Pain management in patients with liver failure or cirrhosis: a narrative review of the literature

Hospitalized Children With Limited English Proficiency: The Strive to Improve Analgesia.

Do antinuclear antibodies in primary biliary cirrhosis patients identify increased risk for liver failure?

Clinical Policy: Critical Issues in the Sedation of Pediatric Patients in the Emergency Department

Organ dysfunctions and medical complications, such as renal failure, liver impairment, coagulation disorders, cardiovascular and respiratory illnesses, may hamper an adequate pain management in haematological patients. To summarize current knowledge on pain management in hematological patients presenting major organ dysfunctions and comorbidity. We also attempted to provide recommendations to optimize analgesia and to minimize side effects in the setting of medically compromised and frail haematological patients. A systematic search of the literature, using relevant key words, was conducted in PubMed. Pain in hematological patients is a common symptom and is often multi-factorial. Most pharmacotherapeutic measures, including causal therapies, analgesics and adjuvant agents routinely applied in pain management, may also be used in the setting of clinical frailty and medical comorbidities; however, comprehensive clinical and functional patient's evaluations and a careful consideration of expected benefits and potential adverse events are required.

Context:Pain management in cirrhotic patients is a major clinical challenge for medical professionals. Unfortunately there are no concrete guidelines available regarding the administration of analgesics in patients with liver cirrhosis. In this review we aimed to summarize the available literature and suggest appropriate evidence-based recommendations regarding to administration of these drugs.Evidence Acquisition:An indexed MEDLINE search was conducted in July 2014, using keywords “analgesics”, “hepatic impairment”, “cirrhosis”, “acetaminophen or paracetamol”, “NSAIDs or nonsteroidal anti-inflammatory drugs”, “opioid” for the period of 2004 to 2014. All randomized clinical trials, case series, case report and meta-analysis studies with the above mentioned contents were included in review process. In addition, unpublished information from the Food and Drug Administration are included as well.Results:Paracetamol is safe in patients with chronic liver disease but a reduced dose of 2-3 g/d is recommended for long-term use. Non-steroidal anti-inflammatory drugs (NSAIDs) are best avoided because of risk of renal impairment, hepatorenal syndrome, and gastrointestinal hemorrhage. Most opioids can have deleterious effects in patients with cirrhosis. They have an increased risk of toxicity and hepatic encephalopathy. They should be administrated with lower and less frequent dosing in these patients and be avoided in patients with a history of encephalopathy or addiction to any substance.Conclusions:No evidence-based guidelines exist on the use of analgesics in patients with liver disease and cirrhosis. As a result pain management in these patients generates considerable misconception among health care professionals, leading under-treatment of pain in this population. Providing concrete guidelines toward the administration of these agents will lead to more efficient and safer pain management in this setting.

To assess the predictors of outcomes for different subtypes of liver failure, and the effectiveness of artificial liver support systems in the treatment of liver failure. The clinical data of 112 patients with hepatitis B virus (HBV)- and non-HBV-related liver failure admitted to the intensive care unit (ICU) of the Fifth People's Hospital of Wuxi were collected from January to December 2020. The relevant etiologies of acute, subacute, acute-on-chronic, subacute-on-chronic, chronic subtype liver failure were analyzed. The efficacies of artificial liver support systems in the treatment of various subtypes of liver failure were also compared. The correlation of various indicators was analyzed by Spearman correlation analysis, the risk factors affecting the prognosis of patients with liver failure were analyzed by multivariate Logistic regression equation, and receiver operator characteristic curve (ROC curve) of subjects was plotted to evaluate the predictive value of each risk factor for the prognosis of patients with liver failure. Among the 112 liver failure patients, 63 were caused by hepatitis B and 49 were caused by non-hepatitis B. The liver failure caused by hepatitis B was 6 times higher than for men than for women, which was higher than that of non-HBV liver failure group (1.33 times). Antithrombin III (AT III) and total bilirubin (TBil) levels of subacute liver failure were higher than those of pre-liver failure in the HBV liver failure group [AT III: (59.33±14.57)% vs. (35.66±20.72)%, TBil (μmol/L): 399.21±112.94 vs. 206.08±126.96, both P < 0.05]. The levels of AT III in patients with pre-liver failure and chronic liver failure in the non-HBV liver failure group were significantly higher than those with acute liver failure [(58.33±15.28)%, (44.00±19.10)% vs. (31.33±7.57)%, both P < 0.05], patients with acute liver failure had significantly lower level of TBil than pre-liver failure (μmol/L: 107.83±49.73 vs. 286.20±128.92, P < 0.05), the TBil levels in patients with subacute and acute-on-chronic liver failure were also significantly higher than that in pre-liver failure group (μmol/L: 417.27±118.60, 373.00±187.00 vs. 286.20±128.92, both P < 0.05). Patients with subacute liver failure, subacute-on-chronic liver failure and chronic liver failure in the non-HBV failure group were significantly longer than those in acute liver failure (days: 36.00±8.31, 27.52±11.71, 27.72±22.71 vs. 11.00±1.41, all P < 0.05). There was no statistically significant difference in the case fatality rate of using the artificial liver support system between the HBV failure group and the non-HBV failure group (55.6% vs. 50.0%, P < 0.05), the levels of AT III in the two groups of surviving patients were significantly higher than that of the dead [HBV liver failure group: (36.20±6.26)% vs. (27.33±8.87)%, non-HBV liver failure group: (41.06±4.16)% vs. (28.71±12.35)%, both P < 0.01]. Correlation analysis showed that there was a clear positive correlation between AT III and TBil in the dead patients of HBV liver failure group and the survival and death patients of non-HBV liver failure group (r values were 0.069, 0.341, 0.064, and P values were 0.723, 1.196 and 0.761, respectively); there was a significant inverse correlation between AT III and TBil in the HBV liver failure group (r = -0.105, P = 0.745). Multivariate Logistic regression analysis showed that AT III was an independent risk factor affecting the prognosis of patients with non-HBV liver failure [odd ratio (OR) = 1.023, 95% confidence interval (95%CI) was -0.001 to 0.001, P = 0.007]. TBil was an independent risk factor affecting prognosis of patients with HBV liver failure (OR = 1.005, 95%CI was -0.002 to -7.543, P = 0.033). The analysis of ROC curve showed that AT III had a predictive value for the prognosis of patients with non-HBV liver failure, the area under the ROC curve (AUC) = 0.747, the 95%CI was 0.592-0.902, P = 0.009. When the optimal truncation value was 39.5%, its sensitivity and specificity were 83.33% and 56.25%, respectively. Artificial liver support system treatment of liver failure was difficult to effectively reduce the mortality of patients with end-stage liver failure. In addition to AT III, TBil also could be used as an indicator to assess liver compensatency and predict prognosis in liver failure patients.

