Alex Konstantatos

Predictors of Pain 12 Months after Serious Injury

OBJECTIVE The majority of patients will report pain 12 months after a serious injury. Determining the independent risk factors for pain after serious injury will establish the degree to which high-risk patients can be detected in the acute setting and the viability of early triage to specialist pain services. DESIGN A prospective cohort study of patients following serious injury was conducted. The initial assessment comprised a comprehensive battery of known and possible risk factors for persistent pain. Patients were assessed at 12 months for pain severity and for the presence of chronic pain. RESULTS Two hundred ninety patients underwent an initial assessment of whom 238 (82%) were followed up at 12 months. At 12 months, 171 (72%) patients reported some pain over the past 24 hours. Thirty-five patients (14.7%) reported chronic pain. Five factors independently predicted the 24-hour pain severity: preinjury physical role function, preinjury employment status, initial 24 hours pain score, higher beliefs in the need for medication, and compensable injury (R(2) = 0.21, P < 0.0001). Four factors predicted the presence of chronic pain at 12 months: not working prior to injury, total Abbreviated Injury Scale, initial pain severity, and initial pain control attitudes (pseudo R(2) = 0.24, P = 0.0001). CONCLUSIONS Factors present at the time of injury can allocate patients into high- or low-risk groups. The majority of cases of chronic pain emerging from the high-risk group warrant more intense clinical attention. We recommend recording these factors in discharge documentation as indicators of persistent pain.

Predictors of Pain Severity 3 Months after Serious Injury

OBJECTIVE Injury is a common initiating event for persistent pain. The presentation of injured patients to hospital represents an opportunity to identify patients at high risk of persistent pain and triage them to early intervention. Although a range of physical, psychological, and social risk factors have been implicated in the transition from acute to persistent pain, these factors have not been tested concurrently in a prospective study. This study aimed to determine the degree to which pain severity at 3 months can be predicted at the time of injury and which independent factors predicted pain severity. DESIGN A large prospective cohort study was conducted recruiting patients from two trauma hospitals during their acute admission. Patients were assessed with a comprehensive battery of known and possible risk factors for persistent pain. Patients were assessed for pain severity on a visual analog scale over the past 24 hours at 3 months. RESULTS Two hundred ninety patients were recruited, and 242 were followed up at 3 months. Older age, female gender, past alcohol dependence, lower physical role function, pain severity, amount of morphine equivalents administered on the day of assessment, and pain control attitudes predicted pain severity at 3 months. The variance attributed to these factors was 22%. CONCLUSIONS Injured patients with a number of these factors may warrant increased monitoring and early triage to specialist pain services.

Adjuvant use of intravenous lidocaine for procedural burn pain relief: A randomized double-blind, placebo-controlled, cross-over trial

BACKGROUND Pain is a major issue for patients with severe burn. High dose intravenous opioids form the mainstay of procedural burns pain management; however it was suggested that intravenous lidocaine assists with minimising the pain experience. This study aimed to evaluate whether intravenous lidocaine improved analgesic efficacy and decreased opioid consumption during a burn wound care procedure. METHODS A prospective double-blind randomized crossover study compared intravenous lidocaine versus placebo alongside patient controlled analgesia (PCA) in 45 patients with severe burn undergoing wound care procedures (i.e. dressing change±debridement) on two consecutive days. Subjects were randomised to either the intervention or control condition on the first dressing day, and received the alternate condition on the second dressing day. During the intervention condition, subjects received lidocaine of 1.5 mg/kg/body weight followed by two boluses of 0.5 mg/kg at 5-min intervals followed by a continuous infusion. During the control condition, 0.9% sodium chloride was administered at an equivalent volume, dose and rate to that of lidocaine. Primary end points included pain intensity as measured by verbal rating scale (VRS), time to rescue analgesia, opioid requests and consumption and overall anxiety and level of satisfaction. RESULTS Changes in the VRS score was significantly lower for lidocaine [difference (95% CI)=0.36 (0.17-0.55)] as compared to placebo. However, there were no significant clinical or statistical differences regarding the effects of lidocaine and placebo on opioid requests and consumption, anxiety or level of satisfaction during the first and second dressing procedures. CONCLUSIONS In this study, the clinical benefit of intravenous lidocaine for pain relief during burn wound dressing changes in terms of overall pain scores and opioid consumption was unremarkable. Further investigations using different lidocaine regimes for the management of procedural burn pain are warranted.

