporting on baseline pain, anxiety, depression, insomnia and sleep quality, and parents reporting on parental catastrophizing and family functioning. At baseline, 2-week, and 4-month postsurgery, youth completed 7 days of daily pain diaries and reported on health-related quality of life. Sequential logistic regression models examined presurgery predictors of acute and chronic postsurgical pain, defined as significant pain with impairment in health-related quality of life. Acute pain was experienced by 27.2% of youth at 2 weeks, while 19.8% of youth met criteria for chronic pain at 4 months. Baseline pain predicted acute pain (odds ratio [OR] = 1.96; 95% confidence interval [CI] = 1.32–2.90), while depressive symptoms (OR = 1.22; 95%CI = 1.01–1.47), and sleep quality (OR = 0.26; 95%CI = 0.08–0.83) predicted chronic pain. Tailored interventions need to be developed and incorporated into perioperative care to address risk factors for acute and chronic pain.PerspectiveLongitudinal results demonstrate adolescents’ presurgery pain severity predicts acute postsurgical pain, while depressive symptoms and poor sleep quality predict chronic postsurgical pain. Tailored interventions should address separate risk factors for acute and chronic pain after adolescent surgery.     

AAAPT Diagnostic Criteria for Acute Abdominal and Peritoneal Pain After Surgery

Abdominal and peritoneal pain after surgery is common and burdensome, yet the lack of standardized diagnostic criteria for this type of acute pain impedes basic, translational, and clinical investigations. The collaborative effort among the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks, American Pain Society, and American Academy of Pain Medicine Pain Taxonomy (AAAPT) provides a systematic framework to classify acute painful conditions. Using this framework, a multidisciplinary working group reviewed the literature and developed core diagnostic criteria for acute abdominal and peritoneal pain after surgery. In this report, we apply the proposed AAAPT framework to 4 prototypical surgical procedures resulting in abdominal and peritoneal pain as examples: cesarean delivery, cholecystectomy, colorectal surgical procedures, and pancreas resection. These diagnostic criteria address the 3 most common surgical procedures performed in the United States, capture diverse surgical approaches, and may also be applied to other surgical procedures resulting in abdominal and peritoneal pain. Additional investigation regarding the validity and reliability of this framework will facilitate its adoption in research that advances our comprehension of mechanisms, deliver better treatments, and help prevent the transition of acute to chronic pain after surgery in the abdominal and peritoneal region.PerspectiveUsing AAAPT, we present key diagnostic criteria for acute abdominal and peritoneal pain after surgery. We provide a systematic classification using 5 dimensions for abdominal and peritoneal pain that occurs after surgery, in addition to 4 specific surgical procedures: cesarean delivery, cholecystectomy, colorectal surgical procedures, and pancreas resection.     

Linguistic Indicators of Pain Catastrophizing in Patients With Chronic Musculoskeletal Pain

The present study examined markers of pain catastrophizing in the word use of patients with chronic pain. Patients (N = 71) completed the Pain Catastrophizing Scale and wrote about their life with pain. Quantitative word count analysis examined whether the essays contained linguistic indicators of catastrophizing. Bivariate correlations showed that catastrophizing was associated with greater use of first person singular pronouns, such as “I” (r = .27, P ≤ .05) and pronouns referencing other people (r = .28, P ≤ .05). Catastrophizing was further significantly associated with greater use of sadness (r = .35, P ≤ .01) and anger (r = .30, P ≤ .05) words. No significant relationships with positive emotion and cognitive process words were evident. Controlling for patients' engagement in the writing task, gender, age, pain intensity, and neuroticism in multiple regression, the linguistic categories together uniquely explained 13.6% of the variance in catastrophizing (P ≤ .001). First person singular pronouns (β = .24, P ≤ .05) and words relating to sadness (β = .25, P ≤ .05) were significant, and pronouns referencing other people (β = .19, P ≤ .10) were trending. The results suggest that pain catastrophizing is associated with a “linguistic fingerprint” that can be discerned from patients’ natural word use.