Pain Management in Patients with Heart Failure: A Survey of Nurses’ Perception

Clinicians’ Practices In Pain Assessment And Management For Elderly With Heart Failure

In the kingdom of Bahrain an estimated 18,000 people suffer from Sickle Cell Disease (SCD) and many experience periodic episodes of sickling crisis. Research studies that examine the knowledge and attitudes of nurses toward pain assessment and management of SCD patients are limited especially in the Middle East. This study aims to assess the level of knowledge and attitudes of nursing staff regarding pain assessment and management of patients with SCD during sickling crisis. A quantitative study design was utilized to recruit a convincence sample of 30 staff nurses working in adult SCD wards in one of governmental hospital in the Kingdom of Bahrain. A modified version of Nurses' Knowledge and Attitude Survey questionnaire regarding Pain was used to examine the research variables. The results of the study showed that a mean score of knowledge was 15.8 out of 33 (47.8% out of 100%). This finding indicates that staff nurses had poor knowledge and negative attitudes toward SCD pain assessment and management. The findings showed no significant difference in the mean score of knowledge in relation with nationality ( p = .693), age ( p = .966), level of education ( p = .732), years of experience ( p = .887), and previous training courses or workshops on pain management ( p = .877). This study suggests the need for implementing of specific strategies to effectively educate the staff nurses about pain assessment and management, and integrate pain management as a major component of the hospital in-house training programs.

BackgroundEffective pain management in elderly patients is crucial for quality of life, yet cultural and institutional factors can significantly impact care delivery, particularly in Arab healthcare settings.AimTo explore the barriers and facilitators to effective pain management in elderly Arab patients from the perspective of nurses.MethodsA qualitative descriptive study was conducted with 12 registered nurses from various departments at Tanta University Hospitals, Egypt. Data were collected through semi-structured interviews, observations, and document analysis. Content analysis was used to identify themes and subthemes.ResultsFive main themes emerged: (1) Cultural Barriers to Pain Expression, including stoicism and religious beliefs; (2) Institutional Barriers to Pain Management, such as resource limitations and time constraints; (3) Facilitators to Effective Pain Management, including family support and nurse adaptability; (4) Interdisciplinary Collaboration, emphasizing teamwork and education; and (5) Emotional and Professional Rewards for nurses. Cultural factors often led to underreporting of pain, while institutional constraints hindered thorough assessments. Nurse adaptability and family support, when present, facilitated better pain management.ConclusionThe study reveals complex interplay between cultural, institutional, and professional factors influencing pain management in elderly Arab patients. Findings suggest the need for culturally sensitive pain assessment tools, enhanced nurse education in pain management, and policies promoting family-centered care and interdisciplinary collaboration.ImplicationsResults can inform the development of culturally appropriate pain management strategies and policies in Arab healthcare settings, potentially improving care quality for elderly patients.

Defining Acute-on-Chronic Liver Failure: Will East and West Ever Meet?

Analgesia and Sedation in Critically Ill Patients With Burns.

The BH3-Only Protein Bid Does Not Mediate Death-Receptor-Induced Liver Injury in Obstructive Cholestasis

Approach to the patient with acute severe autoimmune hepatitis.

IntroductionIn 2005–2050, the global population of elderly people will increase by 12%. This will lead to increased demand for such healthcare services as hospital care or surgical interventions. Pain in elderly patients is a substantial problem. Insufficiently controlled postoperative pain continues to be a widespread phenomenon. Pain management in Poland is usually based on nursing care supervised by an anesthesiologist or surgeon. The aim of the study was to identify barriers to effective nurse-controlled analgesia in postoperative pain management in elderly patients in hospitals with and without a Hospital Without Pain certificate.Material and methodsThe study was conducted after the approval of the study protocol by the Independent Bioethics Committee for Scientific Research of the Medical University of Gdansk. The study project was multicenter and was conducted from July 2012 to December 2013. The research was questionnaire-based and used the Polish version of the Nurses’ Perceived Obstacles to Pain Assessment and Management Practices questionnaire. The project included 676 nurses from hospitals awarded the Hospital Without Pain Certificate and 926 respondents from hospitals without the certificate.ResultsAfter calculating the overall average result in particular groups, healthcare system-related problems were first among the barriers hindering pain management in elderly patients M = (C = 3.81, N/C = 3.87). Patient-related barriers were second (M = 3.77). Physician- and nurse-related barriers took the subsequent positions, with very similar scores M = (C = 3.47, N/C = 3.44) and M = (C = 3.46, N/C = 3.44), respectively.ConclusionsThe greatest barriers to pain management in elderly patients are related to the healthcare system. Nurses from Hospital Without Pain certified hospitals devoted significantly more time to relieving pain through non-pharmacological methods.