Standard Pain Management Research Articles

Diclofenac Versus Ketorolac for Pain Control After Primary Total Joint Arthroplasty: A Comparative Analysis

IntroductionAs total hip arthroplasty (THA) and total knee arthroplasty (TKA) transition to outpatient settings, appropriate pain management remains a challenge. Nonsteroidal anti-inflammatory drugs (NSAIDs) may subvert the need for postoperative opioids. This study evaluated: 1) total opioid consumption; 2) postoperative pain intensity; 3) discharge destination; 4) length of stay (LOS); and 5) THA and TKA patients’ satisfaction in receiving adjunctive intravenous (IV) diclofenac or ketorolac.MethodsIn this retrospective cohort study, patients scheduled to undergo primary THA or TKA by a single surgeon between March 2017 and April 2018 were identified. Patients were stratified based on the receipt of IV diclofenac (THA: n = 25; TKA: n = 51) or IV ketorolac (THA: n = 28; TKA: n = 32) in addition to the standard pain management regimen. Student’s t-testing and Chi-square were used to analyze continuous and categorical variables, respectively.ResultsTKA diclofenac patients had lower opioid consumption 12 hours postoperatively (p: 0.037). TKA patients in the diclofenac cohort were discharged to home less often (p: 0.025). Both diclofenac cohorts had greater patient satisfaction than the ketorolac cohorts (p: <0.05). There was no significant difference between groups in postoperative pain intensity at 24 or 48 hours or in the length of stay (p: >0.05 for all).ConclusionThis study demonstrated that both TKA and THA patients treated with IV diclofenac had no difference in postoperative pain intensity while THA patients had no difference in opioid consumption relative to those treated with IV ketorolac. Further comparison of IV NSAIDs with other IV pain medications may provide broader insight into the ideal management for postoperative pain for this widening patient population.

1E Improving the Image of Pain Care through Advanced Nursing Practice

Through innovation/transformational leadership, our APRN Pain Management Service (APRNPMS) had a goal of developing a model of care that met the JC 2018 Standards for Pain Mgt & provided patients with a comprehensive treatment program that improved comfort and decreased reliance on opioid medication. The APRNPMS recognized that patients lacked access to evidence based nonpharmacologic strategies in the hospital. Faced with the opioid epidemic & new JC 2018 Pain Standards, the PMS developed an action plan to expand services that improve patient comfort & decrease opioid use. An integrative pain management model empowers APRNs to collaborate with clinical nurses in EBP & research projects that add to the literature in this field. APRN service developed a SWOT analysis of the current service. Identifying strengths, weaknesses, opportunities & threats that enhance/impede the development of a robust team with a skill set to provide the integrative modalities patients may benefit from was necessary for this patient-centric model. Recognizing value of current staff, NP licensed acupuncturist, clinical nurse Homeopath & NP certified in hospice & palliative care, & clinical hypnosis, a vision for the APRNPMS was born. The APRNs have built relationships through collaborative working groups to empower clinical nurses to engage in research & EBP projects providing options to their patients without contributing to the opioid epidemic. Evaluation/Outcomes are measured through compliance w/JC standards of Pain Management. Statistics will b presented. Empowering APRN autonomous practice & encouraging innovation in practice model development allows APRNs to use EBP to guide nursing practice and improves APRN satisfaction. Our model is an example of how to improve outcomes, decreases opioid reliance, promotes safety, & optimize healing & wellness.

