Elizabeth G. VanDenKerkhof

Definitions of "respiratory depression" with intrathecal morphine postoperative analgesia: a review of the literature.

PurposeTo review the postoperative intrathecal morphine (ITM) analgesia literature for their definitions of “respiratory depression” (RD).SourceMedline (1966 — June Week 5 2001) and reference lists were searched for original studies involving bolus-dose ITM for postoperative analgesia, which used “respiratory depression” or similar terms.Principal findingsThe search identified 209 studies. These were included if ITM use was appropriate (bolus dose, postoperative analgesia) and the term “respiratory depression” was used, which left 96 studies remaining. Forty-four (46%) did not define “RD” despite using this term. A further 24 (25%) defined RD with respiratory rate (RR) alone. Only 28 (29%) defined RD with more than RR alone. There was no statistically significant association between the presence of a definition for RD with study design, study size or publication period. Also, no significant association existed between rigorousness of RD definitions and the above factors.ConclusionThe term “respiratory depression” has no clear definition from a review of the literature on ITM use for postoperative analgesia. While defining RD with bradypnea is superior to having no definition, this is still inadequate. In future research, the consistent use of terms with specific meanings will facilitate understanding the true incidence of ITM’s respiratory effects. If “respiratory depression” is used, then an explicit definition of its meaning should be provided. Future research must also address what is clinically significant respiratory impairment from intrathecal opioids, and how to optimally monitor for this. Further delineating their risksvs benefits will allow for more optimal dosing.RésuméObjectifPasser en revue les documents sur l’analgésie postopératoire, réalisée avec la morphine intrathécale (MIT), quant à leurs définitions de la “dépression respiratoire” (DR).SourceLa base Medline (1966 — Semaine 5, juin 2001) et les listes de lectures de référence ont été fouillées à la recherche d’études originales sur des bolus de MIT administrés comme analgésie postopératoire, et dans lesquelles on retrouve le terme “dépression respiratoire” ou des termes similaires.Constatations principalesLa recherche nous a fourni 209 études. Les études (96) comportant un usage approprié de la MIT (dose en bolus, analgésie postopératoire) et l’utilisation du terme “dépression respiratoire” ont été retenues. Malgré l’utilisation du terme “DR”, 44 études (46 %) ne la définissaient pas. D’autres études, 24 (25 %), n’utilisaient que le terme “fréquence respiratoire” (FR) pour définir la DR. Seulement 28 (29 %) études en donnaient une définition plus large. Il n’y avait pas d’association significative entre la présence d’une définition de la DR et le devis de l’étude, sa taille ou sa date de publication. Aussi, aucune association significative n’a été trouvée entre la rigueur des définitions de la DR et les facteurs susmentionnés.ConclusionLe terme “dépression respiratoire” n’a pas de définition claire dans les documents examinés sur l’usage de la MIT comme analgésie postopératoire. Il est préférable de définir la DR par la bradypnée que de ne pas la définir, mais cela demeure incomplet. À l’avenir, l’usage uniforme de termes et de leurs définitions spécifiques facilitera la compréhension de la véritable incidence des effets respiratoires de la MIT. Le terme “dépression respiratoire” doit être accompagné d’une définition explicite. Les recherches à venir doivent traiter des affections respiratoires cliniques significatives causées par les opioïdes intrathécaux et de la façon de les déceler le plus efficacement. En déterminant davantage leurs risques et leurs bienfaits, nous pourrons en établir une posologie optimale.

Prevalence and determinants of pain and pain-related disability in urban and rural settings in southeastern Ontario

BACKGROUND Canadian chronic pain prevalence estimates range from 11% to 66%, are affected by sampling and measurement bias, and largely represent urban settings. OBJECTIVES To estimate chronic pain prevalence and factors associated with pain in southeastern Ontario, a region with a larger rural than urban residence. METHODS A systematic sampling with a random start was used to contact households. A telephone-administered questionnaire using the Graded Chronic Pain Scale, with questions on health care and medication use, health status, depression and demographics, was administered to consenting adults (18 to 94 years of age; mean age 50.2+/-16.6 years). RESULTS The response rate was 49% (1067 of 2167), with 76% reporting some pain over the past six months. Low pain intensity with low pain interference prevalence was 34% (grade I), high pain intensity with low pain interference was 26% (grade II), and high pain intensity with high pain interference was 17% (grades III and IV). Of those reporting pain, 49% reported chronic pain (ie, pain for a minimum of 90 days over the past six months) representing 37% of the sample. Being female, unmarried, lower income, poorer self-reported health status and rural residence were associated with increasing pain. Once depression was considered in this pain analysis, residence was no longer significant. Lower rates of health care utilization were reported by rural residents. In those reporting the highest pain grades, poor health, greater medication and health care use, depression and more pain sites were associated with higher odds for pain-related disability. CONCLUSION There is an elevated prevalence of pain in this almost equally split rural/urban region. Further examination of health care utilization and depression is suggested in chronic pain prevalence research.

