Verbal Pain Scale Research Articles

Temporomandibular Joint Problems and Periodontal Condition in Rheumatoid Arthritis Patients in Relation to Their Rheumatologic Status

There are conflicting reports as to whether patients with rheumatoid arthritis (RA) are at high risk for periodontal disease (PD). However, analogous mechanisms of tissue destruction have been reported for the 2 conditions. The present study was undertaken to determine temporomandibular joint (TMJ) problems and periodontal conditions in patients with RA in relation to their rheumatologic status and identify their periodontal needs. One hundred patients with PD, 50 with RA and 50 without RA, were assigned to 1 of 2 age groups (30 to 39 or 40 to 50 years). The plaque index, bleeding index, clinical attachment loss, radiographic bone loss, tooth loss, and TMJ problems were assessed in the 2 groups. Disease duration, level of erythrocyte sedimentation rate (ESR), Health Assessment Questionnaire, and Verbal Descriptor Pain Scale score were assessed in the RA group. Patients with RA were predominantly women, with longer illness duration (11.84 years), higher ESR (32.08 mm/hour), and higher scores on the Health Assessment Questionnaire (0.82). Patients with RA were characterized by significant increases in clinical attachment loss (3.24 mm), bone loss (1.79 mm), missing teeth (6.22), and TMJ problems (54%) than controls. Their periodontal status significantly correlated with illness duration, Health Assessment Questionnaire score, and Verbal Descriptor Pain Scale score. However, no difference in plaque index and bleeding index were observed between the RA and control groups. Unexpectedly, 30- to 40-year-old patients with RA had a significantly higher plaque index (1.54) and greater TMJ deviation (15%) than the older subjects. Patients with advanced RA are more likely to develop more significant periodontal and TMJ problems compared with patients with PD and without RA. There is a great need to instruct patients with RA to consult a dentist to at least decrease PD severity.

Role of transcutaneous electric nerve stimulation in the management of trigeminal neuralgia

Background:Trigeminal neuralgia typically involves nerves supplying teeth, jaws and face of older females. Though the etiology is usually obscure, different treatment modalities have been tried for it viz. medicinal treatment, injection alcohol, peripheral neurectomy, rhizotomy, and microvascular decompression etc. Transcutaneous electric nerve stimulation (TENS) is an emerging and promising option for management of such patients.Aims and Design:The present study was designed with an aim to study the efficacy of TENS in management of trigeminal neuralgia.Materials and Methods:The study was conducted on 30 patients of trigeminal neuralgia confirmed by diagnostic nerve block. They were given bursts of TENS for 20-40 days over the path of the affected nerve and subsequently evaluated at 1 month and 3 month intervals by visual analogue scale (VAS), verbal pain scale (VPS), a functional outcome scales for main daily activities like sleep, chewing, talking, or washing face.Results:The results showed that, on VAS, the score decreased from 8.9 (Pre TENS) to 3.1 at 1 month and 1.3 at 3 months, and on VPS, the score decreased from 3.5 (Pre TENS) to 1.2 at 1 month and 0.3 at 3 months. Similarly, a considerable decrease in scores was seen on functional outcome scale for different activities. No side effects like irritation or redness of skin were seen in any of the patients.Conclusions:Thus, TENS was found to be a safe, easily acceptable, and non-invasive outdoor patient department procedure for management of trigeminal neuralgia.

Assessing Pain and Mood in a Poorly Resourced Country in a Post-Conflict Setting

Accurate pain assessment is important but presents problems in poorly resourced countries. A civil war in Sierra Leone resulted in civilian casualties with pain from deliberate amputation and other injuries. To examine the quality of simple pain and mood scales. Within a pain treatment project, pain was assessed using numerical and verbal descriptor scales, and mood using visual analogue and verbal descriptor scales. The relationships between these scales (translated where necessary) were examined by comparison of pairs of measures. The overwhelming majority (99%) used the scales consistently. The verbal pain scale showed substantial discrimination between the pain words mild/small, moderate/half and half, and severe/serious (F=41.80, P<0.001). Numerical and verbal pain scales were related at a modest level (Kendall's tau-b=0.39, P<0.001, n=272) and not dependent on the level of education. A smaller sample (n=30) provided pain data across three assessment occasions, and both pain scales appeared sensitive to change. The 5-point verbal mood scale collapsed into three categories, with reasonable distinction between mood words (F=14.75, P<0.001). The visual analogue scale proved difficult to explain to civilian casualties in this setting. Verbal pain and mood scales and numerical pain scales appeared to yield useful information in a post-conflict situation. This suggests that adapting these established rating scales for pain, and for mood, was useful to clinicians and acceptable to patients.