EVALUATION OF PAIN SYNDROME AND EFFICIENCY OF PAIN MANAGEMENT IN LUMBAR SPINE SURGERY

Multimodal analgesia for lumbar spine surgery is still a controversial problem, because of possible fusion problems, significant neuropathic component of pain, and influence of anesthesia type. Aim of the study was to assess the efficacy of pain management after lumbar spine surgery considering characteristics of pain, type of anesthesia and analgesic regimen. Material and methods. 254 ASA I-II patients with degenerative lumbar spine disease were enrolled into prospective study. Patients were operated either under spinal anesthesia (SA) or total intravenous anesthesia (TIVA). In postoperative period patients got either standard pain management (SPM – paracetamol±morphine) or multimodal analgesia (MMA – paracetamol+parecoxib+pregabalin±morphine). Results. We revealed neuropathic pain in 53.9 % of patients, who were elected for lumbar spine surgery. VAS pain score in patients with neuropathic pain was higher, than in patients with nociceptive pain. Total intravenous anesthesia was associated with greater opioid consumption during the first postoperative day. Multimodal analgesia based on paracetamol, parecoxib and pregabalin allowed to decrease requirements for opioids, postoperative nausea and dizziness. Pregabalin used for evening premedication had equipotential anxiolytic effect as phenazepam without postoperative cognitive disturbances. Conclusions. Multimodal analgesia is opioid-sparing technique that allows to decrease complications. Spinal anesthesia is associated to a decreased opioid consumption in the 1st postoperative day.

Impact of Intravenous Opioid Shortage on Managing Pain Crisis in Sickle Cell Disease

Background: Vaso-occlusive crisis (VOC) is the hallmark complication of sickle cell disease (SCD) (1), and usually requires intravenous (IV) opioid treatment in emergency room (ER) or acute care center (ACC), a designated observation unit to manage uncomplicated VOC (2). Starting October 2017, there was a critical nationwide drug shortage in parental hydromorphone, a commonly used medication to treat VOC. In April 2018 the University of Illinois Health System (UI Health) adopted a standardized pain management protocol that limited opioids in the ER or ACC to two doses of IV or IM morphine and/or oral opioid. This study evaluates the impact of this standardized pain management protocol on managing VOC in SCD. Methods: A total of 373 SCD adults treated at UI Health from May 2017 to Oct 2018 had at least one ER or ACC visit or hospitalization for VOC. Data on VOC-related patient visits to the ACC, ER, and admissions to the inpatient floors were collected from the electronic medical record and evaluated based on three time periods (prior to shortage: May 2017-Oct 2017; transition: Oct 2017-Apr 2018; and post protocol: Apr 2018-Oct 2018). Descriptive statistics, the Cochrane trend test and Jonckheere-Terpstra trend test were used for data analysis. The study was approved by the Institutional Review Board prior to the initiation of chart review. Results: Between May 2017 and Oct 2018, the 373 SCD adult patients had a total of 1,915 ACC, 2,635 ER and 1,832 inpatient visits. After implementation in April 2018, the compliance rate with the standardized pain protocol was 99.7% in the ACC and 85.1% in the ER. In the ACC, the number of visits decreased after standardized pain protocol implementation, whereas the number of visits increased in the ER (Figure 1). The admission rate to the inpatient service from the ACC increased significantly while the admission rate from the ER remained relatively stable (Table 1). The numbers of opioid doses and the total opioid dose to treat VOC decreased in the ACC, but not in ER. Utilization of oral opioids increased in both settings (Table 1). The number of inpatient hospitalizations increased with implementation of the standardized protocol (542 vs. 626 vs. 664), and the 30-day readmission rate increased (49% vs. 51% vs. 57%, p = 0.003), but the length of hospital stay was reduced (p &lt; 0.001). Summary: Implementation of a standardized pain treatment protocol due to the parenteral hydromorphone shortage decreased the utilization of the ACC compared to the ER and the inpatient service, and resulted in reduced opioid dose but increased admission rates from the ACC. The 30-day readmission rate to inpatient service increased but the length of stay was reduced. A standardized pain protocol that limits opioids to two doses in the acute setting may not be an optimal approach. Reference: F. B. Piel, M. H. Steinberg, D. C. Rees, Sickle Cell Disease. N Engl J Med376, 1561-1573 (2017).J. Han et al., Program expansion of a day hospital dedicated to manage sickle cell pain. Am J Hematol93, E20-E21 (2018). Disclosures Saraf: Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees; Pfizer: Research Funding. Gordeuk:CSL Behring: Consultancy, Honoraria, Research Funding; Global Blood Therapeutics: Consultancy, Honoraria, Research Funding; Novartis: Consultancy, Honoraria, Research Funding; Modus Therapeutics: Consultancy, Honoraria; Imara: Research Funding; Ironwood: Research Funding; Inctye: Research Funding; Pfizer: Research Funding; Emmaus: Consultancy, Honoraria.