Impact of perioperative pain intensity, pain qualities, and opioid use on chronic pain after surgery: a prospective cohort study.

Background and Objectives A better understanding of the pathogenesis of chronic postsurgical pain is needed in order to develop effective prevention and treatment interventions. The objective of this study was to evaluate the incidence and risk factors for chronic postsurgical pain in women undergoing gynecologic surgery. Methods Pain characteristics, opioid consumption, and psychologic factors were captured before and 6 months after surgery. Analyses included univariate statistics, relative risks (RRs) and 95% confidence intervals (95% CIs), and modified Poisson regression for binary data. Results Pain and pain interference 6 months after surgery was reported by 14% (n = 60/433) and 12% (n = 54/433), respectively. Chronic postsurgical pain was reported by 23% (n = 39/172) with preoperative pelvic pain, 17% (n = 9/54) with preoperative remote pain, and 5.1% (n = 10/197) with no preoperative pain. Preoperative state anxiety (RR = 1.8; 95% CI, 1.1–2.8), preoperative pain (pelvic RR = 3.7; 95% CI, 1.9–7.2; remote RR = 3.0; 95% CI, 1.3–6.9), and moderate/severe in-hospital pain (RR = 3.0; 95% CI, 1.0–9.4) independently predicted chronic postsurgical pain. The same 3 factors predicted pain-interference at 6 months. Participants describing preoperative pelvic pain as “miserable” and “shooting” were 2.8 (range, 1.3–6.4) and 2.1 (range, 1.1–4.0) times more likely to report chronic postsurgical pain, respectively. Women taking preoperative opioids were 2.0 (range, 1.2–3.3) times more likely to report chronic postsurgical pain than those not taking opioids. Women with preoperative pelvic pain who took preoperative opioids were 30% (RR = 1.3; 95% CI, 0.8–1.9) more likely to report chronic postsurgical pain than those with preoperative pelvic pain not taking opioids. Conclusions Preoperative pain, state anxiety, pain quality descriptors, opioid consumption, and early postoperative pain may be important predictors of chronic postsurgical pain, which require further investigation.

Pain Prevalence in Nine- to 13-Year-Old School Children

BACKGROUND Despite significant progress in the epidemiology of chronic pain in adults, major gaps remain in our understanding of the epidemiology of chronic pain in children. In particular, the incidence, prevalence and sensory characteristics of many types of pain in Canadian children are unknown. OBJECTIVES A study to obtain the lifetime and point prevalence of common acute pains, recurrent pain syndromes and chronic pains was conducted in a cohort of 495 school children, nine to 13 years of age, in eastern Ontario. METHODS Children reported their pain experiences and described the intensity, affect and duration of the pains experienced over the previous month by completing the Pain Experience Interview -- Short Form. RESULTS The majority of children (96%) experienced some acute pain over the previous month, with headache (78%) being most frequently reported. Lifetime prevalence for certain acute pains differed significantly by sex (P<0.05). Fifty-seven per cent of children reported experiencing at least one recurrent pain, while 6% were identified as having had or currently having chronic pain. DISCUSSION The prevalence of acute pain in this Canadian cohort is consistent with international estimates of acute pain experiences (ie, headache) and recurrent pain problems (ie, recurring headache, abdominal pain and growing pains). However, 6% of children reported chronic pain. The self-completed Pain Experience Interview--Short Form provides a feasible administration technique for obtaining population estimates of childhood pain, and for conducting longitudinal studies to identify risk and prognostic factors for chronic pain.

Chronic Pain After Surgery Time for Standardization? A Framework to Establish Core Risk Factor and Outcome Domains for Epidemiological Studies

