Comparison of the Analgesic Duration of 0.5% Bupivacaine With 1:200,000 Epinephrine Versus 0.5% Ropivacaine Versus 1% Ropivacaine for Low-Volume Ultrasound-Guided Interscalene Brachial Plexus Block: A Randomized Controlled Trial.

BACKGROUND: Bupivacaine and ropivacaine are the preferred long-acting local anesthetics for peripheral nerve blocks as they provide prolonged analgesia in the postoperative period. No studies have directly compared the analgesic duration of these commonly used local anesthetics in the setting of low-volume ultrasound-guided interscalene block (US-ISB). This study was designed to determine which local anesthetic and concentration provides superior analgesia (duration and quality) for low-volume US-ISB. METHODS: Sixty eligible patients scheduled for arthroscopic shoulder surgery were randomized (1:1:1) to receive US-ISB (5 mL) with 0.5% bupivacaine with 1:200,000 epinephrine, 0.5% ropivacaine, or 1% ropivacaine. All individuals were blinded including study participants, anesthesiologists, surgeons, research personnel, and statistician. All participants received a standardized general anesthetic and multimodal analgesia. The primary outcome was duration of analgesia defined as the time from the end of injection to the time that the patients reported a significant increase in pain (>3 numeric rating scale [NRS]) at the surgical site. RESULTS: The mean duration of analgesia for 0.5% bupivacaine with 1:200,000 epinephrine, 0.5% ropivacaine, or 1% ropivacaine was 14.1 ± 7.4, 13.8 ± 4.5, and 15.8 ± 6.3 hours, respectively (analysis of variance [ANOVA], P = .51). There were no observed differences in analgesic duration or other secondary outcomes between the 3 groups with the exception of a difference in cumulative opioid consumption up to 20h00 on the day of surgery in favor of ropivacaine 0.5% over bupivacaine of minimal clinical significance. CONCLUSIONS: In the context of single-injection low-volume US-ISB, we have demonstrated a similar efficacy between equal concentrations of ropivacaine and bupivacaine. In addition, increasing the concentration of ropivacaine from 0.5% to 1% did not prolong the duration of US-ISB.

Comparing the effects of single shot sciatic nerve block versus posterior capsule local anesthetic infiltration on analgesia and functional outcome after total knee arthroplasty: a prospective, randomized, double-blinded, controlled trial.

Peripheral nerve blocks appear to provide effective analgesia for patients undergoing total knee arthroplasty. Although the literature supports the use of femoral nerve block, addition of sciatic nerve block is controversial. In this study we investigated the value of sciatic nerve block and an alternative technique of posterior capsule local anesthetic infiltration analgesia. 100 patients were prospectively randomized into three groups. Group 1: sciatic nerve block; Group 2: posterior local anesthetic infiltration; Group 3: control. All patients received a femoral nerve block and spinal anesthesia. There were no differences in pain scores between groups. Sciatic nerve block provided a brief clinically insignificant opioid sparing effect. We conclude that sciatic nerve block and posterior local anesthetic infiltration do not provide significant analgesic benefits.

Pain descriptors for critically ill patients unable to self-report.

AIM: To examine descriptors used by nurses in two Canadian intensive care units to document pain presence for critically ill patients unable to self-report. BACKGROUND: Systematic documentation of pain assessment is essential for communication and continuity of pain management, thereby enabling better pain control, maximizing recovery and reducing physical and psychological sequelae. METHOD: A retrospective, mixed method, having observational design in two Level-III intensive care units of a quaternary academic centre in Toronto, Canada. During 2008-2009, data were abstracted via chart review guided by a reference compendium of potential behavioural descriptors compiled from existing behavioural pain assessment tools. RESULTS: A total of 679 narrative descriptions were extracted. Behavioural descriptors (232, 34%), physiological descriptors (93, 14%), and descriptors indicating the patient was pain free (117, 17%) were used to describe pain presence or absence. Narratives also described analgesia administered without descriptors of pain assessment (117, 17%) and assessment and analgesic administration prior to a known painful procedure (30, 4%). Emerging themes included life-threatening treatment interference, decisional uncertainty and a wakefulness continuum. CONCLUSION: Inconsistent or ambiguous documentation was problematic in this sample. This may reflect confounding behaviours and concomitant safety priorities. Developing a lexicon of pain assessment descriptors of critically ill patients unable to self-report for use in combination with valid and reliable measures may improve documentation facilitating appropriate analgesic management. Protocols or unit guidelines that prioritize a trial of analgesia before administration of sedatives may decrease decisional uncertainty when patients exhibit ambiguous behaviours such as agitation or restlessness.

Pain prevalence study in a large Canadian teaching hospital. Round 2: lessons learned?

