Administration Of Analgesic Medication Research Articles

Lack of Association Between Press Ganey Emergency Department Patient Satisfaction Scores and Emergency Department Administration of Analgesic Medications

We explore the relationship between Press Ganey emergency department (ED) patient satisfaction scores and ED administration of analgesic medications, including amount of opioid analgesics received, among patients who completed a patient satisfaction survey. We conducted a secondary data analysis of Press Ganey ED patient satisfaction surveys from patients discharged from 2 academic, urban EDs October 2009 to September 2011. We matched survey responses to data on opioid and nonopioid analgesics administered in the ED, demographic characteristics, and temporal factors from the ED electronic medical records. We used polytomous logistic regression to compare quartiles of overall Press Ganey ED patient satisfaction scores to administration of analgesic medications, opioid analgesics, and number of morphine equivalents received. We adjusted models for demographic and hospital characteristics and temporal factors. Of the 4,749 patients who returned surveys, 48.5% received analgesic medications, and 29.6% received opioid analgesics during their ED visit. Mean overall Press Ganey ED patient satisfaction scores for patients receiving either analgesic medications or opioid analgesics were lower than for those who did not receive these medications. In the univariable polytomous logistic regression analysis, receipt of analgesic medications, opioid analgesics, and a greater number of morphine equivalents were associated with lower overall scores. However, in the multivariable analysis, receipt of analgesic medications or opioid analgesics was not associated with overall scores, and receipt of greater morphine equivalents was inconsistently associated with lower overall scores. Overall Press Ganey ED patient satisfaction scores were not primarily based on in-ED receipt of analgesic medications or opioid analgesics; other factors appear to be more important.

Comparison of Outcomes for Children With Cervical Spine Injury Based on Destination Hospital From Scene of Injury

Pediatric cervical spine injury is rare. As a result, evidence-based guidance for prehospital triage of children with suspected cervical spine injuries is limited. The effects of transport time and secondary transfer for specialty care have not previously been examined in the subset of children with cervical spine injuries. The primary objective was to determine if prehospital destination choice affects outcomes for children with cervical spine injuries. The secondary objectives were to describe prehospital and local hospital interventions for children ultimately transferred to pediatric trauma centers for definitive care of cervical spine injuries. The authors searched the Pediatric Emergency Care Applied Research Network (PECARN) cervical spine injury data set for children transported by emergency medical services (EMS) from scene of injury. Neurologic outcomes in children with cervical spine injuries transported directly to pediatric trauma centers were compared with those transported to local hospitals and later transferred to pediatric trauma centers, adjusting for injury severity, indicated by altered mental status, focal neurologic deficits, and substantial comorbid injuries. In addition, transport times and interventions provided in the prehospital, local hospital, and pediatric trauma center settings were compared. Multiple imputation was used to handle missing data. The PECARN cervical spine injury cohort contains 364 patients transported from scene of injury by EMS. A total of 321 met our inclusion criteria. Of these, 180 were transported directly to pediatric trauma centers, and 141 were transported to local hospitals and later transferred. After adjustments for injury severity, odds of a normal outcome versus death or persistent neurologic deficit were higher for patients transported directly to pediatric trauma centers (odds ratio [OR]= 1.89, 95% confidence interval [CI]=1.03 to 3.47). EMS transport times to first hospital did not differ and did not affect outcomes. Prehospital analgesia was very infrequent. Initial destination from scene (pediatric trauma center vs. local hospital) appears to be associated with neurologic outcome of children with cervical spine injuries. Markers of injury severity (altered mental status and focal neurologic findings) are important predictors of poor outcome in children with cervical spine injuries and should remain the primary guide for prehospital triage to designated trauma centers.

Monitoring salivary amylase activity is useful for providing timely analgesia under sedation.