The contribution of specific enhanced recovery after surgery (ERAS) protocol elements to reduced length of hospital stay after ventral hernia repair.

Ventral hernia repair (VHR) is a commonly performed procedure that may be associated with prolonged hospitalization. Enhanced recovery after surgery (ERAS) protocols are intended to decrease hospital length of stay (LOS) and improve outcomes. This study evaluated the impact of compliance with individual VHR ERAS elements on LOS. With IRB approval, a medical record review (perioperative characteristics, clinical outcomes, compliance with ERAS elements) was conducted of open VHR consecutive cases performed in August 2013-July 2017. The ERAS protocol was implemented in August 2015; elements in place prior to implementation were accounted for in compliance review. Clinical predictors of LOS were determined through forward regression of log-transformed LOS. The effects of specific ERAS elements on LOS were assessed by adding them to the model in the presence of the clinical predictors. Two-hundred and thirty-four patients underwent VHR (109 ERAS, 125 pre-ERAS). Across all patients, the mean LOS was 5.4days (SD = 3.3). Independent perioperative predictors (P's < 0.05) of increased LOS were CDC Wound Class III/IV (38% increase above the mean), COPD (35%), prior infected mesh (21%), concomitant procedure (14%), mesh size (3% per 100cm2), and age (8% increase per 10years from mean age). Formal ERAS implementation was associated with a 15% or about 0.7days (95% CI 6%-24%) reduction in mean LOS after adjustment. Compliance with acceleration of intestinal recovery was low (25.6%) as many patients were not eligible for alvimopan use due to preoperative opioids, yet when achieved, provided the greatest reduction in LOS (- 36%). Implementation of an ERAS protocol for VHR results in decreased hospital LOS. Evaluation of the impact of specific ERAS element compliance to LOS is unique to this study. Compliance with acceleration of intestinal recovery, early postoperative mobilization, and multimodal pain management standards provided the greatest LOS reduction.

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.

Peripheral Blood Stem Cell Therapy Does Not Improve Outcomes of Femoral Head Osteonecrosis With Cap‐Shaped Separated Cartilage Defect

A combination treatment with porous tantalum rod implantation and intra-arterial infusion of peripheral blood stem cells (PBSCs) provides a promise for treating early and intermediate stages of osteonecrosis of the femoral head (ONFH). However, its clinical indications and application restrictions remain unclear. This study aims to determine the clinical, histological, and radiological outcomes of a combination treatment using mechanical support and a targeted intra-arterial infusion of PBSCs for painful ONFH with a cap-shaped separation (CSS) cartilage defect. Compared with the standard pain management (control group), this combination treatment did not improve the Harris Hip Score (HHS) at 36 months. Micro-CT and histologic analyses showed severe focal destruction in all CSS-ONFH femoral heads in both the combination and control groups. Femoral heads showed a higher percentage of bone lesions in the combination treatment group than in the control group. There was no significant difference in osteoclast number in the subchondral bone areas between the two groups. A high level of expression of inflammatory cytokines, including tumor necrosis factor-α and interleukin-1β, was detected in blood vessels around the subchondral bone in both groups. The RANKL/OPG (receptor activator of the nuclear factor-kB ligand/osteoprotegerin) ratio was also similar between the control and combination treatment groups. Our results indicate that this combination treatment is not an effective method for the treatment of patients with painful CSS-ONFH. Moreover, this combination treatment did not inhibit inflammatory osteoclastogenesis in patients with more advanced disease. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:269-276, 2020.

