Patient attitudes towards analgesia and their openness to non-pharmacological methods such as acupuncture in the emergency department.

OBJECTIVE: To investigate patient attitudes to analgesia, opioids and non-pharmacological analgesia, including acupuncture, in the ED. METHODS: ED patients with pain were surveyed regarding: pain scores, satisfaction, addiction concern, non-pharmacological methods of pain relief and acupuncture. Data were analysed using logistic regression. RESULTS: Of 196 adult patients, 52.8% were 'very satisfied' with analgesia. Most patients (84.7%) would accept non-pharmacological methods including acupuncture (68.9%) and 78.6% were not concerned about addiction. Satisfaction was associated with male gender, and 'adequate analgesia' but not with opioids. CONCLUSION: Most patients were generally satisfied with ED analgesia and were open to non-pharmacologic analgesia including acupuncture.

Codeine and opioid metabolism: implications and alternatives for pediatric pain management.

PURPOSE OF REVIEW: Use of perioperative opioids for surgical pain management of children presents clinical challenges because of concerns of serious adverse effects including life-threatening respiratory depression. This is especially true for children with history of obstructive sleep apnea. This review will explore current knowledge of clinically relevant factors and genetic polymorphisms that affect opioid metabolism and postoperative outcomes in children. RECENT FINDINGS: Within the past several years, an increasing number of case reports have illustrated clinically important respiratory depression, anoxic brain injuries and even death among children receiving appropriate weight-based dosages of codeine and other opioids for analgesia at home setting particularly following tonsillectomy. Several national and international organizations have issued advisories on use of codeine in pediatrics, based on cytochrome P450 family 2 subfamily D type 6 (CYP2D6) pharmacogenetics. We have discussed the pros and cons of alternatives to codeine for pain management. SUMMARY: Although routine preoperative genotyping to identify children at risk and personalized opioid use for pediatric perioperative pain management is still a distant reality, current known implications of CYP2D6 pharmacogenetics on codeine use shows that pharmacogenetics has the potential to guide anesthesia providers on perioperative opioid selection and dosing to maximize efficacy and safety.

Eficacia analgésica y seguridad de dosis única de morfina intratecal / Analgesic effectiveness and safety of single-dose intrathecal morphine

Introducción: el dolor posoperatorio del hemiabdomen superior es intenso y su control es imprescindible para evitar complicaciones. Objetivos: evaluar la eficacia analgésica y seguridad de dosis única de morfina intratecal en el posoperatorio de la cirugía de hemiabdomen superior de gran envergadura. Método: ensayo clínico aleatorizado a simple ciegas en 40 pacientes, tras intervenciones de hemiabdomen superior. Se emplearon dosis única de morfina intratecal (MIT) de 1 o 2 µg/kg de peso del paciente de acuerdo al grupo de tratamiento. Análisis estadístico con las pruebas Chi cuadrado (x2), exacta de Fisher, análisis de varianza univariado, la prueba de W de Mauchly y la prueba F univariada; nivel de significación de 0,05. Resultados: la administración de opioides durante el acto quirúrgico fue similar en ambos grupos (3,1 ± 2,2 mL vs. 4,1 ± 2,7 mL). En el grupo de dosis de 2 µg/kg de peso de MIT a las 12 y 24 h los pacientes no refirieron dolor; existieron diferencias entre los tratamientos en cuanto al alivio del dolor (p< 0,001) y también entre los momentos en que se midió el mismo (p= 0,001). Se utilizó analgesia de rescate en 25 por ciento de los pacientes. Solo se presentó como complicación la depresión respiratoria. Conclusiones: la dosis única de 2 µg/kg de morfina intratecal es un método eficaz para la analgesia posoperatoria en la cirugía de hemiabdomen superior, la incidencia de complicaciones fue baja y se demostró que ambas dosis son seguras(AU)

