Protocol For Acute Pain Research Articles

Implementing an intravenous ketamine protocol for acute pain in the medical-surgical setting.

A subanesthetic intravenous ketamine infusion is a safe and effective acute pain management modality for moderate to severely painful surgical procedures and may be useful in patients who are at increased risk for opioid-related adverse events. Despite its safety profile, intravenous ketamine is often restricted to the intensive care unit, which results in decreased patient access to this effective therapy. For clinicians who wish to implement an intravenous ketamine protocol in the medical-surgical setting, there are few resources available. In this brief report, we present our ketamine infusion protocol for acute pain and the clinical and financial outcomes 1 year after implementation. In our experience, ketamine infusions on the medical-surgical ward are safe and cost-effective when an established acute pain service protocol is followed. Nurse practitioners play an essential role in increasing patient access to intravenous ketamine infusions and leading change by collaborating with stakeholders to develop a protocol, training nurses and interdisciplinary team members, and providing ongoing support to nursing staff.

On the Relationship Between White Matter Structure and Subjective Pain. Lessons From an Acute Surgical Pain Model

Background: Pain has been associated with structural changes of the brain. However, evidence regarding white matter changes in response to acute pain protocols is still scarce. In the present study, we assess the existence of differences in brain white matter related to pain intensity reported by patients undergoing surgical removal of a mandibular impacted third molar using diffusion tensor imaging (DTI) analysis.Methods: 30 participants reported their subjective pain using a visual analog scale at three postsurgical stages: under anesthesia, in pain, and after the administration of an analgesic. The diffusion data were acquired prior to surgery.Results: DTI analysis yielded significant positive associations of fractional anisotropy in white matter areas related to pain processing (corticospinal tract, corona radiata, corpus callosum) with the differences in pain between the three postsurgery stages. Extent and location of these associations depended on the magnitude of the subjective pain differences. Tractography analysis indicated that some pain–tract associations are significant only when pain stage is involved in the contrast (posterior corona radiata), while others (middle cerebellar peduncle, pontine crossing) are only when anesthesia is involved in the contrast.Conclusions: The association of white matter fractional anisotropy and connectivity, measured before the pain stages, with subjective pain depends on the magnitude of the differences in pain scores.

Comparison of multimodal, sliding scale acute pain protocols with traditional prescribing in non-surgical patients

ABSTRACTObjective: Our institution implemented six multimodal, sliding scale protocols for managing pain in non-surgical inpatients. The purpose of this study was to compare the use of these acute pain protocols with traditional prescribing in regard to pain management efficacy and safety measures.Methods: This retrospective cohort study evaluated hospital in-patients who were prescribed one of the protocols during the first 6 months following implementation, admitted to the hospitalist service, and had received at least two doses of PRN analgesic medication within a 24-hour period. Data collected included baseline demographics, verbal pain rating scores to determine time to achieve analgesia, total opioid use in oral morphine equivalent doses (MEDs), and safety measures. A sample of patients admitted during the same time frame, meeting inclusion/exclusion criteria, but who received traditional analgesic prescribing served as controls.Results: Forty-six adult, non-surgical patients were included in the analysis, and 46 served as controls. The average baseline pain scores were similar between groups (7.26 in protocol, 7.43 in control, p = 0.684). Protocol patients required significantly less time to achieve meaningful analgesia (average 507.52 min) compared to the control group (894.33 min, p = 0.045). Patients in the protocol group used an average of 35.81 MEDs per day compared to 65.77 MEDs in controls (p = 0.019). Patients in the protocol group used significantly fewer PRN analgesic doses (12.70 vs. 24.02, p < 0.0001).Conclusion: Analysis of the implementation of acute pain management protocols indicates that using standardized pain management protocols of opioids, non-opioids, and medications to prevent opioid-related adverse events is more effective than traditional analgesic prescribing for our patient population.