Pain prevalence is an important indicator of quality patient care, representing a basis upon which improvement efforts may be developed. Based on results of an original pain prevalence survey at our institution in 2006, a follow-up prevalence study was conducted in November 2007. Pain and its interference with patients' activities, patient satisfaction with pain management efforts, prescribing practice, and perceived barriers to pain control were all studied using a modified version of the American Pain Society Patient Outcomes Questionnaire. Methodologic objectives included improving the response rate from the earlier study and collecting additional demographic data. A 58% response rate was achieved. Pain prevalence at the time of the survey was 84%, and 25.8% of patients experienced severe pain, on average, over the previous 24 hours. Patients were generally quite satisfied with pain management efforts. Of particular interest were the prescribing practices. Only 50% of patients studied on the medical units had a PRN opioid order. These results reinforce those of our original prevalence study, specifically, that pain is not well controlled at our institution.

Case Study Application of an Ethical Decision-Making Process for a Fragility Hip Fracture Patient.

In Canada, up to 32,000 older adults experience a fragility hip fracture. In Ontario, the Ministry of Health and Long Term Care has implemented strategies to reduce surgical wait times and improve outcomes in target areas. These best practice standards advocate for immediate surgical repair, within 48 hours of admission, in order to achieve optimal recovery outcomes. The majority of patients are good candidates for surgical repair; however, for some patients, given the risks of anesthetic and trauma of the operative procedure, surgery may not be the best choice. Patients and families face a difficult and hurried decision, often with no time to voice their concerns, or with little-to-no information on which to guide their choice. Similarly, health-care providers may experience moral distress or hesitancy to articulate other options, such as palliative care. Is every fragility fracture a candidate for surgery, no matter what the outcome? When is it right to discuss other options with the patient? This article examines a case study via an application of a framework for ethical decision-making.

Pain prevalence study in a large Canadian teaching hospital.

Despite the continued evolution of pain management techniques and an increased awareness of the importance of effective pain management, pain continues to be poorly managed. Following an earlier organization-wide pain collaborative, nursing leaders representing acute and palliative pain services together conducted a pain prevalence study. The purpose of this cross-sectional study was to evaluate the prevalence of pain and the level of interference that pain has on patient activities at a large teaching hospital. Two valid pain measurement tools, the short form of the Brief Pain Inventory (SF-BPI) and the short form of the McGill Pain Questionnaire (SF-MPQ), were chosen to be self-administered. The study revealed a pain prevalence of 71% in a mix of 114 medical and surgical adult inpatients. The SF-BPI results indicated that 31.5% of patients reported pain of moderate to severe intensity and that 11.4% of patients reported pain of severe intensity. The Nursing Advisory Council has committed to supporting an annual prevalence study as part of a corporate goal to monitor pain management across the institution. Forthcoming research will focus on including cognitively impaired patients and conducting thorough chart audits of all patients enrolled in the study. This project provided an opportunity for advanced practice nurses who share a common interest in pain, to collaborate in seeking improvements in pain management for hospitalized patients.

Predicting pain outcomes after traumatic musculoskeletal injury.

Traumatic musculoskeletal injury results in a high incidence of chronic pain; however, there is little evidence about the nature, quality, and severity of the pain. This study uses a prospective, observational, longitudinal design to (1) examine neuropathic pain symptoms, pain severity, pain interference, and pain management at hospital admission and 4 months after traumatic musculoskeletal injury (n = 205), and (2) to identify predictors of group membership for patients with differing moderate-to-severe putative neuropathic pain trajectories. Data were collected on mechanism of injury, injury severity, pain (intensity, interference, neuropathic quality), anxiety (anxiety sensitivity, general anxiety, pain catastrophizing, pain anxiety), depression, and posttraumatic stress while patients were in-hospital and 4 months after injury. A third of patients had chronic moderate-to-severe neuropathic pain 4 months after injury. Specifically, 11% of patients developed moderate-to-severe pain by 4 months and 21% had symptoms immediately after injury that persisted over time. Significant predictors of the development and maintenance of moderate-to-severe neuropathic pain included high levels of general anxiety while in-hospital immediately after injury (P < 0.001) and symptoms of posttraumatic stress 4 months after injury (P < 0.001). Few patients had adequate pharmacological, physical, or psychological pain management in-hospital and at 4 months. Future research is needed among trauma patients to better understand the development of chronic pain and to determine the best treatment approaches.

Survey of Current Practices: Peripheral Nerve Block Utilization by ED Physicians for Treatment of Pain in the Hip Fracture Patient Population.

BACKGROUND: In 2010-11 approximately 968 hip fracture patients presented to emergency departments in the Greater Toronto Local Health Integration Network (GTA-LHIN). Optimal pain management is a frequently overlooked aspect of hip fracture patient care, which may contribute to patient outcomes. Although recommendations have been published, there is currently not a standardized approach to the analgesic management of pain in the hip fracture patient. Nerve blocks, including the fascia iliaca compartment block (FICB), are more effective than traditional opioid analgesics in reducing pain after hip fracture. Research suggests that analgesia via nerve blockade is best initiated early, upon arrival to the emergency department. Emergency physicians are trained in ultrasound, and do utilize regional anaesthesia; however, the frequency of block utilization and techniques used for block insertion are unknown. We sought to undertake the first survey of Emergency Department (ED) staff and resident physicians across the GTA-LHIN, looking at the current ED practice of nerve block analgesia in hip fracture patients. PURPOSE: The primary aim was to determine the prevalence and range of techniques utilized. The secondary aims were to determine the extent of training in nerve block insertion techniques, to gauge opinion on the most important objectives for future training courses, and to seek an understanding of the barriers to establishing a standardized approach for nerve block utilization in hip fracture patients. CONCLUSIONS: This data will be used to develop a multidisciplinary training program specifically for use by ED physicians. ED physicians and anesthesiologists will collaborate to standardize nerve block insertion techniques and develop an optimal analgesic management plan of hip fracture patients at Sunnybrook Hospital.