To detect the criteria and cause of elevated salivary amylase activity (sAMY) in patients undergoing endoscopic submucosal dissection (ESD) under sedation. A total of 41 patients with early gastric cancer removed via ESD under deep sedation (DS) were enrolled. The perioperative sAMY, which was shown as sympathetic excitements (SE), was measured. The time at which a patient exhibited a relatively increased rate of sAMY compared with the preoperative baseline level (IR, %) ≥ 100% (twice the actual value) was assumed as the moment when the patient received SE. Among the 41 patients, we focused on 14 patients who exhibited an IR ≥ 100% at any time that was associated with sAMY elevation during ESD (H-group) and examined whether any particular endoscopic procedures can cause SE by simultaneously monitoring the sAMY level. If a patient demonstrated an elevated sAMY level above twice the baseline level, the endoscopic procedure was immediately stopped. In the impossible case of discontinuance, analgesic medicines were administered. This study was performed prospectively. A total of 26 episodes of sAMY eruption were considered moments of SE in the H-group. The baseline level of sAMY significantly increased in association with an IR of > 100% at 5 min, with a significant difference (IR immediately before elevation/IR at elevation of sAMY = 8.72 ± 173/958 ± 1391%, P < 0.001). However, effective intervention decreased the elevated sAMY level immediately within only 5 min, with a significant difference (IR at sAMY elevation/immediately after intervention = 958 ± 1391/476 ± 1031, P < 0.001). The bispectral indices, systolic blood pressure and pulse rates, which were measured at the same time, remained stable throughout the ESD. Forceful endoscopic insertion or over insufflation was performed during 22 of the 26 episodes. Release of the gastric wall tension and/or the administration of analgesic medication resulted in the immediate recovery of the elevated sAMY level, independent of body movement. By detecting twice the actual sAMY based on the preoperative level, the release of the gastric wall tension or the administration of analgesic agents should be considered.

Presentation With Recurrent Intractable Headache: A Patient With Moyamoya Syndrome: Case Report

This clinical case report represents an interesting manifestation of a neurovascular condition that can be easily overlooked by the practicing healthcare provider. In the United States, a Hispanic patient of non-Asian descent presented with atypical symptoms of intractable headache and nausea with no evidence of neurologic deficits. Further diagnostic work-up was performed as the patient was not responding to traditional analgesic medication administration. Ultimately, cerebral angiogram revealed vascular occlusion with collateral circulation consistent with moyamoya syndrome. Discussion of the challenges and available clinical guidance for healthcare professionals dealing with patients presenting with intractable headache are presented in this report.

Clinical Analgesia in Reptiles

Reptile pain and analgesia is only beginning to be understood in veterinary research and clinical medicine. The diversity of the class Reptilia also makes it difficult to extrapolate analgesic efficacy across species. Many veterinary clinicians argue that the administration of analgesic medication is risky to the patient and may mask behavioral signs of pain, which are considered evolutionarily adaptive for survival. However, veterinarians have an ethical obligation to treat painful conditions in all animals, including reptiles, because effective pain management reduces stress-induced disruption to homeostatic mechanisms and also decreases morbidity and mortality associated with trauma or surgery. Nevertheless, several obstacles limit successful analgesic use, including subjectivity of pain assessment, inadequate knowledge regarding analgesic efficacy across species, pharmacokinetics of analgesic drugs, and the unknown relationship between risks and benefits for this class of drugs. The objective of this review is to provide a current perspective on the practical application of analgesic medication in commonly maintained pet reptile species.