PAIN SYNDROME AND PAIN MANAGEMENT AFTER LUMBAR SPINE SURGERY

Background. Multimodal analgesia (MMA) in spine surgery is in the beginning of implementation because of contradictions about the negative influence of NSAIDs on spinal fusion process. There is no agreement as to the influence of anesthesia method on postoperative pain after lumbar spine surgery. Aim of the study was to examine the influence of anesthesia type and postoperative pain management on narcotic consumption during lumbar spine surgery. Material and methods: 250 ASA I-II patients 18-65 y.o. during elective lumbar spine surgery on 1-2 segments were examined prospectively. Patients were divided into 4 groups: 1А (n=55) – spinal anesthesia (SA) and standard pain management, 1В (n=55) – SA and MMA, 2А (n=70) – intravenous anesthesia with propofol/fentanyl (TIVA) and standard pain management, 2В (n=70) – TIVA and ММА. Standard pain management included acetaminophen 1 g IV 3 times per day and morphine if VAS pain score was e” 4. For MMA we additionally included pregabalin 75 mg 12 hours before surgery and then two times per day during 3 days and parecoxib 40 mg IV twice per day for the first postoperative day. Results: in both MMA groups (1B and 2B) time of the first morphine requirement was significantly longer than in standard pain management groups (1A and 2A). Average dose of morphine during 24 postoperative hours was the biggest in 2A group (TIVA with standard pain management). In MMA patients the incidence of nausea was lower than in standard pain management patients. Dizziness occurred more frequently in TIVA patients with standard pain management. Conclusions: anesthesia type has an influence on the postoperative pain during the first 24 hours: the average morphine consumption is bigger in TIVA patients with standard pain management than in SA patients. MMA decreases narcotic consumption in any type of anesthesia and decreases postoperative nausea and dizziness

Postoperative Pain Responses in Dental Patients on Chronic Opioid Therapy

It is estimated that 5 to 8 million Americans use opioids daily for the management of chronic pain. Yet, opioid therapy for chronic pain is not an evidence-based intervention, and it is increasingly apparent that outcomes are poorer for patients taking opioids (pain severity, functionality, quality of life) (1). A theorized explanation for these poor outcomes is the phenomenon of opioid-induced hyperalgesia (OIH) (2), defined as increased sensitivity to pain related to chronic opioid use, and which may interfere with desired pain relief in the chronic pain patient. This study was designed to compare pain responses and analgesic need in a sample of dental patients on chronic opioid therapy vs. not on opioid therapy, the first study of its kind. A total of 40 adult dental surgical patients are being enrolled in the study, 20 of whom are on opioid therapy for chronic pain, all undergoing a dental surgical procedure with a similar expected trauma rating, and standardized postoperative non-opioid pain management. Those in the opioid group are taking a regular daily dose of opioids ≥ 50mg morphine equivalents/day for ≥ 3 months and those in the control group have not taken an opioid medication within 3 months. Exclusion criteria include active substance use disorder; severe psychiatric disorder; neurological or psychiatric illness that would affect pain responses; history of GI ulcers; NSAID allergy; poor liver or kidney function; or pregnancy. Prior to the surgical procedure, pain perception is measured using 2 standardized experimental pain assays (cold-pressor testing; quantitative sensory testing) to detect OIH. To determine how OIH may affect postoperative pain responses, patient-reported pain severity and documentation of all analgesic consumption for the first 72 hours are collected. If preoperative opioid use is found to result in increased postoperative pain severity, clinical implications may include anticipation of increased analgesic need or preoperative opioid taper.

Do Ice Packs Reduce Postoperative Midline Incision Pain, NSAID or Narcotic Use?

Adequate postoperative analgesia, especially after major abdominal surgery is important for recovery, early mobility, and patient satisfaction. We aimed to study the effects of cryotherapy via an ice pack in the immediate postoperative period, for patients undergoing major abdominal operations. This prospective study was conducted at our tertiary care referral center in a low-middle-income country setting. The preoperative patient characteristics, intra-operative variables, and postoperative outcomes were compared between two sets of patients. Cryotherapy was delivered via frozen gel packs for 24h immediately following laparotomy. Pain relief was assessed with visual analog pain scores (VAS). Comparisons between groups were measured by Chi-square test, Fischer's exact test, or Mann-Whitney U test as appropriate. Sixty-eight patients were included in the study: 33 in the cryotherapy group and 35 in the non-cryotherapy group. Mean postoperative pain scores (VAS) were significantly lower in the cryotherapy group versus the control group (3.97 ± 0.6 vs. 4.9 ± 0.7 on postoperative day (POD) 1; p < 0.001, and 3 ± 0.5 vs. 09 ± 0.8 on POD2; p < 0.001). The median narcotic use in morphine equivalents was lesser in the cryotherapy group from POD 1-3 (66 (IQR-16) vs. 89 (IQR-17); p = 0.001). No significant difference was seen in the NSAID use between the groups. The cryotherapy group was also found to have a lesser incidence of surgical site infection (p = 0.03) and better lung function based on incentive spirometry (p = 0.01) and demonstrated earlier functional recovery based on their ability to perform the sit-to-stand test (p = 0.001). Ice packs are a simple, cost-effective adjuvant to standard postoperative pain management which reduce pain and narcotic use and promote early rehabilitation.

