The relationship between method of pain management during labor and birth outcomes

This study examined the relationship between method of pain management during labor and birth outcomes. A retrospective comparative chart review of 233 primiparous deliveries was conducted and group assignment was based on method of pain control (nonnarcotic, narcotic, or epidural). Epidural analgesia or anesthesia was associated with increased rates of instrumental and cesarean delivery. Augmentation of labor using a synthetic oxytocin was reported in more charts than expected, and the length of the second stage of labor was longer in those who received epidural analgesia or anesthesia. Apgar scores for those who received early epidural analgesia or anesthesia were lower than for those who received late or no epidural analgesia or anesthesia, although Apgar scores were satisfactory across all groups. Between-groups differences were unrelated to time of epidural placement or maternal temperature. Findings are relevant for maternal child nurses who serve as a resource for families wishing to make informed decisions about pain management in labor.     

Administration of analgesia for acute abdominal pain sufferers in the accident and emergency setting.

BACKGROUND: Recent trials suggest that the early administration of analgesia in patients with acute abdominal pain facilitates examination and does not delay diagnosis. We investigated current practice regarding analgesia for these patients. METHODS: All patients admitted via the accident and emergency department with abdominal pain were included. The main outcome measures evaluated were waiting time for analgesia and its relationship to subjective visual analogue pain scores and clinical diagnoses. RESULTS: Data from 107 consecutive patients were investigated; seven patients were excluded. Forty-two per cent were male. The mean age was 40.1 years (6-85). The mean overall waiting time for analgesia was 1.4 h (2 min to 14 h). Sixty-seven per cent received analgesia within one hour, although 22% waited 2-14 h after presentation. Those with mild pain waited significantly longer for analgesia (mean 247 min) than those with severe pain (mean 82 min; P=0.01). Those with moderate pain had intermediate waiting times (mean 111 min), although they were not statistically different from the severe group (P=0.43). Female patients had to wait longer (mean 129 min) than male patients (mean 69 min; P=0.09 analysis of variance). Of 64% who were general practitioner referrals, only 11% (all severe group, P=0.02) received analgesia in the community. Neither clinical diagnosis nor age influenced the timing of analgesia. Seventy-three per cent received analgesia in the casualty department (mean 0.5 h; range 0.02-3.2), whereas those admitted in the ward without receiving analgesia in casualty had to wait significantly longer for their pain relief (mean 5 h; 1.2-14). CONCLUSION: This study shows the need for standardized protocols for analgesia usage in patients presenting with acute abdominal pain.     

超前镇痛护理干预对全髋置换患者术后疼痛的影响

目的探讨围术期护理干预、超前使用镇痛药物对全髋关节置换患者术后疼痛的影响。方法选择本科收住入院进行全髋置换的患者80例,将患者随机分为对照组和干预组,对照组实施常规的术前、术后护理,干预组在常规护理的基础上,加以超前使用镇痛药物和相关护理干预措施,观察并记录两组患者术后的疼痛评分。结果干预组患者的最高疼痛评分平均值明显低于对照组,两组数据分析显示差异有统计学意义（P〈0.05）。结论骨科患者围术期超前使用西乐葆、特耐等镇痛药物的同时并给予相关护理干预措施,术后的疼痛明显减轻,值得推广使用。     

Clinical validation of FLACC: preverbal patient pain scale

PURPOSE: To test the validity of the Faces, Legs, Activity, Cry and Consolability (FLACC) pain assessment tool by measuring changes in scores in response to analgesics. METHOD: METHODS: Pediatric nurses used the FLACC scale to assess pain in 147 children under 3 years of age who were hospitalized in the pediatric intensive care unit (PICU), post-anesthesia care unit (PACU), surgical/trauma unit, hematology/oncology unit, or infant unit. FLACC is an observational tool for quantifying pain behaviors. Facial expression, leg movement, activity, cry, and consolability are each scored 0-2, for a total FLACC score of 0-10. The FLACC measurements were done pre-analgesia, at predicted onset of analgesia, and at predicted peak analgesia. FINDINGS: Pre-analgesia FLACC scores were significantly higher than post-analgesic scores and significantly higher for patients who received opioids than patients who received non-opioids. Peak analgesia FLACC scores across analgesia groups were not significantly different and reflect effective pain relief for patients regardless of analgesic choice. CONCLUSIONS: The FLACC pain assessment tool is appropriate for preverbal children in pain from surgery, trauma, cancer, or other disease processes. The results support pediatric nurses' clinical judgment to determine analgesic choice rather than providing distinct FLACC scores to guide analgesic selection.     