Behavioral pain assessment tool for critically ill adults unable to self-report pain.

BACKGROUND: Critically ill adults often cannot self-report pain. OBJECTIVE: To determine the effect of the Critical-Care Pain Observation Tool on frequency of documentation of pain assessment and administration of analgesics and sedatives in critically ill patients unable to self-report pain. METHODS: Data on patients in 2 intensive care units of a university-affiliated hospital were collected before and after implementation of the tool. Patients were prospectively screened for eligibility; data were extracted retrospectively. RESULTS: Data were recorded for a maximum of 72 hours before and after implementation of the tool in the cardiovascular intensive care unit (130 patients before and 132 after) and in the medical/surgical/trauma unit (59 patients before and 52 after). Proportion of pain assessment intervals with pain assessment documented increased from 15% to 64% (P < .001) in the cardiovascular unit and from 22% to 80% (P < .001) in the other unit. Median total dose of opioid analgesics decreased from 5 mg to 4 mg in the cardiovascular unit (P = .02) and increased from 27 mg to 75 mg (P = .002) in the other unit. Median total dose of benzodiazepines decreased from 12 mg to 2 mg (P < .001) in the cardiovascular unit and remained unchanged in the other unit. Increased documentation of pain assessment was associated with increased age in the cardiovascular unit and with decreased maximum scores on the Sequential Organ Failure Assessment in the other unit. CONCLUSION: Implementation of the tool increased frequency of pain assessment and appeared to influence administration of analgesics in both units.

Critical care nurses' pain assessment and management practices: a survey in Canada.

BACKGROUND: Regular pain assessment can lead to decreased incidence of pain and shorter durations of mechanical ventilation and stays in the intensive care unit. OBJECTIVES: To document knowledge and perceptions of pain assessment and management practices among Canadian intensive care unit nurses. METHODS: A self-administered questionnaire was mailed to 3753 intensive care unit nurses identified through the 12 Canadian provincial/territorial nursing associations responsible for professional regulation. RESULTS: A total of 842 nurses (24%) responded, and 802 surveys could be evaluated. Nurses were significantly less likely (P < .001) to use a pain assessment tool for patients unable to communicate (267 nurses, 33%) than for patients able to self-report (712 nurses, 89%). Significantly fewer respondents (P < .001) rated behavioral pain assessment tools as moderately to extremely important (595 nurses, 74%) compared with self-report tools (703 nurses, 88%). Routine (>50% of the time) discussion of pain scores during nursing handover was reported by 492 nurses (61%), and targeting of analgesia to a pain score or other assessment parameters by physicians by 333 nurses (42%). Few nurses (n = 235; 29%) were aware of professional society guidelines for pain assessment and management. Routine use of a behavioral pain tool was associated with awareness of published guidelines (odds ratio, 2.5; 95% CI, 1.7-3.7) and clinical availability of the tool (odds ratio, 2.6; 95% CI, 1.6-4.3). CONCLUSIONS: A substantial proportion of intensive care unit nurses did not use pain assessment tools for patients unable to communicate and were unaware of pain management guidelines published by professional societies.

Survey of assessment and management of pain for critically ill adults.

OBJECTIVE: To investigate critical care nurses' current practice and knowledge related to pain assessment and management for critically ill adults able and unable to self-report pain. DESIGN: Cross sectional self-report survey. RESULTS: Survey response rate was 57%. Though more respondents used formal pain assessment tools often or routinely for patients able to self-report compared to patients unable to communicate (P<0.0001), there was no difference in perceived importance of pain assessment tools. Nurses were less confident in their ability to accurately assess pain for patients unable to self-report (P<0.0001). Behaviours most frequently considered routinely indicative of pain were grimacing (88/140, 62.9%), vocalisation (78/140, 55.7%) and wincing (73/140, 52.1%). Haemodynamic instability, nursing workload and patient inability to communicate were the barriers considered to interfere with pain assessment and management most frequently. Enablers to effective management included pain prioritisation, and adequate prescription of analgesia. Most respondents (118/140 84.3%) had received continuing education on topics related to pain. CONCLUSIONS: Though nurses considered pain assessment equally important for patients unable and able to selfreport, formal assessment tools were used less frequently and nurses were less confident in their ability to assess pain for patients unable to self-report.