An Acute Pain Service experience initiating methadone for opioid use disorder in hospitalized patients with acute pain.

Inform readers of the use of a clinical pathway that includes initiation of methadone in hospitalized patients with acute pain who have untreated opioid use disorder (OUD). A retrospective chart review with frequency distributions and descriptive statistics calculated to describe demo-graphic and clinical characteristics of the sample. Urban academic hospital. One hundred twenty consecutive patients with untreated OUD cared for by the Acute Pain Service (APS). APS leadership spearheaded development of a clinical pathway to standardize pain management and optimize outcomes. The authors outline pathway development and describe 120 patients managed using this pathway, initiated on methadone for OUD. The sample included patients, average age 40 years, predominantly non-Hispanic white (74.2 percent), male (61.7 percent), unemployed (88.2 percent), and on Medicaid (84.2 percent). 96.7 percent had a history of heroin use, and 52.1 percent had engaged in previous medication-assisted treatment (MAT). Methadone or other opioids were held for signs of intoxication/sedation in 10.9 percent or for prolonged corrected QT interval in 1.7 percent. The majority received at least one other analgesic agent. For those prescribed opioids upon discharge, the average maximum morphine equivalent dose was 68.2 mg/day for approximately 3 days. 68.3 percent agreed to schedule post-discharge MAT, and of these, 68 percent attended their intake appointment. A small percentage (4.7 percent) left the hospital against medical advice. This pathway provides an example of an effective and safe response to address the opioid epidemic and pro-vide quality care to patients with OUD and pain.

Management of pain in individuals with spinal cord injury: Guideline of the German-Speaking Medical Society for Spinal Cord Injury.

Introduction: Pain is a prominent complication in spinal cord injury (SCI). It can either occur as a direct or as an indirect consequence of SCI and it often heavily influences the quality of life of affected individuals. In SCI, nociceptive and neuropathic pain can equally emerge at the same time above or below the level of injury. Thus, classification and grading of pain is frequently difficult. Effective treatment of SCI-related pain in general and of neuropathic pain in particular is challenging. Current treatment options are sparse and their evidence is considered to be limited. Considering these aspects, a clinical practice guideline was developed as basis for an optimized, comprehensive and standardized pain management in SCI-related pain.Methods: The German-Speaking Medical Society for Spinal Cord Injury (Deutschsprachige Medizinische Gesellschaft für Paraplegiologie – DMGP) developed a clinical practice guideline that received consensus from seven further German-speaking medical societies and one patient organization. The evidence base from clinical trials and meta-analyses was summarized and subjected to a structured consensus-process in accordance with the regulations of the Association of Scientific Medical Societies in Germany (AWMF) and the methodological requirements of the “German instrument for methodological guideline appraisal”.Results: This consensus-based guideline (S2k classification according to the AWMF guidance manual and rules) resulted in seven on-topic statements and 17 specific recommendations relevant to the classification, assessment and therapy of pain directly or indirectly caused by SCI. Recommended therapeutic approaches comprise pharmacological (e.g. nonsteroidal anti-inflammatory drugs or anticonvulsants) and non-pharmacological (e.g. physical activity or psychotherapeutic techniques) strategies for both nociceptive and neuropathic pain.Discussion: Assessment of SCI-related pain is standardized and respective methods in terms of examination, classification and grading of pain are already in use and validated in German language. In contrast, valid, evidence-based and efficient therapeutic options are limited and ask for further clinical studies, ideally randomized controlled trials and meta-analyses.

Prophylactic gabapentin decreases fatigue and swallowing difficulty in patients undergoing concurrent chemo-radiation (CCR) for head and neck cancer (HNC): Interim results from a randomized controlled trial.