A randomized controlled trial on the efficacy of intermittent cervical traction for patients with chronic neck pain

Objective: To investigate the efficacy of intermittent cervical traction in the treatment of chronic neck pain over a 12-week follow-up. Design: A randomized controlled trial. Setting: Hospital-based outpatient practice. Subjects: Seventy-nine patients with chronic neck pain. Interventions: Subjects were randomly assigned to either experimental group (n = 39, mean age = 50.5 ± 9.8) or control group (n = 40, mean age = 48.8 ± 9.1). Experimental group received intermittent cervical traction and control group received infrared irradiation alone; twice a week over a period of six weeks. Outcome measurements: The values of Chinese version of the Northwick Park Neck Pain Questionnaire (NPQ), verbal numerical pain scale (VNPS), and cervical active range of motion (AROM) were measured at baseline, six-week and 12-week follow-up. Results: No significant differences were found between the two groups in the NPQ (P > 0.05), VNPS (P > 0.05) and AROM (P > 0.05).

Preoperative lornoxicam for pain prevention after tonsillectomy in adults

Study Objective To evaluate the efficacy of preoperative lornoxicam on postoperative pain management following tonsillectomy. Design Prospective, randomized, double-blinded, placebo-controlled study. Setting King Fahd University Hospital. Patients 40 adult, ASA physical status I and II patients scheduled for tonsillectomy. Interventions Patients were randomly allocated to two groups to receive either intravenous (IV) lornoxicam 16 mg (Group L) or saline as control (Group C) preoperatively. Anesthesia was induced using IV fentanyl and propofol, while endotracheal intubation was facilitated with rocuronium, and maintenance was accomplished using nitrous oxide and sevoflurane. Measurements Pain scores at rest and on swallowing, intraoperative bleeding, interval until first request for rescue diclofenac suppository, and total diclofenac dose given in the first 12 and 24 hours postoperatively were recorded. The frequency of postoperative complications including bleeding, hypoxia, nausea and vomiting also were observed. Main Results Pain scores at rest were significantly lower in Group L than Group C at all observation times. Similarly, pain scores on swallowing were lower in Group L during the first 4 postoperative hours. The maximum verbal pain scale (VPS) in the control group was 7 (5.75 - 8 median, interquartile range) and in the lornoxicam group, it was 4 (4 - 5 median, interquartile range) ( P < 0.001). The total diclofenac dose during the immediate postoperative 12 hours was significantly lower in Group L than Group C (65 ± 24 mg vs. 20 ± 25 mg, respectively; P < 0.001). No significant differences were noted for intraoperative bleeding. The frequency of postoperative nausea and vomiting was similar in both groups. Conclusion Preoperative 16 mg lornoxicam was effective for immediate postoperative pain relief after tonsillectomy in adults.

