Ketorolac Tromethamine – Routes and Clinical Implications

Opioids have long been used for analgesic purposes for a wide range of procedures. However, the binding of these drugs to opiate receptors has created various challenges to the clinician due to unfavorable side effect profiles and the potential for tolerance and abuse. In 1989, ketorolac became an approved nonsteroidal inflammatory drug (NSAID) for injectable use as an analgesic. Over the last 20 years, numerous studies have been conducted involving ketorolac. These studies have provided additional information about various routes of administration and their effect on the efficacy and the side effect profile of ketorolac. Moreover, ketorolac has been compared with several widely used analgesics. This review evaluates both the potential benefits and potential drawbacks of ketorolac generally, and specifically discusses routes of administration, including their advantages and disadvantages when compared to several traditional analgesics in both inpatient and outpatient settings.     

Pain in older persons with severe dementia. Psychometric properties of the Mobilization–Observation–Behaviour–Intensity–Dementia (MOBID‐2) Pain Scale in a clinical setting

Scand J Caring Sci; 2010; 24; 380–391
Pain in older persons with severe dementia. Psychometric properties of the Mobilization–Observation–Behaviour–Intensity–Dementia (MOBID‐2) Pain Scale in a clinical setting Background: To assess pain in older persons with severe dementia is a challenge due to reduced self‐report capacity. Recently, the development and psychometric property testing of the Mobilization–Observation–Behaviour–Intensity–Dementia (MOBID) Pain Scale was described using video‐recording. The purpose of this article was to present the further development of this instrument. In MOBID‐2 Pain Scale, the assessment of inferred pain intensity is based on patient’s pain behaviours in connection with standardized, guided movements of different body parts (Part 1). In addition, MOBID‐2 includes the observation of pain behaviours related to internal organs, head and skin registered on pain drawings and monitored over time (Part 2). Objective: The aim of this study was to examine psychometric properties of the MOBID‐2 Pain Scale, like inter‐rater and test–retest reliability, internal consistency, as well as face‐, construct‐ and concurrent validity. Subjects and Setting: Patients with severe dementia (n = 77) were examined by 28 primary caregivers in clinical practice, who concurrently and independently completed the MOBID‐2 Pain Scale. Characteristics of the patients’ pain were also investigated by their physicians (n = 4). Results: Prevalence of any pain was 81%, with predominance to the musculoskeletal system, highly associated with the MOBID‐2 overall pain score (rho = 0.82). Most frequent and painful were mobilizing legs. Pain in pelvis and/or genital organs was frequently observed. Moderate to excellent agreement was demonstrated for behaviours and pain drawings (κ = 0.41–0.90 and κ = 0.46–0.93). Inter‐rater and test–retest reliability for pain intensity was very good, ICC (1, 1) ranging 0.80–0.94 and 0.60–0.94. Internal consistency was highly satisfactory; Cronbach’s α ranging 0.82–0.84. Face‐, construct‐ and concurrent validity was good. Overall pain intensity by MOBID‐2 was well correlated with physicians’ clinical examination and defined pain variables (rho = 0.41–0.64). Conclusion: On the basis of pain behaviours, standardized movements and pain drawings, MOBID‐2 Pain Scale was shown to be sufficiently reliable, valid and time‐effective for nurses to assess pain in patients with severe dementia.     