6059 Background: Preliminary data suggest that gabapentin (G) administered during HNC radiation may decrease treatment associated pain. To confirm this, we undertook a prospective, randomized trial in HNC patients undergoing CCR. Primary outcomes: pain severity (scale of 0-10) and opioid use. Exploratory outcomes: local and systemic symptoms measured by the Vanderbilt Head and Neck Symptom Survey version 2 plus the general symptom survey (VHNSSv2/GSS). We report results of the exploratory endpoints from the interim analysis. Methods: Measures: VHNSSv2 - 50 items, demonstrated reliability/validated, captures acute/chronic local HNC specific symptoms; GSS – 11 item checklist, demonstrated content validity, captures acute/chronic systemic symptoms. Population: HNC patients (≥ stage 2) undergoing primary or adjuvant CCR. Procedures: Randomized to standard pain management (SPM) or SPM + G dose escalated to 900mg tid. VHNSSv2/GSS completed weekly during treatment beginning week 1 and ending the last week of radiation therapy. Results were analyzed using a mixed-effects regression analysis adjusting for baseline levels of each symptom. Results: 71 patients completed a mean of 5.5 surveys. Patients on G experienced a reduction in overall systemic symptoms as measured by the GSS (11-items, p = 0.0073), fatigue (two-items, p = 0.013 ) sleep disturbance (five items, p &lt; 0.0001) , neurosensory eating (3 items, p = 0.026), phlegm-related symptoms (4 items, p = 0.004), and trend to better smell (2 items, p = 0.055). No impact on swallow, xerostomia, voice, dental or musculoskeletal symptoms was noted. Conclusions: This exploratory analysis suggests that G may moderate neurological and neuropsychiatric toxicities in HNC patients undergoing CCR. Further studies are warranted.

Sublingual sufentanil tablet system for postoperative analgesia after gynecological surgery.

Gynecological procedures are among the most frequent surgical interventions, and effective postoperative analgesia is associated with improved patient comfort. Despite the efficacy of neuraxial analgesia, limitations and potential complications have led to seek new strategies for pain relief. A novel, pre-programmed, non-invasive, hand-held system (Sufentanil Sublingual Tablet System [SSTS]) displayed good results in the orthopedic setting. However, it has never been applied in gynecological procedures. This retrospective observational case series evaluates receiving SSTS for postoperative analgesia. Data from 42 consecutive patients undergoing open gynecological surgery with Pfannenstiel incision were retrieved from medical charts in two Italian hospitals. The mean age was 49±11 years, and mean BMI was 24.4±4.6 kg/m2. We reported effective relief on both static and dynamic pain all along the perioperative period, with good effect on patient's rehabilitation. Postoperative nausea and vomiting is the most common adverse effect, but the incidence was strongly decreased with medical prophylaxis. SSTS was easy to prepare, use and manage by both patients and care providers. SSTS may be an interesting option for postoperative analgesia in gynecologic procedures. The efficacy in the management of dynamic pain is an interesting outcome that needs to be compared with the other standards of pain management, such as neuraxial techniques. Rigorous studies are required to give conclusive evidence, but this is the first report, to our knowledge, of SSTS use in open gynecologic procedures. Our preliminary experience encourages the routine application of SSTS in gynecologic surgery and will help designing future randomized controlled trials on the topic.

Prioritizing a sequence of short-duration groups as the standardized pathway for chronic noncancer pain at an Australian tertiary multidisciplinary pain service: preliminary outcomes.

To describe implementation and report preliminary outcomes of a resource-efficient, standardized group pathway for chronic noncancer pain. Descriptive cross-sectional study of a group-based pain management pathway in comparison with an Australasian benchmarking data set. An Australian tertiary multidisciplinary pain service. Patients with chronic noncancer pain actively participating in the group pathway in 2016. Referred patients were prioritized to a short-duration group-based standardized pain management pathway linking education, assessment, and treatment groups. Measures of pain, mood, self-efficacy, and catastrophizing and reduction in daily opioid use were collated from the Australasian data set. In 2016, 928 patients were actively engaged with the pain service. More patients were prioritized to receive treatment in a group format in comparison with other Australasian services (68.4% vs 22%). A greater percentage of patients attended their first clinical contact within 3 months of referral (81.4%) compared with the Australasian average (68.6%). Comparable improvements in average pain intensity, pain interference, depression, anxiety, stress, pain catastrophizing, and self-efficacy were observed. There was significantly greater reduction in opioid use, including for those taking more than 40 mg of oral morphine equivalent daily dose. Implementation of a sequence of short-duration groups as the default clinical pathway resulted in shorter waiting times and noninferior outcomes in key areas for patients completing the program, compared with Australasian averages. Given the resource efficiencies of the group process, this finding has implications for service design.