Narcotic Use in Long-term Care

Introduction/Objective: Pain is a common problem, which has a significant functional and quality of life impact on nursing home residents. The prevalence of substantial pain is thought to be as high as 80% among nursing home residents. Several causes of pain have been identified the most common being arthritis, others include cancer, low back pain, crystal induced arthropathies, and leg cramps. Multiple studies found that pain is both under recognized and under treated in nursing homes. The multiple medical problems as well as cognitive impairment and communication difficulties represent some of the difficulties in assessing and treating pain in these individuals. Pain in elderly long-term care residents has many well-documented consequences. Some of these consequences include depression, anxiety, decreased socialization, sleep disturbance, impaired ambulation, and increased health care utilization. Other conditions that may be worsened by pain are gait disturbances, slow rehabilitation, and adverse effects from multiple drug prescriptions. The most widely used management strategy is administration of analgesic medications. Non-opioid analgesics carry a high incidence of adverse effects in the elderly the most prominent being gastrointestinal bleeding from long-term use of NSAIDs. Opioids have been widely studied for persistent pain with proved efficacy. Older people constitute a heterogeneous population, making optimum dosage and common side effects difficult to predict. Some of the common adverse effects include constipation, nausea and vomiting, sedation, impaired judgment, impaired psychomotor function, and respiratory depression. Lower starting doses, longer dose intervals, and slow titration are used to limit these effects. A careful review of indication, comorbid conditions, degree of benefit and potential side effects is needed at the time of opioid prescription. Once a prescription is in place, a regular review of appropriate dosing, drug substitution and discontinuation is needed. A clear documentation of indication and review are often lacking in clinical practice. If this is truly the case then a policy of careful titration to effect and initially frequent review would seem sensible. The objective of this study is to establish the prevalence of opioid use and the associated documentation of indications and in a long-term facility.

Postoperative Self‐Report of Pain in Children: Interscale Agreement, Response to Analgesic, and Preference for a Faces Scale and a Visual Analogue Scale

To augment available validation data for the Faces Pain Scale - Revised (FPS-R) and to assess interscale agreement and preference in comparison with the Coloured Analogue Scale (CAS) in pediatric acute pain. The present prospective, multicentre study included 131 inpatients five to 15 years of age (mean age 8.8 years; 56% male) seen in postoperative recovery. They provided CAS and FPS-R pain scores before and after administration of analgesic medication. Nurses and physicians used the same tools as observational scales. Children and health care providers indicated which scale they preferred. FPS-R scores for the intensity of postoperative pain correlated highly with the corresponding CAS scores in all age groups (0.66 <or= r <or= 0.88). There were no significant mean differences in any age group between the scales. Scores on the two scales differed by 210 or less in 81% to 91% of children, depending on age. Both scales demonstrated expected changes in postoperative pain following administration of an analgesic. Scores at the upper end point were given by approximately 20% of children five to six years of age on both scales, compared with 2% to 9% in the older age groups. Health care providers' observational ratings were significantly lower than self-ratings. The FPS-R was preferred over the CAS by most children in all age groups and both sexes. Global satisfaction of the health care providers was similar for both tools. These results support the use of the FPS-R for most children five years of age or older in the postoperative period. Further research is needed to identify young children, particularly those younger than seven years of age, who have difficulty with self-report tools, and to establish methods for training them in the reliable use of these measures.

Postoperative Pain Characteristics in Turkish Orthopedic Patients

Postoperative pain is a subjective concept that can only be defined by the individual experiencing it. This research was planned as a descriptive study to make postoperative pain assessments of patients who have undergone major orthopedic surgery. The study sample consisted of 150 patients who met the inclusion criteria and agreed to participate in the study. Data were collected using a questionnaire form that included sociodemographic, postoperative pain characteristics, and the McGill Pain Questionnaire. The data obtained were assessed using the SPSS 10.0 program. The mean age of the patients was 54.13 ± 18.12 years, 67.3% were female, 72.7% of the patients had a history of previous surgery, 43.3% had had hip prosthesis surgery, and 70.7% when their analgesic medications were taken on PRN basis. They experienced “external” pain at the surgical site and in pressure areas according to type of surgery and verbalized their pain at the highest percentages as “throbbing,” “tiring,” “troublesome,” and “nagging.” In addition the majority of the patients (95.3%) stated that their pain was decreased with analgesic medication administration, and 78.7% stated that position change and physical therapy (69.3%) increased their pain. In the assessment of pain severity on the third postoperative day, the Present Pain Intensity was determined to be a mean of 1.75 ± 1.02 (on a scale of 0 to 5), and 78.7% had “intermittent” pain. In addition, worst/severe pain severity was determined to be a mean of 4.55 ± 0.70 on the third postoperative day. Statistically significant differences were found between patients’ pain severity scores ( p ≤ .001). This study determined pain characteristics on the third postoperative day in Turkish orthopedic patients. After an evaluation of the conclusions, nurses must learn the postoperative pain characteristics of orthopedic patients to implement safe and effective postoperative pain management.