Introduction and Objectives:Many studies have reported putative factors for the development of chronic pain after surgery. However, advances in knowledge about the etiology and prognosis of chronic postsurgical pain (CPSP) could be gained by improving methodology within studies of surgical pain. The purpose of this study was to review predictive factors and to propose core risk factor and outcome domains for inclusion in future epidemiological studies investigating CPSP. Methods:Using the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials as a framework we reviewed risk factor and outcome domains, methodological issues and standardized measurement tools based on findings from narrative and systematic reviews, primary clinical and epidemiological studies and published guidelines for chronic pain clinical trials. Results:Five “core” risk factor domains (demographic, pain, clinical, surgery-related, and psychological) and 4 outcome domains (pain, physical functioning, psychological functioning, and global ratings of outcome) were identified. Important methodological issues, related to the definition and timing of follow-up to assess transition from acute to chronic pain are discussed. We also propose the use of validated, standardized measurement tools to capture risk factor and outcome domains at multiple time points. Discussion:There is potential to advance the field of CPSP research by striving for consensus among pain experts; this would advance current evidence by improving our ability to compare findings from different studies and would facilitate the aggregation of surgical cohort datasets to allow international comparisons. We propose these findings as a starting point to build a comprehensive framework for epidemiological studies investigating chronic pain after surgery.

Informed consent for labour epidurals : what labouring women want to know

Purpose: To determine A) what a labouring woman expects to hear about epidural analgesia before consenting, B) if she feels able to understand the risks and thereby assess if we are obtaining informed consent.Methods: Sixty actively labouring women were surveyed immediately after requesting an epidural. Demographic, labour, epidural and consent information were included in the questionnaire. Answers were categorical (yes/no, multiple choice) or scored on a scale from 0 to 10 (visual analogue scale).Results: The majority of parturients wanted all potential epidural complications but not their incidences disclosed in the consent process. However, a discussion of risks would not dissuade women from consenting to an epidural in the majority of cases. Labouring women have a moderate understanding of epidural risks. The ability to understand risks was not affected by labour pain, anxiety, opioid premedication, duration of labour pain, desire for an epidural, previous epidural experience, level of education or age.Conclusion: This prospective survey characterizes what 60 reasonable labouring women wanted to know about labour epidural analgesia. Parturients wanted all risks of epidural analgesia disclosed in the informed consent process. The majority of women did not want the incidences quoted. This study suggests that labouring patients are as able to give informed consent as are other members of our patient population.RésuméObjectif: Déterminer ce qu’une parturiente en travail voudrait connaître de l’analgésie épidurale avant de consentir à la recevoir et vérifier si elle croit en comprendre les risques. De là, évaluer si nous obtenons un consentement éclairé.Méthode: On a interrogé 60 femmes en travail obstétrical actif immédiatement après leur demande d’une analgésie épidurale. Le questionnaire comprenait des données personnelles, des informations sur le travail, l’analgésie épidurale et le consentement. Les résponses étaient catégorielles (oui/non, choix multiples) ou cotées sur une échelle visuelle analogique de 1 à 10.Résultats: La majorité des femmes voulait que toutes les complications possibles de l’analgésie épidurale soient révélées dans la formule de consentement, mais non leur incidence. Une discussion sur les risques ne les a pas empêchées d’accepter cette analgésie dans la majorité des cas. Les femmes en travail ont une connaissance moyenne des risques de l’analgésie épidurale. La capacité de comprendre les risques n’a pas été influencée par les douleurs du travail, l’anxiété, la prémédication avec des opioïdes, la durée des douleurs, le désir d’une analgésie épidurale, l’expérience antérieure de cette analgésie, le niveau d’éducation ou l’âge.Conclusion: Cette enquête prospective a précisé ce que 60 parturientes en travail obstétrical veulent connaître sur l’analgésie épidurale. Elles ont demandé que tous les risques de l’analgésie épidurale soient inscrits à la formule du consentement éclairé, mais la majorité ne voulait pas qu’on y ajoute l’incidence. Cette enquête permet d’affirmer que les patientes en travail peuvent donner leur consentement éclairé aussi bien que tout autre patient.

Using a personal digital assistant enhances gathering of patient data on an acute pain management service: a pilot study