Introduction: The superior hemiabdomen postoperative pain is severe and essential to be managed in order to avoid complications. Objectives: To assess the analgesic effectiveness and safety of single-dose intrathecal morphine in the postoperative period of the upper hemiabdomen major surgery. Method: Single-blind randomized clinical trial in 40 patients, after upper hemiabdomen interventions. We used single doses of intrathecal morphine (ITM) of 1 or 2 mg/kg per patient weight according to the treatment group. The statistical analysis used the Chi-square test, Fisher's exact test, univariate analysis of variance, Mauchly's test and Univariate F-test; the significance level was 0.05. Results: Opioids administration during surgery was similar in both groups (3.1 ± 2.2 mL vs. 4.1 ± 2.7 mL). In the 2 mg/kg of ITM dose group, the patients reported no pain after 12 and 14 hours; there were differences between treatments regarding pain relief (p< 0.001) and also between the time when it was measured (p= 0.001). Rescue analgesia was used in 25 percent of the patients. Respiratory depression was the only onset complication. Conclusions: ITM at a single dose of 2 µg/kg is an effective method for postoperative analgesia in upper hemiabdomen surgery, the incidence of complications was low and both doses proved safe(AU)

Alternativas analgésicas al dolor de parto / Analgesic alternatives for labour pain

Introducción: Actualmente se ha observado un mayor interés por parte de las madres y su entorno, por la aplicación de otros métodos analgésicos no invasivos. Por lo tanto, es un tema de gran importancia para los profesionales de la salud relacionados con la atención al parto, los cuales deben desarrollar las habilidades necesarias para ayudar a aquellas mujeres que optan por un parto promovido por la aplicación alternativa de medidas analgésicas. Objetivos: Se pretende evaluar la efectividad y eficacia de las principales alternativas analgésicas al parto que la literatura científica nos ofrece. Metodología: Se ha realizado una búsqueda bibliográfica en las siguientes bases de datos: Medline, Pubmed, The Cochrane Database of Systematic Reviews y Ebsco. Resultados: Los estudios consultados reflejan que las diferentes alternativas analgésicas como la aplicación de electroterapia, acupuntura, masoterapia o termoterapia en el parto son efectivas en grado moderado en la reducción del dolor. Conclusiones: La aplicación de medidas analgésicas alternativas resulta de efectividad comprobada, no obstante, es necesaria la elaboración de mayores estudios clínicos con una metodología consensuada que avale la efectividad de dichas intervenciones (AU)

Introduction: Currently there has been an increased interest from mothers and their environment, by the application of other non-invasive analgesic methods. Therefore, it is a major issue for health professionals related to delivery care, which should develop the skills necessary to help those women who choose childbirth alternative promoted by the application of analgesic action. Objectives: We sought to evaluate the effectiveness and efficiency of the main alternatives analgesic delivery that literature offers us. Methods: We performed a literature search in the following databases: Medline, Pubmed, The Cochrane Database of Systematic Reviews and Ebsco. Results: The studies surveyed reflect that different alternatives as applying analgesic electrotherapy, acupuncture, massage therapy or thermotherapy in childbirth are moderate effective in reducing pain. Conclusions: The application of alternative analgesic action is proven effective, however, it is necessary the development of larger clinical studies with a methodology agreed to endorse the effectiveness of such interventions (AU)

Sedation, analgesia, and local anesthesia: a review for general and interventional radiologists.

Radiologists, like other physicians, need to know how to use sedatives, analgesics, and local anesthetics; however, their exposure to patients requiring discomfort control is limited, not just during residency but also in postgraduate practice. The purpose of this article is to provide a reference guide for radiologists who need pertinent and ready information on discomfort control. The authors discuss policies and standards that the Joint Commission has established for sedation providers; also discussed are the clinical pharmacology and dosage recommendations for the sedative, analgesic, anesthetic, and reversal agents that radiologists are most likely to use. Monitored anesthesia care and patient-controlled analgesia pumps, and in what circumstances they may be appropriate, are discussed. Anesthesia consultations are not uncommon when a nonanesthesiologist needs either of these services. Stiff chest syndrome, serotonin release syndrome, and systemic toxicity due to local anesthesia, all life-threatening conditions that sedation and analgesia providers may encounter, are discussed. The causes of these conditions and their necessary treatments are included in the discussion, along with cases in which a nonanesthesiologist may need an anesthesia consultation. It is important to understand that the control of pain and anxiety are not mutually exclusive but can occur either separately or together; when an agent that controls anxiety and an agent that controls pain are given together, the overall effect is synergistic. It is also important to understand the concept of multimodal analgesia; this is the use of opioids and nonopioids together to take full advantage of the analgesic effects of each component while minimizing potential side effects. Radiologists are fully capable of providing effective and safe pain control on their own and with the assistance of an anesthesiologist.