Use of a triage pain protocol in the ED

Purposes This study was designed to evaluate the ability of a triage pain protocol to improve frequency and time to delivery of analgesia for musculoskeletal injuries in the emergency department (ED). Basic Procedures Frequency and time to analgesic administration were measured before and after use of a triage pain protocol. The protocol allowed analgesic medications to be given at the time of triage. Main Findings Time to medication administration was 76 minutes (95% confidence interval [CI], 68-84 minutes) before and 40 minutes (95% CI, 32-47 minutes) after the protocol. Five hundred fifty-nine (70%) of 800 patients received analgesics using the protocol compared with 212 of 471 (45%) patients prior. Principal Conclusions Use of a triage pain protocol increased the number of patients with musculoskeletal injury who received pain medication in the ED. Use of the protocol also resulted in a decrease in the time to analgesic medication administration.

Parental Administration of Analgesic Medication in Children After a Limb Injury

To document parental administration of analgesic medication to children with pain from acute limb injury before coming to the emergency department (ED). Research assistants interviewed parents of children 0 to 18 years old who presented to the ED with acute limb injury, asking about analgesic use before arriving to the ED. Parents were also asked for personal and demographic information. Parents who did not give pharmacological analgesia were asked why they decided not to administer medications. All parents were asked if they will administer analgesia in the future. A total of 72% of parents administered analgesia (pharmacological or others) to their children. Only 28% of the children received pharmacological analgesics before arriving to the ED. Child's mean age was higher for the group receiving medications, compared with those not receiving medications (99 +/- 50 vs 122 +/- 52 months, respectively; P = 0.005). The main parental concern about analgesic use was of potential masking of the clinical signs and symptoms before being seen by a physician. Prehospital analgesic administration by parents is mainly nonpharmacological largely because of parental concern of interference with medical assessment or underestimating the child's pain. Parental concern of masking symptoms and parental perception of no pain in a child were significant factors in determining parental comfort level in using pharmacological analgesics.

Caudal 0.2% ropivacaine is less effective during surgery than 0.2% levobupivacaine and 0.2% bupivacaine: a double‐blind, randomized, controlled trial

We hypothesized that without the analgesic effects of volatile anesthetics, caudal 0.20% ropivacaine would be less effective during surgical stimulation than 0.20% bupivacaine or 0.20% levobupivacaine. This trial was designed to examine whether the combination of a caudal block with 0.20% ropivacaine and i.v. anesthesia resulted in reduced analgesic efficacy during surgery compared with caudal 0.20% levobupivacaine or 0.20% bupivacaine in children. Ninety ASA I-II children between 1 and 7 years old, scheduled for inguinal hernia repair or orchidopexy under propofol anesthesia were randomized to receive a caudal block with 1 ml x kg(-1) of 0.2% bupivacaine, 0.2% ropivacaine or 0.2% levobupivacaine. The primary outcome measure of the study was the clinical efficacy of the caudal block during surgery. Secondary outcome measures were postoperative pain relief and residual motor blockade. Four children were excluded and 86 were analyzed. The proportion of children with effective caudal block during surgery was significantly higher in children receiving levobupivacaine (26/28) or bupivacaine (27/29) compared with patients receiving ropivacaine (21/29) (P = 0.03). There were no significant differences among groups in the analgesic onset time (P = 0.1), incidence of residual motor blockade (P = 0.4), number of patients requiring analgesia after operation or in the time from caudal injection to the first administration of analgesic medication (P = 0.3). Combined with propofol anesthesia, 0.2% levobupivacaine and 0.2% bupivacaine are more effective than 0.2% ropivacaine for caudal use in children undergoing inguinal hernia repair or orchidopexy.