Predicting the effectiveness of virtual reality relaxation on pain and anxiety when added to PCA morphine in patients having burns dressings changes.

BACKGROUND Pain arising in burns sufferers is often severe and protracted. The prospect of a dressing change can heighten existing pain by impacting both physically and psychologically. In this trial we examined whether pre-procedural virtual reality guided relaxation added to patient controlled analgesia with morphine reduced pain severity during awake dressings changes in burns patients. METHODS We conducted a prospective randomized clinical trial in all patients with burns necessitating admission to a tertiary burns referral centre. Eligible patients requiring awake dressings changes were randomly allocated to single use virtual reality relaxation plus intravenous morphine patient controlled analgesia (PCA) infusion or to intravenous morphine patient controlled analgesia infusion alone. Patients rated their worst pain intensity during the dressing change using a visual analogue scale. The primary outcome measure was presence of 30% or greater difference in pain intensity ratings between the groups in estimation of worst pain during the dressing change. FINDINGS Of 88 eligible and consenting patients having awake dressings changes, 43 were assigned to virtual reality relaxation plus intravenous morphine PCA infusion and 43 to morphine PCA infusion alone. The group receiving virtual reality relaxation plus morphine PCA infusion reported significantly higher pain intensities during the dressing change (mean=7.3) compared with patients receiving morphine PCA alone (mean=5.3) (p=0.003) (95% CI 0.6-2.8). INTERPRETATION The addition of virtual reality guided relaxation to morphine PCA infusion in burns patients resulted in a significant increase in pain experienced during awake dressings changes. In the absence of a validated predictor for responsiveness to virtual reality relaxation such a therapy cannot be recommended for general use in burns patients having awake dressings changes.

A prospective cohort study comparing early opioid requirement between Chinese from Hong Kong and Caucasian Australians after major abdominal surgery

BACKGROUND The relationship between ethnicity and early opioid consumption is not well understood. Our prospective cohort study tested whether Chinese patients in Hong Kong require less opioid after major abdominal surgery compared with Caucasian patients in Australia. METHODS Matched cohorts of patients from Hong Kong (n=68) and Australia (n=68) were recruited. Patient attitudes and expectations to pain management documented. After operation, all patients received i.v. morphine using a patient-controlled analgesia device. Postoperative opioid consumption, pain intensity, and incidence of opioid-related side-effects were recorded. RESULTS The average (sd) opioid requirement (i.v. morphine equivalent) at 72 h after surgery was significantly less among Chinese patients [86.8 (62.6) mg (95% CI 71.8, 101.8)] compared with Caucasian patients [130.6 (71.9) mg, (P<0.0005) (95% CI 113.4, 147.8)]. Numeric rating scale pain score (0-10) was, however, higher in Chinese patients compared with Caucasian Australians, 5.3 (2.7) vs 4.4 (2.3) (P=0.029). The incidence of pruritus among Chinese patients was significantly higher than Caucasians at 24-48 h (P=0.001) and 48-72 h (P=0.001). Chinese patients also reported a strong preference for others to manage their pain, and their nurse carers were more likely to expect severe pain after surgery. CONCLUSIONS Chinese patients in Hong Kong required less opioid and experienced greater pain intensity and pruritus than Caucasian patients. Clinicians should consider differences in the side-effect profile of morphine and patient expectations related to pain control when planning postoperative analgesia for patients of Chinese ethnicity.

Analgesia Best Practice After Cardiac Surgery

Sources of pain after cardiac surgery include sternotomy, rib retraction, conduit harvest, and drain tubes sites. An analgesic regimen should consider individual patient characteristics, including age, preoperative history of pain and response to analgesics, comorbidities, and psychologic state. Intraoperative and postoperatively administered opioids remain the mainstay of therapy, but adjunctive analgesics such as paracetamol, nonsteroidal anti-inflammatory drugs and tramadol, and regional techniques, can reduce opioid consumption and opioid-induced respiratory depression. This may facilitate earlier tracheal extubation, mobilization, and recovery.