The Association Between Acute Pain and Posttraumatic Stress Symptoms in Children and Adolescents 3\xa0Months After Accidental Injury

Previous research suggests that acute pain is a risk factor for later posttraumatic stress symptoms (PTSS). In a prospective cohort study, we examined the association between acute pain from accidental injury and PTSS in children and adolescents, taking into account factors potentially related to pain or posttraumatic stress. Participants were 135 children and adolescents, 8–18 years old. We measured the worst experienced pain since the accident took place with a visual analogue scale. Three months after the accident, posttraumatic stress was assessed with a self-report measure. We found a positive association between acute pain and posttraumatic stress. The amount of pain was negatively associated with injury severity in girls and positively associated with the presence of an extremity fracture in boys. In children who reported severe pain, this pain was significantly associated with PTSS and may account for around 10% of the variance in the severity of PTSS. Although the experience of pain is subjective, our study indicates that severe pain is associated with the severity of later PTSS. Timely management of pain according to acute pain protocols in all phases and disciplines after accidental injury is therefore recommended.

Abstract PR347

Background & Objectives: Postoperative pain management is challenging. There is still room for improvement despite established acute pain protocols. We compared the efficacy between two low doses of intraoperative ketamine infusions in reducing the first 24 hours postoperative morphine consumption. Materials & Methods: Fifty patients with American Society of Anesthesiologists’ (ASA) Physical Status I or II aged between 18 to 65 years undergoing open gynaecological surgeries were randomised into three groups to receive intraoperative infusions of normal saline (Group A), ketamine at 0.25 mg/kg/hour (Group B) or ketamine at 0.5 mg/kg/hour (Group C). All patients received intraoperative intravenous morphine 0.1 mg/kg. Postoperative morphine consumption via patient controlled analgesia device, visual analogue scale (VAS) for pain and ketamine side effects were recorded at times zero, 10, 20, 30 minutes, and 6, 12, 24 hours postoperatively. Results: Mean cumulative 24 hours postoperative morphine consumption was significantly reduced in Groups B and C (23.1 ± 8.4 mg and 16.7 ± 7.2 mg respectively) when compared to Group A (30.9 ± 11.1 mg). Group C had significantly lower VAS pain scores and rescue morphine requirements in the postoperative period. There were no significant adverse side effects in all 3 groups. Conclusion: Intraoperative ketamine infusion at 0.5 mg/kg/hour significantly improved pain control and reduced postoperative morphine consumption.

Opioid Pharmacokinetics-Pharmacodynamics: Clinical Implications in Acute Pain Management in Trauma.

To evaluate acute traumatic pain protocols and to suggest optimization by characterizing opioid pharmacokinetics and pharmacodynamics (PK-PD). MEDLINE (1946 to November 2015), EMBASE (1974 to November 2015), International Pharmaceutical Abstracts (1970 to December 2014), and Cochrane Database of Systematic Reviews (2005 to November 2015). morphine, hydromorphone, fentanyl, trauma, acute pain, intravenous, opioid, pharmacokinetics, and pharmacodynamics. Literature characterizing opioid PK-PD was included. Additionally, studies evaluatingoutcomes of opioids for acute severe pain in adult trauma patients were selected. PK-PD literature suggests that morphine exhibits an effect delay of 1.6 to 4.8 hours; however, clinical significance is doubtful. The relative onset of morphine is approximately 6 minutes, and duration, 96 minutes. Morphine 0.1 mg/kg IV then 0.05 mg/kg every 5 minutes achieved pain control in 40% of patients at 10 minutes and 76% at 60 minutes. The effect delay of hydromorphone (orally) is 18 to 38 minutes; its relative onset (IV), 5 minutes; and duration, 120 minutes. Hydromorphone every 15 minutes achieved variable success in clinical trials. The effect delay of fentanyl IV is 16.4 minutes; relative onset, 2 minutes; and duration, 7 minutes. One randomized controlled trial used fentanyl 0.1 µg/kg IV every 5 minutes. Further integration of opioid PK-PD into acutepain protocols is possible. One opioid should not be deemed more effective but rather titrated to effect. Morphine and hydromorphone can be titrated IV every 5 minutes until adequate pain control. Fentanyl can be titrated every 3 minutes.