PurposeHandheld computer technology provides a unique opportunity for health care professionals to access real time or near real time patient information and evidence-based resources at the point-of-care. The purpose of this study was to assess one physician’s experience using acute pain assessment software on a personal digital assistant (PDA) to assess patients on an acute pain management service (APMS).MethodsUsing a historical control and a “time and motion” study design, comparisons were made on acute pain assessment time and comprehensiveness when patient assessments are documented on a PDA vs the current paper-based method.ResultsThe study physician (a PDA-user) reported feeling comfortable with the assessment software after five patient assessments. PDA assessments were more likely to contain documentation regarding pain and side effects (e.g., nausea, pruritus, hypotension) than the paper assessments. The median time of the “assessment only” component of the patient encounter was 53 sec longer using the PDA compared to paper (P < 0.00), however, the median “total encounter” (chart review, assessment, documentation) time was 74 sec shorter using the PDA vs paper (P < 0.00).DiscussionThe findings of this preliminary study suggest that the PDA is a reliable tool that meets the data management requirements within an APMS setting. This study found that patient assessments documented using acute pain software developed for use on a PDA were as efficient and content-rich as paper assessments. The PDA may even enhance the efficiency of the patient assessment process through the provision of more comprehensive digital data for research, clinical, and administrative needs.RésuméObjectifLordinateur nomade offre une chance unique aux professionnels de la santé d’accéder en temps réel ou presque à des renseignements sur le patient et à des ressources cliniques sur place. Notre objectif était d’estimer l’expérience d’un médecin qui utilise le logiciel d’évaluation de la douleur aiguë sur un assistant numérique personnel (ANP) pour examiner les patients d’un service de traitement de la douleur aiguë (STDA).MéthodeDans notre étude de type contrôle historique et tempsmouvement, nous avons comparé le temps et la représentativité de l’évaluation de la douleur aiguë pour des études de patients documentées sur ANP vs la méthode courante sur papier.RésultatsLe médecin (un utilisateur d’ANP) s’est dit à l’aise avec le logiciel après cinq évaluations. Les examens avec l’ANP ont plus de chance de contenir de la documentation sur la douleur et les effets secondaires (comme les nausées, le prurit, l’hypotension) que celles sur papier. Le temps moyen de la partie ‘évaluation seule’ de la rencontre avec le patient a été plus longue de 53 sec avec l’ANP, comparé au papier (P < 0,00), mais le temps moyen de ‘l’entrevue complète’ (revue du dossier, évaluation, documentation) a été plus court de 74 sec avec l’ANP vs le papier (P < 0,00).DiscussionLes résultats de cette étude préliminaire indiquent que l’ANP est un outil fiable qui répond aux exigences de gestion des données dans le cadre d’un STDA. Les évaluations de patients documentées à l’aide du logiciel sur la douleur aiguë, mis au point pour un usage sur ANP, ont été aussi efficaces et riches de contenu que les évaluations sur papier. L’ANP peut même améliorer le procédé d’évaluation du patient en fournissant plus de données numériques détaillées pour la recherche, les besoins cliniques et administratifs.

The epidemiology of chronic pain in Canadian men and women between 1994 and 2007: Results from the longitudinal component of the National Population Health Survey

BACKGROUND: The epidemiology of chronic pain is poorly understood due to a paucity of longitudinal studies limiting the ability to develop prevention strategies for a condition resistant to many current therapies.

A comparison of paper with electronic patient-completed questionnaires in a preoperative clinic

In this unblinded randomized control trial we compared electronic self-administered Pre-Admission Adult Anesthetic Questionnaires (PAAQ) using touchscreen technology with pen and paper. Patients were recruited in the Preassessment Clinic if they had completed a PAAQ in the surgeon’s office. Patients were randomized to study PAAQ using paper, hand-held computer (PDA), touchscreen desktop computer (kiosk), or tablet. Patients also completed a preference and satisfaction survey. The main outcome measures were percent agreement between the prestudy and study PAAQ and time to completion. Only six of the 366 patients approached refused to participate. The median time to completion of the PAAQ was shortest on the kiosk (2.3 min) and longest on the PDA (3.2 min) (&khgr;2 = 14.5; P = 0.002). The mean agreement between the prestudy and the study PAAQ was approximately 94% across all study arms. The proportion of participants expressing comfort before and after completing the PAAQ increased from 10% to 97% on the computerized arms and from 60% to 64% on the paper arm. Touchscreen computer technology is an accurate, efficient platform for patient-administered PAAQ. Patients expressed comfort using the technology and preference for computerized versus paper for future questionnaires.

In Canada, anesthesiologists are less likely to respond to an electronic, compared to a paper questionnaire

PurposeA randomized unblinded controlled trial was used to assess the utility of electronic questionnaires in a survey of Canadian anesthesiologists.MethodsPostal or electronic questionnaires were sent between November 2001 and March 2002 to 1,333 anesthesiologists registered with the Canadian Anesthesiologists’ Society. The primary outcome measure was the difference in response rates between electronic and postal questionnaires. Secondary outcome measures included a comparison of demographic characteristics, cost, and knowledge and practice regarding prophylactic perioperative beta blockade.ResultsThe overall response rate was 52%. E-mail participants were half as likely as postal participants to respond to the questionnaire (35% vs 69%, relative risk = 0.51, 95% confidence interval 0.45–0.58). Respondents who provided an e-mail address were younger and more likely to be affiliated with an academic institution. There were no significant differences in responses to knowledge and practice questions. The electronic arm was faster than the postal arm and the cost per reply was one-third the cost of the postal arm (