Central pain in multiple sclerosis – Sensory abnormalities

Many patients with multiple sclerosis (MS) develop central neuropathic pain (CP). In the present study somatosensory abnormalities have been analysed in detail in 62 patients with MS and CP (42 women, 20 men; mean age 52 years) and in a control group of 10 women and 6 men (mean age 47 years) with MS and sensory symptoms, but without pain. Assessment included clinical testing and quantitative methods (QST) for the measurement of perception thresholds for touch, vibration, and temperatures. All CP patients except two (97%) had abnormal thresholds for innoxious and/or noxious temperatures, compared to 81% in the control group (p < 0.05). There was a tendency towards the opposite regarding sensibility to touch, which was decreased in 66% vs. 87% (n.s.), vibration (55% vs. 81%; n.s.) and to joint movement (32% vs. 62%; p < 0.04). Comparisons between painful and non‐painful regions showed both the absolute threshold values and the index values to be significantly more abnormal, in the CP regions, for warmth (p < 0.001), cold (p < 0.05), difference limen (innoxious warmth and cold, p < 0.01), cold pain (p < 0.01) and heat pain/cold pain combined (p < 0.001). Also the comparisons between regions with central pain and regions with sensory symptoms in the controls showed significantly more abnormal thresholds in the CP patients for warmth (p < 0.05), cold (p < 0.01), difference limen (innoxious warmth and cold, p < 0.01) and heat pain/cold pain combined (p < 0.001). The results support the general hypothesis that only patients who have lesions affecting the spinothalamo‐cortical pathways run the risk of developing central pain.     

The content of advocacy in procedural pain care – patients’ and nurses’ perspectives

Title. The content of advocacy in procedural pain care ‐ patient’ and nurses’ Perspectives. Aim. This paper is a report of an exploration of the content of nursing advocacy from the point of view of patients and nurses in the context of procedural pain care. Background. Nursing advocacy is every nurse’s professional duty, grounded in patients’ legal and moral rights. Nevertheless, earlier research has approached advocacy as a whistle‐blowing event from the nurse’s perspective. Method. This cross‐sectional study was conducted with a cluster sample of otolaryngology patients (n = 405) and nurses (n = 118) in 11 hospital units in Finland during 2007. The data were collected using an instrument measuring the content of advocacy and analysed statistically. Results. Advocacy in procedural pain care is a process which takes place in the patient–nurse relationship through role identification in decision‐making about pain care. This prompts counselling and responding activities, which in turn lead to some degree of empowerment on the part of both patient and nurse. However, advocacy is partly dependent on the nurse’s own role identification: in the context of pain care it seems that the nurse’s pain care skills and influence over pain care plans are important factors in the decision to advocate or not. At best, patients have some role in decision‐making about their care; at worst, they are subjected to paternalism. Conclusions. Advocacy is an integral part of the nursing care process. It is important that this key ethical aspect of professional nursing is discussed in nursing education and systematically applied in nursing practice through on‐the‐job training, feedback and collaboration.     

Aspirin or paracetamol – what’s good for you?

Paracetamol is widely used as an over the counter analgesic because it is perceived to be safer than aspirin. In carefully selected trial populations, aspirin therapy carries a relatively low (but statistically significant) absolute risk increase in gastrointestinal adverse events. The risk from aspirin may potentially be higher in individuals who have risk factors for peptic ulcer or gastrointestinal haemorrhage. As such, paracetamol may well be the preferred choice in many instances.     

Chronic pain following donor nephrectomy – A study of the incidence,nature and impact of chronic post‐nephrectomy pain

Chronic pain is a consequence of some types of surgery, but its incidence following open donor nephrectomy has never been investigated. We surveyed 123 patients who underwent open donor nephrectomy at our institution over a 10‐year period, to determine the incidence, severity and nature of chronic pain and its effect on quality of life. Of the 81 (66%) responders, 27 (33%) had experienced prolonged pain, and 21 (26%) still had chronic pain related to their surgery. The overall incidence of severe, disabling pain (visual analogue score ≥7) was 12% and of neuropathic pain was 14%. The average loss in quality adjusted life years (QALYs) was 1.053 for chronic pain sufferers, but was 1.851 for those who suffered specifically from neuropathic pain. Only one third of patients with chronic pain were receiving any treatment, and none were receiving neuropathic adjuvants or specialist pain management interventions. We conclude that the incidence of chronic pain following donor nephrectomy is underestimated and therefore under managed. Given the voluntary and altruistic nature of this procedure, and the enormous personal and social benefits which result from successful donor transplantation, those involved with the preparation and post‐operative management should be more aware of, and actively question donors about chronic pain so that diagnosis and appropriate therapy can be commenced as early as possible.     