Effect of Acetaminophen on Behavior, Well‐Being, and Psychotropic Medication Use in Nursing Home Residents with Moderate‐to‐Severe Dementia

To evaluate the effect of regularly scheduled administration of analgesic medication on behavior, emotional well-being, and use of as-needed psychotropic medications in nursing home residents with moderate-to-severe dementia. Randomized, double-blind, placebo-controlled, crossover trial. Nursing-home based. Twenty-five nursing home residents with moderate-to-severe dementia. Participants received 4 weeks of acetaminophen (3,000 mg/d) and 4 weeks of placebo. Behavior and emotional well-being were assessed using Dementia Care Mapping, an observational method that quantifies time spent in behaviors across 26 domains (e.g., social interaction, unattended distress) and assesses emotional state while behaviors are being observed. Agitation was measured using the Cohen-Mansfield Agitation Inventory. As-needed psychotropic medication use was aggregated from medication logs. Participants spent more time in social interaction, engaged with media, talking to themselves, engaged in work-like activity, and experiencing unattended distress when they received acetaminophen than they did when they received placebo. Participants also spent less time in their rooms, less time removed from the nursing home unit, and less time performing personal care activities when they received acetaminophen. There were no effects on agitation, emotional well-being, or as-needed psychotropic medication use. Untreated pain inhibits activity in nursing home residents with moderate-to-severe dementia. Pain treatment in this group may facilitate engagement with the environment.

The Linearity of the Visual Analogue Scale in Patients with Severe Acute Pain

The visual analogue scale (VAS) is a standard measurement tool in pain research and clinical practice, and has been shown to have linear scale properties for mild to moderate pain. Our aim was to evaluate the scaling properties of the VAS in subjects with severe acute pain. After Ethics Committee approval we studied 22 patients and asked them to rate the severity of their pain on a 100 mm VAS at the initial assessment (VAS1), and again after administration of analgesic medication. The subject was asked to nominate when they considered their pain intensity had halved, and at this time they were asked to rate this on a second VAS (VAS0.5). When the subject had received satisfactory relief of their pain, they were asked to describe how much their pain had been relieved and were then asked to rate their final pain state using a third VAS (VASfinal). The mean (SD) scores were VAS1 84 (14) (range 56-100), VAS0.5 42 (13) and VASfinal 21 (16). The mean (95% CI) for VASratio was 0.51 (0.45-0.57). The mean (SD) patients' estimate of pain relief was 77 (21)% from that of baseline, with a mean (SD) VASfinal 0.26 (0.20), 95% CI 0.17-0.38. The correlation of the patients' estimate of pain relief with the VASfinal was r=0.89, rho=0.87, both P<0.001. The VAS is a linear scale in subjects with severe acute pain. Changes in the VAS score represent a relative change in the magnitude of pain sensation.

Preemptive analgesia for postoperative pain relief in lumbosacral spine surgeries: a randomized controlled trial*1

<h2>Abstract</h2><h3>Background context</h3> Administration of analgesic medication, before the actual onset of painful stimulus, is more effective than that after the onset of painful stimulus. This is the principle of preemptive analgesia. Although it is often considered superior to other forms of analgesia, its role in postoperative pain relief after lumbosacral spinal surgery has not been fully investigated. <h3>Purpose</h3> To analyze the efficacy of preemptive analgesia with a single caudal epidural injection for patients undergoing surgeries on the lumbosacral spine by the posterior approach. <h3>Study design/setting</h3> Randomized, double-blinded and controlled clinical trial. <h3>Patient sample</h3> Eighty-two patients who underwent discectomy in the lumbosacral spine by the posterior approach, with or without instrumentation, were randomized to the control group (n=40) and to the study group (n=42). <h3>Methods</h3> Patients in control group received a single caudal epidural injection of 20 ml of normal saline. Patients in study group received a single caudal epidural injection of 20 ml containing bupivacaine and tramadol as the active agents. The time interval between this injection and the surgical incision was never less than 20 minutes in either of the groups. This facilitated enough time for the drug to get fixed to the nerve roots, leading to effective preemptive analgesia. <h3>Outcome measures</h3> Patients were monitored for postoperative pain immediately after surgery when they had completely recovered and regained consciousness from general anesthesia, and subsequently 4, 8, 12 and 24 hours thereafter. Pain was quantified using the visual analog scale (VAS) and the verbal rating scale (VRS). The time at which supplemental analgesic medication was first demanded in the postoperative period by the patient was also noted. <h3>Results</h3> The two groups were comparable for age, sex, body weight and the type of surgery they underwent. Because the data did not have a normal Gaussian distribution, the one-tailed Mann-Whitney test, being a nonparametric test, was adopted for statistical analysis. Accordingly, VAS and VRS values at all time intervals were significantly lower (p<.0001) in the study group as compared with the control group. This indicated significantly better pain relief in the study group. There was also a significant delay (p=.0041) in the first demand for supplemental analgesic medication in the postoperative period in the study group. No complication specific to the procedure was noted except for the development of postoperative urinary retention, which was transient and appropriately managed with urinary catheterization. <h3>Conclusions</h3> Preemptive analgesia with a single caudal epidural injection of bupivacaine and tramadol is a safe, simple and effective method for postoperative pain relief.