Nurses' practices regarding procedural pain management of preterm infants

BackgroundIt is well known that preterm neonates can feel pain which can be expressed through specific behaviors and signs. Repeated and untreated pain has consequences for the preterm neonates such as hypersensitivity to pain, as well as important repercussions on their motor and intellectual development. The use of non-pharmacological interventions for pain management by nurses is imperative to prevent these consequences in the NICU. The aim of this study is to survey neonatal nurses' interventions for pain management of preterm neonates. MethodsTwenty (20) nurses were recruited for this pilot observational survey study. Standard pain management interventions used by nurses during heel prick were evaluated by means of a questionnaire. In addition, 11 out of the 20 nurses were observed during heel prick to evaluate what and how interventions were done. ResultsAll infants (n = 11) received at least one pain management intervention during heel prick. Heterogeneity in pain management practices used by nurses is considerable. For 95% (19/20) of nurses, sucrose is a standard intervention reported in the survey but observations showed that it not always applied (64%). Positioning is more used (64%) by nurses than reported in the survey (45%). Swaddling also was also reported as a standard intervention by 45% of nurses, but it does not appear to be adequately performed (36%). ConclusionAccording to the results, it would be essential to review nurses' knowledge and skills regarding standard pain management interventions, during painful procedures, as the quality of these practices is questionable. Homogeneity of the standard of care is particularly important in research to allow an appropriate comparison between study groups and prevention study bias.

Self-administered vaginal lidocaine gel for pain management with intrauterine device insertion: a blinded, randomized controlled trial

A major barrier to intrauterine device use is fear of pain during insertion. Trials exploring analgesic interventions for intrauterine device insertion have yielded mixed results, and no standardized pain management guidelines currently exist for this procedure. In an abortion-related study, self-administered lidocaine gel over a prolonged time interval showed promise as a method of pain control. The objective of the study was to assess pain control with intrauterine device insertion after patient-administered lidocaine gel compared with placebo. We conducted a randomized, blinded trial of women undergoing levonorgestrel or copper intrauterine device insertion in an outpatient gynecology clinic between July 2016 and April 2017. Participants self-administered either 20 mL of 2% lidocaine gel or placebo gel vaginally at least 15 minutes prior to intrauterine device insertion. No other analgesics were administered. The primary outcome was pain during intrauterine device insertion, measured on a 100-mm visual analog scale (0 being no pain and 100 being worst pain imaginable). Secondary outcomes included anticipated and baseline pain and pain with speculum insertion and tenaculum placement. In a postprocedure questionnaire, participants reported acceptability of vaginal gel and willingness to wait for pain control. Median values were assessed because of the nonnormal distribution of visual analog scale scores using the Mann-Whitney U test. Predictors of intrauterine device insertion pain were assessed using a multiple linear regression. In total, 220 women were randomized and 215 were included in analysis (108 in lidocaine gel, 107 in placebo gel groups). Median (range) time from gel administration to speculum insertion was 21 (14-74) and 20 (12-43) minutes in the lidocaine and placebo groups, respectively (P= .13). The median pain scores during intrauterine device insertion were not significantly different: 65 (1-99) mm in the lidocaine group and 59 (5-100) mm in the placebo group (P= .09). Among secondary outcome time points, only median pain scores at speculum insertion were significantly different between the lidocaine and placebo groups (7 [0-81] mm vs 11 [0-80] mm, respectively; P= .046). Anticipated pain and menstrual pain were both predictors of pain with intrauterine device insertion. The majority of women in both groups found the amount of vaginal leakage following gel insertion to be acceptable (>80%). Ninety-two percent of participants (n= 194) stated they would be willing to wait before intrauterine device placement for a potential analgesic effect. Self-administered lidocaine gel at least 15 minutes before intrauterine device insertion does not appear to reduce pain compared with placebo but may help with speculum insertion. We found that women are willing to extend visit time to gain pain control. Self-administration of local anesthetic is acceptable to patients and should be considered in future research.