REGIONAL ANALGESIA FOR POST-OPERATIVE PAIN MANAGEMENT--INITIAL EXPERIENCE IN A LOW RESOURCE SETTING.

OBJECTIVE: The aim of this study is to demonstrate the use of some regional anaesthetic techniques in effective postoperative pain control in a low resource setting. We also wanted to find out the potential benefits and prospects of regional techniques to achieve effective postoperative analgesia. DESIGN: This study was a prospective observational study in which 25 patients presenting for various orthopaedic and general surgical procedures were recruited randomly. SETTING: Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Nigeria from December, 2008 to May, 2009. SUBJECTS: Eligible patients were males and females aged 21-55 years. These included emergency and elective cases. RESULTS: The age range was 21-55 years with a mean age of 34 years. Of the 25 patient studied, 14 of them were men and 11 women constituting 56% and 44% respectively. Our study shows that Hausa/Fulani ethnic group made up 75% of the study population. Intraoperatively, the anaesthetic techniques used were general anaesthesia (only) in 13 patients (52%), Regional techniques consisting of spinals, epidurals, combined spinals and epidurals and brachial plexus blocks in nine patients (36%) and three (12%) of the patients had a combination of general anaesthesia (GA) and regional anaesthesia (RA). For post-operative pain management, nine patients (36%) had continuous brachial plexus block using intermittent injections, 13 (52%) patients had epidural catheters with intermittent top-up injections and three (12%) patients received combined spinal and epidural with an epidural catheter left in-situ for intermittent top-ups. The drugs used for top-ups included 0.125% plain bupivacaine (15 patients), 0.125% plain bupivacaine + 2.5 mcgs/ml Fentanyl (10 patients) in 10 ml aliquots. The outcome was good in most patients with 19 patients (82.4%) experiencing only mild pain (numeric pain score 0-3). Onset of post-operative pain was 13-18 hours in most (52%) of patients with majority of patients (80%) requiring only a single dose of opioid in 24 hours. There was no incidence of infection at site of catheter insertion one week after the procedure. CONCLUSION: Regional techniques if used properly can provide superior pain control in the post-operative period. There is reduction in the requirements of opioids in the immediate post-operative when regional techniques are used for pain management. We need to encourage the use of these techniques especially in our setting where resources are sparse and potent analgesics are not always available.

[Recommendations for sedation during flexible bronchoscopy]. / Empfehlung zur Sedierung in der flexiblen Bronchoskopie.

Flexible bronchoscopy is a standard examination today and is conducted not only in nearly every hospital but also in privately owned practices. The vast majority of patients want sedation for this examination. Such a procedure is nearly always necessary in complex and interventional procedures, irrespective of the patient's wish. The recommendation at hand to use sedation measures for flexible bronchoscopy is based on the results of numerous clinical studies and also takes account of individual experiences in this area. The structural and procedural requirements and the requirements for staff training are defined and should describe the minimum standard when it comes to conducting a bronchoscopy under sedation. Furthermore the drugs recommended for sedation are discussed and their methods of application shown. Finally the recommendations also include suggestions for patient clarification, monitoring and discharge. They should provide the examiner with concrete operating options and therefore above all increase patient safety.

Evidence-based guideline: treatment of painful diabetic neuropathy--report of the American Association of Neuromuscular and Electrodiagnostic Medicine, the American Academy of Neurology, and the American Academy of Physical Medicine & Rehabilitation.

The objective of this report was to develop a scientifically sound and clinically relevant evidence-based guideline for the treatment of painful diabetic neuropathy (PDN). The basic question that was asked was: "What is the efficacy of a given treatment (pharmacological: anticonvulsants, antidepressants, opioids, others; non-pharmacological: electrical stimulation, magnetic field treatment, low-intensity laser treatment, Reiki massage, others) to reduce pain and improve physical function and quality of life (QOL) in patients with PDN?" A systematic review of literature from 1960 to August 2008 was performed, and studies were classified according to the American Academy of Neurology classification of evidence scheme for a therapeutic article. Recommendations were linked to the strength of the evidence. The results indicate that pregabalin is established as effective and should be offered for relief of PDN (Level A). Venlafaxine, duloxetine, amitriptyline, gabapentin, valproate, opioids (morphine sulfate, tramadol, and oxycodone controlled-release), and capsaicin are probably effective and should be considered for treatment of PDN (Level B). Other treatments have less robust evidence, or the evidence is negative. Effective treatments for PDN are available, but many have side effects that limit their usefulness. Few studies have sufficient information on their effects on function and QOL.