Preemptive analgesia for postoperative pain relief in lumbosacral spine surgeries: a randomized controlled trial

Background context Administration of analgesic medication, before the actual onset of painful stimulus, is more effective than that after the onset of painful stimulus. This is the principle of preemptive analgesia. Although it is often considered superior to other forms of analgesia, its role in postoperative pain relief after lumbosacral spinal surgery has not been fully investigated. Purpose To analyze the efficacy of preemptive analgesia with a single caudal epidural injection for patients undergoing surgeries on the lumbosacral spine by the posterior approach. Study design/setting Randomized, double-blinded and controlled clinical trial. Patient sample Eighty-two patients who underwent discectomy in the lumbosacral spine by the posterior approach, with or without instrumentation, were randomized to the control group (n=40) and to the study group (n=42). Methods Patients in control group received a single caudal epidural injection of 20 ml of normal saline. Patients in study group received a single caudal epidural injection of 20 ml containing bupivacaine and tramadol as the active agents. The time interval between this injection and the surgical incision was never less than 20 minutes in either of the groups. This facilitated enough time for the drug to get fixed to the nerve roots, leading to effective preemptive analgesia. Outcome measures Patients were monitored for postoperative pain immediately after surgery when they had completely recovered and regained consciousness from general anesthesia, and subsequently 4, 8, 12 and 24 hours thereafter. Pain was quantified using the visual analog scale (VAS) and the verbal rating scale (VRS). The time at which supplemental analgesic medication was first demanded in the postoperative period by the patient was also noted. Results The two groups were comparable for age, sex, body weight and the type of surgery they underwent. Because the data did not have a normal Gaussian distribution, the one-tailed Mann-Whitney test, being a nonparametric test, was adopted for statistical analysis. Accordingly, VAS and VRS values at all time intervals were significantly lower (p<.0001) in the study group as compared with the control group. This indicated significantly better pain relief in the study group. There was also a significant delay (p=.0041) in the first demand for supplemental analgesic medication in the postoperative period in the study group. No complication specific to the procedure was noted except for the development of postoperative urinary retention, which was transient and appropriately managed with urinary catheterization. Conclusions Preemptive analgesia with a single caudal epidural injection of bupivacaine and tramadol is a safe, simple and effective method for postoperative pain relief.

Pain in older subacute care patients: associations with clinical status and treatment.

To examine the relationship between patient pain levels and clinical status and treatment in older adults. A correlational study involving patient and nurse ratings of pain and retrospective review of clinical records. A subacute care inpatient facility. Seventy-five older adults (mean age: 75.9 years) who met entry criteria for pain, age, and mental status. Patients and nurses made independent ratings of pain over a 7-day period. Clinical data included measures of mental status, depression, behavioral signs of discomfort, functional independence, and analgesic medication use. Nurse ratings of patient pain were uncorrelated with patient ratings and underestimated pain relative to patient reports. Nurse ratings correlated with levels of behavioral discomfort and with doses of opioid medication. Patient ratings were associated with functional limitations, depression, and behavioral signs of discomfort, but were minimally related to administration of opioids or other pain medication. Patient mental status did not appreciably moderate these relationships. These findings support a growing literature indicating deficiencies in pain assessment of older patients and suggest inappropriate administration of analgesic medications for these patients. More systematic assessment of pain, including the use of instruments with established psychometric properties for older patients, may improve pain control and enhance functional rehabilitation in this group.