Racial disparity in analgesic treatment for ED patients with abdominal or back pain

Objective

Research on how race affects access to analgesia in the emergency department (ED) has yielded conflicting results. We assessed whether patient race affects analgesia administration for patients presenting with back or abdominal pain.

Methods

This is a retrospective cohort study of adults who presented to 2 urban EDs with back or abdominal pain for a 4-year period. To assess differences in analgesia administration and time to analgesia between races, Fisher exact and Wilcoxon rank sum test were used, respectively. Relative risk regression was used to adjust for potential confounders.

Results

Of 20?125 patients included (mean age, 42 years; 64% female; 75% black; mean pain score, 7.5), 6218 (31%) had back pain and 13?907 (69%) abdominal pain. Overall, 12?109 patients (60%) received any analgesia and 8475 (42%) received opiates. Comparing nonwhite (77 %) to white patients (23%), nonwhites were more likely to report severe pain (pain score, 9-10) (42% vs 36%; P < .0001) yet less likely to receive any analgesia (59% vs 66%; P < .0001) and less likely to receive an opiate (39% vs 51%; P < .0001). After controlling for age, sex, presenting complaint, triage class, admission, and severe pain, white patients were still 10% more likely to receive opiates (relative risk, 1.10; 95% confidence interval, 1.06-1.13). Of patients who received analgesia, nonwhites waited longer for opiate analgesia (median time, 98 vs 90 minutes; P = .004).

Conclusions

After controlling for potential confounders, nonwhite patients who presented to the ED for abdominal or back pain were less likely than whites to receive analgesia and waited longer for their opiate medication.     

The effect of foot massage on patients'' perception of care following laparoscopic sterilization as day case patients

This randomized-controlled study examined the effects of foot massage on patients' perception of care received following surgery. The sample of 59 women who underwent laparoscopic sterilization as day case patients were randomly allocated into two groups. The experimental group received a foot massage and analgesia post-operatively, whilst the control group received only analgesia post-operatively. Each participant was asked to complete a questionnaire on the day following surgery. This examined satisfaction, memory and analgesia taken. The 76% response rate was comparable with other patient satisfaction studies following day-case surgery. Statistical analysis showed no overall significant difference in the pain experienced by the two groups; however, the mean pain scores recorded following surgery showed a significantly different pattern over time, such that the experimental group consistently reported less pain following a foot massage than the control group. This study has attempted to explore the use of foot massage in a systematic way and is therefore a basis for further study.     

曲马朵超前镇痛复合腹腔内注射罗哌卡因对腹腔镜胆囊切除术后内脏痛的影响

目的观察曲马朵联合腹腔内注射罗哌卡因应用于腹腔镜下胆囊切除术的术后镇痛效果。方法选择行腹腔镜下胆囊切除术的患者60例,随机分为曲马朵复合罗哌卡因组和对照组。2组患者均在手术开始前静脉注射曲马朵100 mg。复合组患者于气腹结束前,向膈下喷洒0.2%罗哌卡因10 mL。在手术缝合腹壁切口前,向每个切口局部注入相同局麻药液5ml。对照组给以同等剂量生理盐水。记录术后2、6、12、24 h VAS评分、镇痛药用量及副反应发生情况。结果复合组于术后2、6、12、24 h的VAS评分显著小于对照组（P〈0.01）。24 h的镇痛药物需求量复合组显著少于对照组（P〈0.01）。结论腹腔镜下胆囊切除术中腹腔内局部应用罗哌卡因联合曲马朵超前镇痛效果良好,可显著减少术后镇痛药需求。     