Factors associated with self-reported pain scores among ED patients

IntroductionPain is a common presenting complaint among emergency department (ED) patients. The verbal numeric pain scale is commonly used in the ED to assess self-reported pain. This study was undertaken to describe and compare pain scores in a variety of painful conditions and identify factors associated with self-reported pain scores. MethodsThe study was a prospective, observational, descriptive survey study conducted at an urban university hospital ED. Eligible participants included consenting adults 18 years and older, with an acute painful condition, who spoke English, and were not in severe distress. Through a structured interview, collected data included pain score; diagnosis; medical history; previous painful experiences; and demographic information including age, insurance status, and highest level of education completed. ResultsAmong 268 eligible participants, 263 (98%) consented and completed the study protocol. Seventy-one percent of participants were 50 years old or younger; 55%, women; and 68%, white. Fifty-four percent had private insurance, and 81%, high school education or higher. The most common chief complaints were soft tissue injury (33%), abdominal pain (18%), and chest pain (13%). The median self-reported pain score was 7/10 (mean, 6.7; interquartile range, 6-9; range, 0-10). The most common previous painful experiences were childbirth (21%), major trauma (18%), and surgery (14%). Participants cited reasons for self-reported pain scores, including current feeling of pain (62%), comparison to previous pain (31%), and comparison to hypothetical pain (12%). The number of previous ED visits was positively correlated with current pain score (Spearman correlation R = 0.28; P < .001). The chief complaints associated with the highest pain scores included dental pain (mean pain score, 8.5) and back pain (mean pain score, 7.6). Chief complaints associated with the lowest pain scores included chest pain (mean pain score, 5.2) and other medical conditions (mean pain score, 5.3). Factors associated with higher pain scores included younger age (P < .001, Kruskal-Wallis), Medicaid insurance (P = .02), and lower educational status (P = .01). There was not a statistically significant association between current pain score and sex, race, previous painful experiences, or number of hospital admissions. ConclusionEmergency department patients with acute painful conditions report a wide range of self-reported pain scores. Participants rated pain based on current feeling of pain or comparison to previous or hypothetical pain. Chief complaints with highest pain scores included dental pain and back pain. Factors associated with higher pain scores included younger age, Medicaid insurance, lower educational status, and higher number of previous ED visits.

Efficacy of Thoracic Epidural Analgesia With or Without Intercostal Nerve Cryoanalgesia for Postthoracotomy Pain

We evaluated effects of thoracic epidural analgesia combined with intercostal nerve cryoanalgesia or epidural analgesia alone on acute and long-term pain after posterolateral thoracotomy. Forty-two elective thoracotomy patients were randomly assigned to two groups, epidural combined with cryoanalgesia or epidural alone. A thoracic epidural catheter was inserted before induction of anesthesia. At the end of the operation, cryoanalgesia was performed to 3 intercostals nerves: 1 at the level of the incision, 1 caudal, and 1 cranial. Cryoanalgesia was blinded to the investigating anesthetists and patients. To avoid impingement of intercostal nerves, chest closure in all patients was performed using intracostal sutures through drilled holes in adjacent ribs. In the postanesthesia care unit, epidural infusion of ropivacaine (1 mg/mL) with fentanyl (5 μg/mL) was started and continued 3 days. Thereafter, pain was treated with oral strong or weak opioids combined with nonsteroidal antiinflammatory drugs or acetaminophen. Pain was assessed with the verbal pain scale or visual analog scale. Patients visited a local pain clinic at 8 weeks and at 6 months postoperatively. The cryoanalgesia group had more neuropathic-type pain compared with the epidural-alone group 8 weeks after operation (p < 0.05). The cryoanalgesia group had also more pain on normal daily activities 8 weeks after the operation (p < 0.05). After 6 months, there were no statistically significant differences between groups. Intercostal cryoanalgesia seems to increase the incidence of long-term pain after thoracotomy.

Reliability and validity of the Modified Preverbal, Early Verbal Pediatric Pain Scale in emergency department pediatric patients

Research has demonstrated that children are at particular risk for oligoanalgesia due to assessment difficulties when they are unable to self-report. We sought to evaluate the psychometric properties of the Modified Preverbal, Early Verbal Pediatric Pain Scale (M-PEPPS) when used in an emergency department pediatric population. We conducted a secondary analysis of data from a prospective, observational study of pain in emergency patients to evaluate the M-PEPPS tool. Data from 118 pediatric patients was subjected to item analysis, reliability analysis, and common factor analysis. Item difficulties suggest that the items capture the range of pain states from mild to severe. Corrected item-total correlations indicate that the instrument discriminates between various levels of pain. Common factor analysis yielded a single, unrotated common factor solution providing evidence that the M-PEPPS measures the single construct of pain. Cronbach's alpha for the scale (0.954) suggests excellent reliability. Findings indicate that the M-PEPPS instrument is reliable when used by emergency nurses to measure pediatric pain. The single-factor common factor solution provides support for the scale as measuring the single construct of pain. Additional research is necessary to establish the degree of change in score required for a clinically meaningful reduction in pain to be present.