The Analgesic Effect of Electroacupuncture on Acute Thermal Pain Perception-a Central Neural Correlate Study with fMRI

BackgroundElectrical acupuncture (EA) has been utilized in acute pain management. However, the neuronal mechanisms that lead to the analgesic effect are still not well defined. The current study assessed the intensity [optimal EA (OI-EA) vs. minimal EA (MI-EA)] effect of non-noxious EA on supraspinal regions related to noxious heat pain (HP) stimulation utilizing an EA treatment protocol for acute pain and functional magnetic resonance imaging (fMRI) with correlation in behavioral changes. Subjects underwent five fMRI scanning paradigms: one with heat pain (HP), two with OI-EA and MI-EA, and two with OI-EA and HP, and MI-EA and HP.ResultsWhile HP resulted in activations (excitatory effect) in supraspinal areas known for pain processing and perception, EA paradigms primarily resulted in deactivations (suppressive effect) in most of these corresponding areas. In addition, OI-EA resulted in a more robust supraspinal sedative effect in comparison to MI-EA. As a result, OI-EA is more effective than MI-EA in suppressing the excitatory effect of HP in supraspinal areas related to both pain processing and perception.ConclusionIntensities of EA plays an important role in modulating central pain perception.

Pain management in emergency departments: a review of present protocols in The Netherlands

This descriptive study presents availability and content of acute pain protocols in emergency departments (EDs) in The Netherlands. Current acute pain protocols were collected and an a priori list of questions was used for analysis. Findings were compared with current international standards. Sixty-six of the 108 EDs responded. Fifty-six percent of the protocols did not address adults and 35% did not address children. Protocols were rather conservative and showed poor multidisciplinary approach. Seventy-three percent required a diagnosis before pain relief. Six percent did not include opioids, 36% did not allow intravenous opioids and only 49% allowed direct administration of opioids in severe pain. Pain measurement was included in 55% and in only 5% a target score was defined. Nonpharmacological approaches were mentioned in 6%. Acute pain protocols are lacking in many EDs. Most protocols did not apply current standards. We exposed an area with space for leadership.

Assessment and management of acute pain in cats

Abstract: Cats are popular pets, but until recently, their peri‐operative and traumatic pain had been seriously underestimated and under‐treated. The lack of treatment stems from difficulty in recognizing pain, lack of licensed analgesic drugs, fear of toxic side effects, and lack of information specific to cats. Fortunately, in the last decade, many advances have been made in feline analgesia. It is now obvious that because of the cat's unique metabolism, species‐specific studies are essential. Opioids are the mainstay of any analgesic protocol for acute pain and can be used with few side effects. Other drugs that can be utilized include the α2‐agonists, local anesthetics, and non‐steroidal anti‐inflammatory drugs. Pain assessment in cats is challenging and developing, and validating pain scoring systems remains an important goal. The information in this article will help the critical care and emergency clinician formulate a safe and effective analgesic plan for feline patients.

The frequency and timing of respiratory depression in 1524 postoperative patients treated with systemic or neuraxial morphine

Study Objective To describe the frequency and timing of intravenous patient-controlled analgesia (IV-PCA) or neuraxial morphine–induced postoperative respiratory depression. Design Audit of data captured by routine quality assurance of the acute pain protocols that were implemented by nurses performing routine postoperative care. Setting The surgical wards of a university-affiliated, 700-bed, tertiary hospital. Patients and Interventions In real time, the data of all patients enrolled into our Acute Pain Service (APS) were entered and stored in the APS database. Thereafter, patients who had received IV morphine via a PCA device or neuraxial morphine between January 1999 and December 2002 were isolated. From this subset, all patients in whom a respiratory rate (RR) less than 10 breaths per minute was recorded were retrieved. Measurements and Main Results From a total of 4500 patients, IV or neuraxial morphine was administered to 1524 patients. Eighteen (1.2%) cases of an RR less than 10 breaths per minute were recorded (13 patients, 4 patients, and 1 patient in the IV-PCA, daily epidural morphine, and single-dose intrathecal morphine groups, respectively). A direct correlation between intraoperative fentanyl administration and postoperative respiratory depression was demonstrated between the IV-PCA ( P = 0.03) and epidural groups ( P = 0.05). The time from IV-PCA initiation or last neuraxial morphine administration until the diagnosis of respiratory depression ranged between 2 hours and 31.26 hours and 2 hours and 12.15 hours, respectively. Ten (55.6%) patients received naloxone. Conclusion Morphine-induced respiratory depression may occur at any time during the APS admission. However, the optimal frequency of intermittent RR monitoring is unknown. Furthermore, because multiple variables (age, sex, prior opioid administration, site of operation) may affect morphine-induced respiratory depression, further investigation must be performed to determine the ideal monitoring protocol.