Epidural analgesia provided during labor by obstetricians: outcome analysis

BACKGROUND: Epidural analgesic has been given during labor by attending obstetricians at Minden Medical Center since 1976. This outcome analysis was done to determine the frequency, effectiveness, and complications of epidural analgesia from January 1, 1993 through December 31, 1995. METHODS: Each of the 1,851 obstetric patient charts for the 3-year period was reviewed retrospectively. RESULTS: Among the 1,704 patients who had labor, 1,565 (91.8%) received epidural analgesia. Epidural analgesia was effective for adequate pain relief in 1,484 patients (94.8%). Hypotension was treated by ephedrine in 24 patients (1.53%). Subarachnoid puncture necessitating a blood patch for treatment of postural headache occurred in 4 patients (0.26%), and unexpected spinal anesthesia occurred in 3 patients (0.19%). A high level of analgesia, above the T5 dermatome, occurred in 16 patients (1.02%). CONCLUSION: Obstetricians at this hospital provided epidural analgesia for a high percentage (91.8%) of patients in labor. Adequate pain relief was obtained in 94.8% of the patients who received epidural analgesia. No serious complications occurred.     

Pain, analgesic use, and morbidity in appendectomy patients

Pain has immunosuppressive effects among the critically and chronically ill, and opioids may immunomodulate pain's deleterious effects. However, little is known about the relations between acute pain, acute illness, and morbidity among previously healthy surgical patients. This study retrospectively examined these relations in appendectomy patients (N = 61). Eleven patients (18%) had morbidity, with atelectasis (11.5%) the most frequent complication. There were no differences between those patients with and without morbidity and pain intensity, method of opioid administration, and total opioid dose. Patients who received nonopioid analgesics received fewer opioids, less preemptive analgesia, and had less morbidity, whereas patients whose appendixes perforated received higher opioid doses and received more preemptive analgesia. Although the relations between acute pain, opioid use, and morbidity among previously healthy surgical patients are unclear, findings infer that clinical practice does not follow guidelines advocated by analgesic experts.     

Time to analgesia for care delivered by nurse practitioners in the emergency department – a retrospective chart audit

ObjectivesTo evaluate quality of care delivered to patients presenting to the emergency department (ED) with pain and managed by emergency nurse practitioners by:

• 1Evaluating time to analgesia from initial presentation
• 2Evaluating time from being seen to next analgesia
• 3Measuring pain score documentation

BackgroundThe delivery of quality care in the emergency department (ED) is emerging as one of the most important service indicators being measured by health services. Emergency nurse practitioner services are designed to improve timely, quality care for patients. One of the goals of quality emergency care is the timely and effective delivery of analgesia for patients. Timely analgesia is an important indicator of ED service performance.MethodsA retrospective explicit chart review of 128 consecutive patients with pain and managed by emergency nurse practitioners was conducted. Data collected included demographics, presenting complaint, pain scores, and time to first dose of analgesia. Patients were identified from the ED patient information system (Cerner log) and data were extracted from electronic medical records.ResultsPain scores were documented in 67 (52.3%; 95% CI: 43.3–61.2) patients. The median time to analgesia from presentation was 60.5 (IQR 30–87) minutes, with 34 (26.6%; 95% CI: 19.1–35.1) patients receiving analgesia within 30 minutes of presentation to hospital. There were 22 (17.2%; 95% CI: 11.1–24.9) patients who received analgesia prior to assessment by a nurse practitioner. Among patients who received analgesia after assessment by a nurse practitioner, the median time to analgesia after assessment was 25 (IQR 12–50) minutes, with 65 (61.3%; 95% CI: 51.4–70.6) patients receiving analgesia within 30 minutes of assessment.ConclusionsThe majority of patients assessed by nurse practitioners received analgesia within 30 minutes after assessment. However, opportunities for substantial improvement in such times along with documentation of pain scores were identified and will be targeted in future research.     