Effect of preemptive multimodal analgesia for arthroscopic knee ligament repair

Background and Objectives: Administration of analgesic medication before surgery, rather than at the completion of the procedure, may reduce postoperative pain. Similarly, administration of multiple analgesics, with different mechanisms of action, may provide improved postoperative pain control and functional recovery. The purpose of our study was to compare pain scores and intravenous opioid consumption after outpatient anterior cruciate ligament (ACL) reconstruction in patients who received a multimodal drug combination (intravenous [IV] ketorolac, intra-articular morphine/ropivacaine/epinephrine, and femoral nerve block with ropivacaine) either before surgery or immediately at the completion of the surgical procedure. Methods: Forty patients presenting for same-day arthroscopic ACL repair using a semitendinosis tendon graft were included in this study. The patients were randomized to receive the following drugs either 15 minutes before skin incision or immediately after skin closure: (1) Ketorolac 30 mg IV. (2) Intra-articular injection of 20 mL ropivacaine 0.25% + morphine 2 mg and epinephrine 1:200,000. (3) Femoral nerve block with 20 mL ropivacaine 0.25%. Verbal pain scores were obtained in the postanesthesia care unit (PACU) and on postoperative days 1, 3, and 7. IV patient controlled analgesia (PCA) morphine consumption in the PACU was also recorded. Results: Verbal pain rating scores were lower in group I (preemptive) for 2.0 hours after arrival in the PACU. There was no difference between groups in pain scores on postoperative days 1, 3, and 7. Mean IV PCA morphine consumption in the PACU was lower in group I (6.4 mg) versus group II (12.3 mg), P < .05. Conclusion: Preemptive, multimodal administration of our 3-component analgesic drug combination resulted in lower pain scores during the initial stay in the PACU unit and lower consumption of IV PCA morphine in the PACU. However, pain scores were similar in both groups on postoperative days 1, 3, and 7; thus, there was no measurable long-term advantage associated with preemptive multimodal drug administration. Reg Anesth Pain Med 2001;26:125-130.

Analgesic drug prescription and use in cognitively impaired nursing home residents.

Prior research has documented the high prevalence of pain in elderly adults and the difficulties associated with properly assessing and treating pain in elders with cognitive impairment. To investigate the prescription and administration of analgesic medications to treat pain in cognitively impaired nursing home residents. The current sample consisted of 339 nursing home residents (295 women and 44 men) with a mean age of 87 years (range 66-104). Forty-six percent of the sample had diagnosed cognitive impairment, and 55% had at least one diagnosed painful condition. Data for this correlational study were drawn from four nursing homes in Western Pennsylvania. The Multidimensional Observation Scale for Elderly Subjects was used to assess behavioral indicators of cognitive impairment, and chart review was used to obtain demographic, medication, and diagnostic data. The results indicated that cognitively impaired nursing home residents are prescribed and administered significantly less analgesic medication, both in number and in dosage of pain drugs than their more cognitively intact peers. In multiple regression analyses holding the presence of painful conditions constant, more disoriented and withdrawn residents were prescribed significantly less analgesia by physicians; more disoriented, withdrawn, and functionally impaired residents were administered significantly less analgesia by nursing staff. The findings highlight the difficulties of assessing pain in cognitively impaired elders and the lack of knowledge among health care providers about effective pain management.

IMPROVING PAIN MANAGEMENT FOR HIP FRACTURED ELDERLY

This article discusses a quality assurance project that examined the effect of two modalities of pro re nata (PRN) analgesic medication administration on pain and mobility of elderly postoperative hip surgery patients. Several approaches to improving pain management in these patients are recommended.