Psychosocial predictors and correlates for chronic post‐surgical pain (CPSP) – A systematic review

Chronic post‐surgical pain (CPSP) is a serious problem. Incidence as high as 50% has been reported, depending on type of surgery undergone. Because the etiology of chronic pain is grounded in the bio‐psychosocial model, physical, psychological, and social factors are implicated in the development of CPSP. Biomedical factors such as pre‐operative pain, severe acute post‐operative pain, modes of anesthesia, and surgical approaches have been extensively examined, therefore this systematic review focuses on psychosocial elements. A systematic search was performed using the PubMed, PsychINFO, Embase, and Cochrane Databases. Fifty relevant publications were selected from this search, in which psychosocial predictors for and correlates to CPSP were identified. The level of evidence was assessed for each study, and corresponding score points were awarded for ease of comparison. The grade of association with CPSP for each predictor/correlate was then determined. Depression, psychological vulnerability, stress, and late return to work showed likely correlation with CPSP (grade of association=1). Other factors were determined to have either unlikely (grade of association=3) or inconclusive (grade of association=2) correlations. In addition, results were examined in light of the type of surgery undergone. This review is intended as a first step to develop an instrument for identifying patients at high risk for CPSP, to optimize clinical pain management.     

Intranasal fentanyl in 1–3‐year‐olds: A prospective study of the effectiveness of intranasal fentanyl as acute analgesia

The primary objective of the present study was to determine the effectiveness of intranasal fentanyl analgesia in children aged 1–3 years with acute moderate to severe pain presenting to the ED. We also aimed to gather information on the safety and acceptability of intranasal fentanyl in this age group. Two paediatric ED enrolled children aged 1–3 years, with acute moderate or severe pain. Intranasal fentanyl was administered (1.5 µg/kg) via a mucosal atomiser device using a 50 µg/mL solution of fentanyl. Physiological parameters (heart rate, respiratory rate, oxygen saturations and level of consciousness) were measured at regular intervals. Objective pain assessment was completed using the Faces, Legs, Arms, Cry, Consolability (FLACC) score. Forty‐six children presenting with acute moderate to severe pain were included. The median FLACC score before intranasal fentanyl administration was 8 (interquartile range [IQR] 5–10), decreasing to 2 (IQR 0–4) 10 min post fentanyl (P < 0.0001) and 0 (IQR 0–2) 30 min post fentanyl (P < 0.0001). A clinically significant decrease in FLACC scores was seen in 93% of children 10 min post fentanyl administration and 98% of children 30 min post fentanyl. Intranasal fentanyl delivery using a mucosal atomiser was well tolerated by all children. There were no adverse drug reactions or adverse events detected. Intranasal fentanyl is an effective, safe and well‐tolerated mode of analgesia for children aged 1–3 years with moderate to severe pain.     

Neck–shoulder pain and depressive symptoms: A cohort study with a 7‐year follow‐up

Background: The presence of neck–shoulder pain as a predictor of depression is not widely studied. Aim: To analyse the association of neck–shoulder pain at baseline with depressive symptomatology after a 7‐year follow‐up. Methods: A total of 604 subjects who had not had depressive symptomatology at baseline participated in 7‐year follow‐up survey. The number of subjects with depressive symptomatology (Beck Depression Score ≥ 10) after 7‐year follow‐up were measured in three groups – subjects without neck–shoulder pain, with infrequent neck–shoulder pain and with daily neck–shoulder pain at baseline. Results: A total of 77 (13%) participants had developed depressive symptomatology by the follow‐up. Prevalence of depressive symptomatology in follow‐up in subjects without neck–shoulder pain, with infrequent neck–shoulder pain and with daily neck–shoulder pain at baseline pain was 9.5%, 11.2% and 28.4%. In multivariate logistic regression analysis odds for having depressive symptomatology in daily neck–shoulder pain subjects was almost three fold higher (OR, 2.64, 95% CI, 1.27–5.48) compared to those without neck–shoulder pain. Conclusions: Frequent neck–shoulder pain is a preceding symptom for the depressive symptomatology in adults.