膝关节术后的无痛康复护理

目的 探讨无痛护理方法对膝关节患者术后疼痛、睡眠时间、关节活动度及出院满意度的影响.方法 选择120例实施膝关节手术患者进行随机分为观察组（60例）和对照组（60例）,对照组按照传统护理模式进行护理,观察组按照无痛护理方案进行护理.结果 术后72 h观察组患者的静息痛、活动痛评分与对照组比较差异有统计学意义（P＜0.05）;术后3 d观察组患者的睡眠时间与对照组比较差异有统计学意义（P＜0.05）;术后观察组患者的主动直腿抬高时间、主动屈膝90.时间、出院时膝关节平均活动度与对照组比较差异有统计学意义（P＜0.05）;观察组的出院满意度高于对照组.结论 无痛康复护理措施可以减轻膝关节手术患者的术后疼痛,改善睡眠质量,缩短住院时间,提高患者的出院满意度,同时具有并发症少、安全、可行的优点. 关键词：膝关节手术;无痛康复;护理     

Racial Differences in Receiving Morphine among Prehospital Patients with Blunt Trauma

Background

Pain management is an important part of prehospital care, yet few studies have addressed the effects of age, sex, race, or pain severity on prehospital pain management.

Objectives

To examine the association of sex, age, race, and pain severity with analgesia administration for blunt trauma in the prehospital setting.

Methods

In this retrospective cohort study, we used the automated registry of a large urban Emergency Medical Services agency to identify records of all patients transported for blunt trauma injuries between February 1 and November 1, 2009. We used bivariable and multivariable analyses with logistic regression models to determine the relationship between analgesia administration and patient sex, race, age, pain score on a pain scale, and time under prehospital care.

Results

We identified 6398 blunt trauma cases. There were 516 patients (8%) who received analgesia overall; among patients for whom a pain scale was recorded, 25% received analgesia. By multivariable analysis, adjusting for race, sex, age, time with patient, and pain score, African-American and Hispanic patients were less likely than Caucasian patients to receive analgesia. Pain score and prehospital time were both significant predictors of analgesia administration, with higher pain score and longer prehospital time associated with increased administration of pain medication. Neither sex nor age was a significant predictor of analgesia administration in the regression analysis.

Conclusion

This study suggests that Caucasians are more likely than African-Americans or Hispanics to receive prehospital analgesia for blunt trauma injuries. In addition, patients with whom paramedics spend more time and for whom a pain score is recorded are more likely to receive analgesia.     

Newborn behavioral and physiological responses to circumcision

PURPOSE: To examine the effect of preoperative acetaminophen given as analgesia before circumcision on newborns' behavioral response. STUDY DESIGN AND METHODS: A convenience sample of 53 male newborn infants (GA 35 to 42 weeks) who were.24 hours of age and whose parents had consented to circumcision were enrolled in the study. All of the infants enrolled were the patients of providers who did not routinely use anesthesia for circumcision. They were assigned to two groups based on physician standing order for preoperative acetaminophen. The first group received oral acetaminophen during the preoperative period; the second group received no preoperative analgesia. No further analgesia or anesthesia was given, as was the customary policy. Behavioral observations using the Neonatal Inventory Pain Scale (NIPS) and physiologic monitoring occurred at 5 minutes preoperatively, during application of restraints, at 1-minute intervals intraoperatively and at 5, 15, 30, and 60 minutes postoperatively. RESULTS: There were no differences in the demographic variables between groups. The overall mean NIPS scores for the following characteristics were lower (indicating more relaxation) in newborns who received preoperative analgesia: arm movements (0.27 vs 0.52); leg movements (0.27 vs 0.59); facial expression (0.24 vs 0.27); state of arousal (0.15 vs 0.46); and breathing quality (0.20 vs 0.38). However, newborns who received pre-op analgesia had higher crying scores (0.42 vs 0.33), although both groups had mean crying scores in the lowest range. CLINICAL IMPLICATIONS: Despite its small sample size, this study suggests that preoperative analgesia before circumcision could be helpful in managing the pain of circumcision. Nurses have a responsibility to advocate for policy and practices changes that provide interventions for pain relief for all newborns.     