Patient-Controlled Analgesia: An Update on Its Use in the Treatment of Postoperative Pain

Summary It is impossible to accurately predict how much pain a patient will experience after an operation or how much analgesic medication will be required to provide adequate pain relief. Thus, physicians and nurses necessarily rely on subjective methods to determine the analgesic regimen for patients experiencing postoperative pain. In reviewing the literature, it is obvious that “there is a deficient link in the chain that involves the patient who experiences pain and requests medication, the physician prescribing the analgesic drugs, and the nurse who assesses the pain and makes the decision about when to administer analgesics.”46 Problems arise because of the inherent difficulties in determining the appropriate dose and dosing interval, resulting in some patients being overmedicated while others continue to experience unacceptable levels of pain. Given the narrow “therapeutic window” for an individual patient, a carefully titrated dose of analgesic drug is needed to maintain adequate analgesia without undesirable side effects. PCA is a system designed to accommodate the wide range of analgesic requirements that can be anticipated when managing acute postoperative pain.33 PCA can also minimize the anxiety resulting from the slow onset of pain relief associated with most commonly used therapeutic modalities. A major psychological advantage with PCA therapy relates to its ability to minimize the time delay between the perception of pain and the administration of analgesic medication. In addition, the increased attention being paid to the PCA-treated patient both preoperatively and postoperatively might provide a psychological benefit to the patient. The comfort that patients experience as a result of compassionate and attentive nursing and medical care would be expected to significantly decrease their analgesic drug requirement.15 Although the concept of PCA therapy is not new,21, 30, 36 recent progress in the area of infusion pump technology has renewed interest in this concept. Early clinical studies have demonstrated that safe and effective postoperative pain relief can be achieved with a variety of PCA infusers. With PCA therapy, Graves et al have reported that patients experience minimal sedation during awake hours and progressively increase their physical activity during the postoperative period.24 These investigators suggested that results are better when patients control their own analgesia. In the postoperative situation, PCA is used for maintenance of analgesia. Thus, patients should receive a titrated loading dose prior to initiating self-administered analgesic therapy. If the therapy is to be successful, it is important that the nurse assess the individual patient’s response to the analgesic regimen. Given the marked pharmacodynamic variability that exists among patients with respect to their postoperative analgesic requirements, it will occasionally be necessary to alter the amount of the bolus dose and the duration of the lockout interval in order to optimize the therapeutic regimen. To achieve optimal results with PCA, both the patient and the staff should understand the basic principles upon which the therapy is based. Finally, applications of PCA therapy are not limited to the postsurgical ward. This concept can be applied to the management of acute and chronic cancer pain on medical and oncology wards. Others have suggested that PCA therapy could be used in obstetric suites, intensive care units, coronary care units, as well as in clinical research. Individuals with either markedly increased or decreased analgesic requirements can be adequately managed using a PCA delivery system. Thus, the rational use of a PCA infusion device allows the individual to overcome variations in both pharmacokinetic and pharmacodynamic factors by titrating the rate of narcotic administration to meet their individual analgesic needs. If recurrent (or intractable) nausea or vomiting develops, the patient can be switched to a different narcotic analgesic or antiemetic therapy can be administered. The commonly used antiemetic drugs (for example, droperidol, hydroxyzine) would be expected to enhance the sedation produced by the opioid analgesics. In conclusion, PCA provides improved titration of analgesic drugs, thereby minimizing individual pharmacokinetic and pharmacodynamic differences. PCA therapy decreases patient anxiety resulting from delays in receiving pain-relieving medication and from the slow onset of analgesic action when these drugs are administered either intramuscularly or in the extradural space. With PCA therapy, patients are able to maintain an acceptable level of analgesia with minimal sedation and few side effects. The potential for overdose can be minimized if small bolus doses are used with a mandatory lockout interval between successive doses. Finally, studies of the cost-effectiveness of PCA therapy are important if this therapeutic approach is to achieve even more widespread acceptance.