Penthrox alone versus Penthrox plus periprostatic infiltration of local analgesia for analgesia in transrectal ultrasound-guided prostate biopsy

The objective of this study was to compare pain intensity in patients undergoing transrectal ultrasound (TRUS)‐guided biopsy of the prostate with Penthrox alone compared with Penthrox plus periprostatic infiltration of local analgesia (PILA).

The ‘green whistle’: A novel method of analgesia for transrectal prostate biopsy

Periprostatic infiltration of local anaesthetic (PILA) is accepted as the current ‘gold standard’ of analgesia for TRUS‐guided biopsy. However, it does not account for discomfort of anal probe insertion and has not received wide uptake amongst clinicians. A better method is therefore sought. PenthroxTM (methoxyflurane) is an effective systemic analgesic that is self‐administered via a hand‐held inhaler. Its use in TRUS‐guided biopsy has not been previously reported.

A Cross‐Sectional Exploratory Survey of Knowledge, Attitudes and Daily Self‐Reported Pain Assessment Practice among Nurses in Mainland China

AIMS AND OBJECTIVES To describe the level of knowledge, attitudes, and self-reported quality of practice in pain assessment among nurses of Mainland China and explore links with current hospital pain policy and continuing education. BACKGROUND Knowledge is necessary for skilled pain assessment among nurses. Little is currently known regarding knowledge, attitude toward, and self reported pain assessment by nurses from Mainland China. METHODS Quantitative research and cross-sectional convenience sampling assessed nursing knowledge, attitude, and practice among 101 nurses working in high-level hospitals in Mainland China. RESULTS 81.2% of nurses participating in the survey were from high-level (level three) hospitals in Mainland China. 24.8% of the nurses attended continuing education in pain assessment. No nurses from the 76 hospital staffs surveyed were able to recall any hospital policy regarding pain assessment. Knowledge regarding pain assessment was rated at 1.9 (SD = 1.6) on a (0-7) scale. 27.7% of nurses possessed a positive attitude toward pain assessment. Pain assessment was not routine in most of the hospitals surveyed. Nurses who attended continuing education showed greater knowledge and more positive attitudes regarding pain assessment but did not show improvement in their quality of practice. CONCLUSIONS This study identified inadequate knowledge and low level of self-reported pain assessment practice among nurses working in high-level hospitals in Mainland China. Current education did not influence nursing self-reported pain assessment practice. Knowledge of pain evaluation should be improved through newer approaches to education. A better policy framework for pain evaluation may also contribute to improvement.

A Randomized, Double-Blind, Placebo-Controlled Study of the Analgesic Efficacy of Intravenous Acetaminophen in Ambulatory Surgery

Purpose: We investigated whether intraoperative intravenous acetaminophen has the potential to reduce pain after ambulatory surgery and reduce time to discharge from the post anaesthesia care unit and hospital. Methods: We tested this hypothesis by conducting a prospective randomized, double-blind clinical trial in patients undergoing ambulatory surgery. A total of 145 patients were randomized to pre and postoperative placebo (50), intravenous (IV) operative and postoperative oral acetaminophen (49), and pre and postoperative oral acetaminophen (48). Results: The primary end point; visual analogue scale mean pain intensity over 24 hours after completion of surgery, was not significantly different between the 3 groups, control group 2.0 (1.6), mean (SD), (IV) acetaminophen group 2.1 (1.9) and oral acetaminophen group 2.1 (1.6); (p=0.93). Time to fitness for discharge from the postoperative care unit (p=0.77) and time to fitness for discharge from hospital (p=0.27) also did not vary significantly between the three groups. Conclusion: The addition of intraoperative IV acetaminophen to a standard analgesia regimen in patients undergoing ambulatory surgery did not significantly improve pain control or discharge times after surgery compared with pre and postoperative oral acetaminophen or placebo.