Naloxone fails to reverse pain thresholds elevated by acupuncture: acupuncture analgesia reconsidered

We were unable to demonstrate the reversal of dental acupunctural analgesia following the injection of 0.4 mg naloxone using evoked potential methodology. Since our findings differed from those of Mayer, Price and Rafii who used pain threshold methods, we attempted to replicate their study. Subjects who demonstrated acupunctural analgesia during electrical stimulation of the LI-4 point on the hands received either 1.2 mg naloxone or normal saline under double blind conditions. Pain thresholds elevated by acupuncture failed to reverse when naloxone was given. Review of experimental design issues, other related human subjects research, and animal studies on acupunctural analgesia provided little convincing evidence that endorphins play a significant role in acupunctural analgesia. Because endorphins can be released in response to a stressor, endorphin presence sometimes correlates with acupunctural treatment in animal studies and some human studies, especially those involving pain patients. The primary analgesia elicited by acupunctural stimulation seems to involve other mechanisms.     

Efficacy of fentanyl analgesia for trauma in critical care transport

INTRODUCTION: Pain relief is one of the most important interventions for out-of-hospital patient care providers. This paper documents the need for and benefits from the administration of fentanyl to trauma patients during critical care transport. METHODS: We underwent a retrospective review of the transport charts of 100 trauma patients who received fentanyl analgesia during transport and who were able to use a numeric response scale to rate their pain from 0 to 10. RESULTS: Mean initial pain report was 7.6 +/- 2.2 units, relieved to 3.7 +/- 2.8 units by a mean total fentanyl dose of 1.6 +/- 0.8 microg/kg (P < .001). Neither initial pain level nor pain relief differed between male and female patients, but did differ between patients originating at the site of injury and those transferred between hospitals. Fentanyl dose correlated poorly with the magnitude of pain relief (r = 0.22), but a dose greater than 2 microg/kg provided more relief than lower doses (5.1 +/- 2.1 vs 3.6 +/- 2.4, P < .02). CONCLUSION: Fentanyl analgesia from these critical care transport teams provided significant pain relief to trauma patients. Pain reduction was greater for patients who received more than 2.0 microg/kg of fentanyl.     

The Effects of Add-On Self-Care Therapy on Epidural Catheter Analgesia and Pain in Patients after Surgical Stabilization of Multiple Rib Fractures

BackgroundEpidural (EPI) catheter analgesia is frequently prescribed as a regional analgesic technique to patients with multiple rib fractures (MRF) following surgical stabilization of rib fractures (SSRF).AimsWe aimed to study the effect of add-on self-care therapy on recovery and quality of life (QoL) in patients on EPI analgesia after surgical stabilization of rib fractures (SSRF).Design/settings/participants/subjectsA total of 267 eligible patients with MRF who received EPI catheter analgesia after SSRF were recruited, and assigned to one of two groups in a random fashion: intervention group received education on self-care therapy, while the control group did not.MethodsPain scores, incentive spirometry (IS) volumes, oxygen saturation (SpO2), respiratory rate, hospital length of stay (LoS) and QoL were evaluated.ResultsCompared with control group, the intervention group showed significantly improved pain scores, IS volume, respiratory rate, and SpO2. Hospital LoS was shorter for the intervention group than the control group. Overall QoL scores in the intervention group were also significantly better than control patients.ConclusionsEducation on self-care therapy significantly benefited pain management, recovery, and QoL for patients with MRF who received EPI catheter analgesia after SSRF operation.     