Analgesia in fast-track paediatric cardiac patients.

OBJECTIVE: We introduced a fast-track program for our cardiac operations requiring adjustment in anaesthesia techniques to facilitate rapid extubation and discharge from the intensive care unit (ICU). Our objective was to investigate the quality of analgesia in fast-track paediatric cardiac patients. METHODS: We performed a retrospective review of the records of all patients who were fast-tracked in our institution between January 2006 and January 2007. Data collected included surgical procedure, anaesthesia technique, intra-operative opioids, ventilation time, intensive care stay, postoperative morphine consumption, pain scores, patient-controlled analgesia/nurse-controlled analgesia (PCA/NCA) duration, supplemental analgesia and incidence of vomiting. RESULTS: Fifty-four patients were studied, with a median age of 5.6 years (8 months-18 years), median weight 15.6 kg (range: 6.4-101 kg), median intensive care unit (ICU) ventilation time 1.1h (range: 0-8h) and median ICU stay of 4.1h (1-52 h). All patients received intra-operative fentanyl, median dose of 16.8 mcg kg⁻¹ (range: 15-20 mcg kg⁻¹). Twenty-three children received a bolus of morphine intra-operatively median dose of 102 mcg kg⁻¹ (range: 50-170 mcg kg⁻¹). Those patients who did not receive a morphine bolus intra-operatively, received a 100 mcg kg⁻¹ loading dose of morphine in the ICU. Twenty-four patients received intravenous paracetamol intra-operatively and five patients were given both paracetamol and diclofenac. Twenty-five children were not given either paracetamol or diclofenac intra-operatively. During the postoperative period, all patients received morphine by infusion administered via either PCA (18%) or NCA)(73%). The median PCA/NCA infusion time was 28.9h. Forty-eight patients received paracetamol and non-steroidal analgesics postoperatively, either diclofenac or ibuprofen. Five patients received only paracetamol and only one patient required no supplemental analgesia. The bedside nurse reported the pain scores on an hourly basis on a 10-point visual analogue score where 0=no pain and 10=strongest pain. Pain scores showed that most patients after day 0 (which was the day of surgery) had only mild pain. CONCLUSIONS: Our data showed that our program achieves high-quality analgesia in fast-track paediatric cardiac patients.

Ethics, law, and pain management as a patient right.

Ethical and legal considerations in pain management typically relate to 2 issues. The first refers to pain management as a human right. The second involves the nature of the patient-physician relationship as it relates to pain management. Although pain physicians often like to think of pain management as a human right, it remains difficult to support this position as a point of law or as a matter of ethics. Medical organizations generally do not define pain management as a specific duty of the physician, apart from the provision of competent medical care. To date, neither law nor ethics creates a duty of care outside of the traditional patient-physician relationship. Absent a universal duty, no universal right exists. Pursuing pain management as a fundamental human right, although laudable, may place the power of the government in the middle of the patient-physician relationship. Despite apparent altruistic motives, attempts to define pain management as a basic human right could have unintended consequences, such as nationalization of medicine to ensure provision of pain management for all patients.

The management of cancer-related breakthrough pain: recommendations of a task group of the Science Committee of the Association for Palliative Medicine of Great Britain and Ireland.

A task group of the Science Committee of the Association for Palliative Medicine of Great Britain and Ireland (APM) was convened to produce some up-to-date, evidence-based, practical, clinical guidelines on the management of cancer-related breakthrough pain in adults. On the basis of a review of the literature, the task group was unable to make recommendations about any individual interventions, but was able to make a series of 12 recommendations about certain generic strategies. However, most of the aforementioned recommendations are based on limited evidence (i.e., case series, expert opinion). The task group also proposed a definition of breakthrough pain, and some diagnostic criteria for breakthrough pain.

Determining factors that have an impact upon effective evidence-based pain management with older people, following colorectal surgery: an ethnographic study.

