Lorie Rietman Wild

Pain behaviors observed during six common procedures: Results from Thunder Project Ii*

ObjectivePatients frequently display behaviors during procedures that may be pain related. Clinicians often rely on the patient’s demonstration of behaviors as a cue to presence of pain. The purpose of this study was to identify specific pain-related behaviors and factors that predict the degree of behavioral responses during the following procedures: turning, central venous catheter insertion, wound drain removal, wound care, tracheal suctioning, and femoral sheath removal. DesignProspective, descriptive study. SettingMultiple units in 169 hospitals in United States, Canada, England, and Australia. PatientsA total of 5,957 adult patients who underwent one of the six procedures. InterventionsNone. Measurements and Main ResultsA 30-item behavior observation tool was used to note patients’ behaviors before and during a procedure. By comparing behaviors exhibited before and during the procedure as well as behaviors in those with and without procedural pain (as noted on a 0–10 numeric rating scale), we identified specific procedural pain behaviors: grimacing, rigidity, wincing, shutting of eyes, verbalization, moaning, and clenching of fists. On average, there were significantly more behaviors exhibited by patients with vs. without procedural pain (3.5 vs. 1.8 behaviors; t = 38.3, df = 5072.5; 95% confidence interval, 1.6–1.8). Patients with procedural pain were at least three times more likely to have increased behavioral responses than patients without procedural pain. A simultaneous regression model determined that 33% of the variance in amount of pain behaviors exhibited during a procedure was explained by three factors: degree of procedural pain intensity, degree of procedural distress, and undergoing the turning procedure. ConclusionsBecause of the strong relationship between procedural pain and behavioral responses, clinicians can use behavioral responses of verbal and nonverbal patients to plan for, implement, and evaluate analgesic interventions.

Postoperative epidural morphine is safe on surgical wards.

The use of epidural morphine for postoperative analgesia outside of intensive care units remains controversial. In this report our anesthesiology-based acute pain service documents experience with 1,106 consecutive postoperative patients treated with epidural morphine on regular surgical wards. This

Evaluation of intravenous ketorolac administered by bolus or infusion for treatment of postoperative pain. A double-blind, placebo-controlled, multicenter study.

BackgroundKetorolac is a nonsteroidal analgesic that may provide postoperative analgesia without opioid-related side effects. This double-blind, randomized, multicenter study evaluated the analgesic efficacy and safety of intravenous ketorolac in 207 patients during the first 24 h after major surgery. MethodsSubjects were assigned to receive one of three analgesic regimens: a ketorolac infusion, ketorolac boluses, or placebo. All subjects had access to intravenous morphine via patient-controlled analgesia (PCA). Evaluations included PCA morphine used, pain assessment (categorical pain intensity scores and visual analogue pain scores), pain relief (categorical pain relief scores), sedation, presence of adverse events, and overall rating of regimens by study observers and patients. ResultsPatients in the ketorolac infusion group (but not the ketorolac bolus group) used less morphine (average 33 mg) than did the placebo group (44 mg) (P = 0.009). Significant differences favoring both ketorolac groups were seen in the pain intensity and the categorical pain relief scores at various time points during the study. At the termination of the study, compared with the placebo group, categorical pain intensity scores were lower in the ketorolac bolus group; visual analogue pain scores were lower in both ketorolac groups; and pain relief scores were higher in the ketorolac bolus group. The incidence of vomiting was significantly greater in the placebo group (27%) than in the ketorolac infusion group (12%) or bolus group (9%) (P = 0.032 and P = 0.005, respectively). The incidence of postoperative fever was 10% in the ketorolac bolus group and 25% in the placebo group (P = 0.013). Study observers noted less nursing difficulty while caring for patients in the ketorolac infusion group (P = 0.015). Study observers and patients in both ketorolac groups reported statistically significant overall drug superiority compared with placebo. ConclusionsIt is concluded that intravenous boluses or infusions of ketorolac in conjunction with PCA morphine provide effective, safe analgesia after major surgery and improve on the response to PCA morphine alone.

Paralyzed with pain: the need for education

This report surveyed the pharmacologic knowledge of the physician housestaff and intensive care nurses regarding the analgesic and anxiolytic effects of narcotics, benzodiazepines and neuromuscular blockers. The results demonstrated a commonly held misconception that muscular paralysis is a calm and painless state. The authors instituted an educational program stressing the need for analgesic and anxiolytic medications in conjunction with paralytic agents.

Translating research into practice. Implications of the Thunder Project II.

The Thunder Project II study described procedural pain in a variety of acute and critical care settings. The procedures studied were turning, tracheal suctioning, wound drain removal, nonburn wound dressing change, femoral sheath removal, and central venous catheter insertion. Turning had the highest mean pain intensity, whereas femoral sheath removal and central venous catheter insertion had the least pain intensity in adults. Nonwound dressing change had the highest pain intensity for teenagers. Pain occurred in procedures that are often repeated several times a day as well as in those that may be single events. There is a wide range of pain responses to any of these procedures; as a result, standardized and thoughtful pain, and distress assessments are warranted. Planning of care, including the use of preemptive analgesic interventions, needs to be individualized. Future studies are needed to describe patient responses to other commonly performed nursing procedures and to identify effective interventions for reducing procedural pain and distress.

Pain management. An organizational perspective.

To sustain optimal pain-relieving care for acutely and critically ill patients, organizations must have systems in place to support evidence-based interventions, facilitate expert practice in the area of pain management, and encourage ongoing communication among patients, families, and providers. The key to success may be to create an organizational culture that is supportive of all practitioners to use effectively the many therapeutic options available to manage pain. Although redesigning structures to support pain management care can be done with relative ease, altering the culture of the practice environment and the behavior of care providers may prove more challenging. Cultural changes occur slowly, but as the practice changes do take hold, so do the results. The steps to change an organizational culture around pain management include understanding the existing system and involving key formal and informal leaders. Most experts recommend not attacking the existing culture head-on but living the culture you are trying to create and understanding that the transformation is not going to take place overnight. The use of evidence-based collaborative practice and quality improvement models may be a key to improving the practice environment for pain management. Evidenced-based pain management practice combined with an organizational commitment to optimal pain management for all patients helps to create and sustain the environment to effect the change.