Reducing Time to Pain Medication Administration for Pediatric Patients with Long Bone Fractures in the Emergency Department.

Introduction:Pain management is a critical aspect of effective long bone fracture treatment. Pediatric patients frequently report suboptimal pain management, which is an area of growing public concern. The purpose of this quality improvement project was to develop a protocol with the goal to administer pain medication to children presenting with suspected long bone fractures ≤47 minutes of emergency department arrival.Methods:A multidisciplinary team developed a standardized protocol for pain management of patients presenting with musculoskeletal pain utilizing acetaminophen as the first-line agent under a nurse-initiated order. Following education and implementation, weekly reports generated using the International Classification of Diseases codes of fractures were reviewed to assess compliance with the protocol. This study evaluates the frequency of a second pain medication administration and reduction in vital signs and pain scores.Results:Implementation of a pain management protocol reduced median time to pain medication administration to 26 minutes. Overall, 63% (n = 638) of patients required a second pain medication. Of these, 66.5% (348/523) who initially received acetaminophen and 59.7% (286/479) who initially received an opioid required a second pain medication. No significant changes in pre and posttreatment vital signs were found between groups. Patients who initially received opioids experienced a greater reduction in posttreatment pain scores.Conclusions:Using a standardized pain management protocol in combination with comprehensive education effectively reduces median time to pain medication administration in pediatric patients with long bone fractures. Acetaminophen is a rapid and effective first-line agent for managing pain in this population.

Acute pain in cats: Recent advances in clinical assessment.

Pain assessment has gained much attention in recent years as a means of improving pain management and treatment standards. It has become an elemental part of feline practice with ultimate benefit to feline health and welfare. Currently pain assessment involves mostly the investigation of sensory-discriminative (intensity, location and duration) and affective-motivational (emotional) domains of pain. Specific behaviors associated with acute pain have been identified and constitute the basis for its assessment in cats. The publication of pain scales with reported validation - the UNESP-Botucatu multidimensional composite pain scale and the Glasgow feline composite measure pain scale - and species-specific studies have advanced our knowledge on the subject. Facial expressions have also been shown to be different between painful and non-painful cats, and very recently the Feline Grimace Scale has been validated as a tool for acute pain assessment. Despite recent advances, several challenges still exist. For instance, the effects of disease and sedation on pain scoring/ assessment are unknown. Also, specific painful conditions (eg, dental pain) have not been systematically investigated. The development and validation of instruments for pain assessment by cat owners is warranted, as these tools are currently lacking. This article reviews the use, advantages, disadvantages and limitations of the two validated pain scales, and presents a practical, stepwise approach to feline pain recognition and assessment using a dynamic and interactive process. The authors also offer perspectives regarding current challenges and future directions.

Effect of Music Therapy on Pain Perception, Anxiety, and Opioid Use During Dressing Change Among Patients With Burns in India: A Quasi-experimental, Cross-over Pilot Study

This study was conducted to assess the effect of music therapy on pain, anxiety, opioid use, and hemodynamic variables during burn dressing change. Patients in a tertiary care burn unit who were >10 years old, conscious, able to respond, and oriented to time, place, and person participated in a 2-month, quasi-experimental, cross-over pilot study. Each served as his/her own control. Dressings were changed every other day alternating between the control (standard pain management) and experimental (control plus patient-selected music) intervention. Pain was assessed using a numerical rating scale, anxiety was scored using the State Trait Anxiety Test (higher scores indicated more pain and anxiety), and hemodynamic parameters and analgesics were recorded. Wilcoxon Test and chi-squared tests were utilized for statistical analysis. Median pain scores (5, interquartile range [IQR] IQR: 3-7; and 6, IQR: 5-8) and median anxiety scores (12, IQR: 8-17; and 14, IQR: 10-19) were significantly lower during the experimental than during the standard dressing change, respectively (P <.001), and opioids were used significantly less frequently during the experimental change (P = .002). Music therapy helps reduce anxiety, pain, and opioid use during burn dressing change.