Comparative evaluation of preventive analgesia with xefocam, ropivacaine, and transdermal drug delivery system of durogesic in patients after craniotomy

The goal of this study was to comparatively evaluate the efficacy of pre-emptive analgesia in patients after supra- and infratentorial craniotomy. Three hundred and sixty-two postcraniotomy patients aged 16 to 72 years were recruited in the study. The patients were divided into 5 groups. The first two groups received traditional analgesia on demand with metamizole sodium and ketoprofen (Group 1) or xefocam (Group 2). Groups 3-5 had different preemptive analgesia modes. Scheduled dosing of xefocam (8 mg i.v. 30 min prior to surgery and then 8 mg every 8 hours within 48 hours) was used in Group 3. Group 4 underwent scalp nerve block and skin infiltration with ropivacaine. Group 5 had a scheduled dosing of fentanyl (12-18 hours before surgery, Durogesic was applied to the patient's skin in a dose 25 microg per hour for 3 days). Postoperative pain was assessed using the visual analogue scale (VAS) at 6, 18, 30, 42, and 54 hours after surgery. The patients who received pre-emptive analgesia showed significantly lower VAS scores than those who had traditional analgesia (p < 0.05).     

The National Trend in Quality of Emergency Department Pain Management for Long Bone Fractures

Background
Despite national attention, there is little evidence that the quality of emergency department (ED) pain management is improving.
Objectives
To compare the quality of ED pain management before and after implementation of the Joint Commission on the Accreditation of Healthcare Organizations' standards in 2001.
Methods
The authors performed a retrospective cohort study by using the National Hospital Ambulatory Medical Care Survey from 1998–2003. Patients who presented to the ED with a long bone fracture (femur, humerus, tibia, fibula, radius, or ulna) were compared. The authors extracted data on patient, visit, and hospital characteristics. The primary outcomes were the proportion of patients who received assessment of pain severity and who received analgesic treatment.
Results
There were 2,064 patients with a qualifying fracture in the study period, 834 from 1998–2000 and 1,230 from 2001–2003. Compared with the early period, a higher proportion of patients in the late period had their pain assessed (74% vs. 57%), received opiates (56% vs. 50%), and received any analgesic (76% vs. 56%). Patients in the late period had higher odds of receiving any analgesia (adjusted odds ratio [OR], 1.43) and opioid analgesia (adjusted OR, 1.27) compared with the early period. Patients in the middle age group (adjusted OR, 2.28) or those seen by physician assistants (adjusted OR, 2.05) were more likely, whereas those with Medicaid (adjusted OR, 0.58) and those in the Northeast were less likely, to receive opiates.
Conclusions
Although the quality of ED pain management for acute fractures appears to be improving, there is still room for further improvement.     

Using a patient-controlled analgesia multimedia intervention for improving analgesia quality

Aim. To evaluate the effects of analgesia quality provided by a patient‐controlled analgesia multimedia intervention on the pain management of postsurgical patients in Taiwan. Background. The concept of patient‐controlled analgesia has become the mainstream pain treatment method because of its characteristic of instant self‐administering medication. It is an important mission of nursing professionals to communicate effective and correct knowledge of patient‐controlled analgesia on how to relieve pain and improve quality of care. Design. A quasi‐experiment research design was used for this study. Sixty subjects recruited from a medical teaching centre of Taiwan were assigned into either the experimental (n = 30) or control group (n = 30). The experimental group received the patient‐controlled analgesia multimedia intervention. The control group only received one‐on‐one patient education of routine nursing guide and pain management with pamphlet. The pain cognition and American Pain Society patient outcome questionnaires were used as measures of effects for the interventions. Results. The results showed the experimental group, compared with the control group, had significant improvement in pain cognition and analgesia quality. There is significant correlation between pain cognition and analgesia quality. Conclusions. After intervening, the patients approved of the patient‐controlled analgesia multimedia intervention and affirmed the value of early acquisition of such information to their postsurgical treatments and recoveries. The higher the pain cognition patients obtained, the better the analgesia quality patients had. Relevance to clinical practice. Applying the patient‐controlled analgesia multimedia intervention for surgical patients to improve pain cognition, the utility of patient‐controlled analgesia, pain relief and patient satisfaction is recommended.