AIM: The aim of this project was to examine pain management practices with older people admitted to the colorectal unit of an acute hospital trust. BACKGROUND: Although pain assessment and management are judged to be a priority, little research has examined the care older people receive in the acute surgical setting. Thus, pain in older people (65 years and over) can be under recognized and unrelieved. With the number of older people requiring surgery increasing, it is important to identify factors in the practice context that enhance or inhibit effective pain management. DESIGN: The project drew upon an in-depth ethnographic approach. METHOD: Sixty-two hours of around the clock, non-participant observation of nursing practice was completed. Thirty-nine (78%) nurses and forty-six (42%) patients were observed. Seven (6%) additional patients participated in pre- and postoperative interviews and 35 (90%) nurses completed the Nursing Work Index--Revised Questionnaire. FINDINGS: Holistic pain assessment for older people was found to be deficient in the acute surgical setting. Nurses appeared unaware of the importance of addressing the particular pain needs of older patients. Inflexible analgesic prescriptions provided the mainstay treatment of pain, with minimal consideration given to non-pharmacological strategies. Older people wanted to be active participants in their care. However, existing pain management practices disempowered older patients, making them reluctant or unable to discuss their pain with ward staff. CONCLUSION: Comprehensive pain assessment, improved documentation and proficient communication, inclusive of older patients, are necessary to improve pain management practices. It is imperative that patients, nurses, doctors and Acute Pain Service work in collaboration to challenge pain management practices and implement change. RELEVANCE TO CLINICAL PRACTICE: The project demonstrated some of the multiple and complex factors that affect the older persons' pain experience and identified three action research cycles for further development work.

Chest drain removal pain and its management: a literature review.

AIMS AND OBJECTIVES: The purpose of this review was to analyse critically the published research on chest drain removal pain and its management. The findings of descriptive and non-pharmacological intervention studies were summarized and studies of analgesic efficacy were critiqued in depth. BACKGROUND: The removal of a chest drain is a painful and frightening experience, particularly for children. However, there is limited research regarding the amount of pain experienced or effectiveness of analgesia for this procedure. RESULTS: Fourteen studies were reviewed, including five descriptive studies; three studies of non-pharmacological interventions; and six randomized controlled trials of morphine, local anaesthetics and Entonox. The search revealed only two paediatric studies. Many of the studies had design limitations or were poorly reported. The majority of studies indicated that patients experienced moderate to severe pain during chest drain removal, even when morphine or local anaesthetics were given. CONCLUSIONS: Morphine alone does not provide satisfactory analgesia for chest drain removal pain. Non-steroidal anti-inflammatory drugs, local anaesthetics and inhalation agents may have a role to play in providing more effective analgesia for this procedure. RELEVANCE TO CLINICAL PRACTICE: Analgesic protocols for the management of painful procedures such as chest drain removal are unsatisfactory and practice in this area should be revised. More research is needed to determine the efficacy of drugs other than morphine, particularly Entonox and to investigate multi-modal techniques of management further.

APS position statement on the use of placebos in pain management.

In the spring of 2003, the board of directors of the American Pain Society asked the APS Ethics Committee to formulate a position statement for the Society concerning the use of placebos in clinical practice (cf, reference ). A subset of the Ethics Committee under my direction composed such a statement based on the available scientific and ethical literature. We then sought feedback from the entire ethics committee as well as numerous prominent voices in the literature and presented the statement to the membership for discussion at the 2004 annual APS meeting in Vancouver, British Columbia, at both a symposium and an ethics special interest group meeting. The resultant document was approved by the APS Board and is published here for widespread distribution to the membership.

Issues of importance: maintaining comfort and compassion for patients in pain.

Addressing issues in the management of pain can create dilemmas for those caring for patients. This session examined the realities of current societal pressures, provider bias, and caregiver concerns in providing quality individualized pain management. This program also addressed how holistic care can improve the management of cancer pain.

Medical house officers' attitudes toward vigorous analgesia, terminal sedation, and physician-assisted suicide.

In 2000, the authors surveyed 236 medical house officers in three internal medicine residency programs in Connecticut to assess attitudes toward vigorous analgesia, terminal sedation, and physician-assisted suicide. The goal was to identify associations between these attitudes and training, demographic, and religious factors. The results of the study indicated that most medical house officers supported vigorous analgesia, the majority supported terminal sedation, but only a minority supported physician-assisted suicide. Some house officers' attitudes toward terminal sedation and assisted suicide may have been influenced by their religious commitments and the pressures of training.