Evaluation of the Outcomes of Ice Application for the Control of Pain Associated with Chest Tube Irritation

The aim of this study was to evaluate the effectiveness of the use of ice for the control of pain associated with chest tube irritation. The randomized and single-blinded study consisted of 40 patients (20 in the control and 20 in the study group) who underwent thoracotomy with chest tube placement. The same general anesthesia protocol was used for all patients, and the procedure was performed by the same surgery team. Procedures such as decortication and thoracic wall resection were not included in the study. Standard postoperative analgesic methods were applied to all patients. Additionally, ice (in flexible and bendable cold gel packs wrapped in fine cloth sheaths) was applied to the chest tube insertion site at the 24th, 28th, 36th, and 40th postoperative hours for 20 minutes. To assess the effectiveness of ice application, Verbal Category Scale and Behavioral Pain Scale methods were used to measure the severity of pain. Average pain severity scores during the mobilization activities, including coughing and walking, were compared and found to be significantly lower in the study group patients who received cold therapy than in the control group patients (p < .05). Additionally, analgesic consumption was lower in the study group than in the control group patients (p < .05). As a result, the application of ice to the chest tube insertion site reduced pain associated with irritation along with the need for analgesics.

Effect of Relaxation Exercises on Controlling Postoperative Pain

This study examines the effect of relaxation exercises on controlling postoperative pain in patients who have undergone upper abdominal surgery. This is a cross-sectional and crossover study conducted on 60 patients who underwent upper abdominal surgery between October 2006 and June 2007, in the General Surgery Department, Health and Research Practice Center, Trakya University, Edirne, Turkey. We assessed the patients’ pain levels before and after the relaxation exercises. Patients’ personal information forms were used to collect data, and pain levels were determined using the verbal pain scale. We used the Wilcoxon T test, nonparametric Spearman correlation analysis, and nominal by interval eta analysis to assess the data, percentage, and frequency analyses. Pain levels were found to be reduced after the relaxation exercises compared with the levels before the relaxation exercises (z = −5.497; p < .001). Relaxation exercises, a nonpharmacologic method, are effective in reducing postoperative pain and should therefore be included in a regimen to control postoperative pain in patients who have undergone upper abdominal surgery.

60: Reliability and Validity of the Modified Preverbal, Early Verbal Pediatric Pain Scale In Emergency Department Pediatric Patients

Pain is an important impetus for patients to seek emergency care, with as many as 78% of emergency patients reporting the presence of pain. Despite this, clinicians continue to struggle to provide adequate pain management to emergency patients. Children are at particular risk for oligoanalgesia, due in part to difficulties assessing pain when children are unable to self-report the presence and characteristics of their pain. The purpose of this study was to evaluate the psychometric properties of the Modified Preverbal, Early Verbal Pediatric Pain Scale (M-PEPPS) when used in an emergency department pediatric population.

Patient Weight as a Predictor of Pain Response to Morphine in the Emergency Department

Study Objectives: There is little evidence that patient weight is associated with pain response to morphine in the emergency department (ED). The primary outcome of this study is to identify demographic variables including patient weight that are associated with an adequate pain reduction after the first dose of morphine. Methods: A retrospective chart review of all patients with severe nontraumatic abdominal pain receiving intravenous morphine was conducted in our ED over a 3-month time period. Pain score, using an 11-point verbal numerical pain scale (0-10), was measured before and after each dose of morphine. Adequate response was defined as a ≥ 4-point reduction from baseline pain score. Results: A total of 105 patients were included in the analysis. Univariate logistic regression analyses stratified by dose (2 or 4 mg) showed that patient weight was not predictive of adequate pain response after the first dose of morphine (2 mg: odds ratio = 1; 95% confidence interval 0.97-1.03; P = .88; 4 mg: odds ratio = 1; 95% confidence interval 0.97-1.03; P = .86). Conclusions: Patient weight may not predict pain response to morphine in the ED. Dosing strategies based on patient weight may not be necessary in this patient population.

Microsurgical Subinguinal Varicocelectomy—An Experience of 327 Operations in 224 Patients

Objective Varicocele is associated with male infertility and/or scrotal pain. Microsurgical varicocelectomy provides advantages of reliable identification of spermatic vessels and has been advocated as the gold standard procedure for varicocele repair. The purpose of this study was to assess the outcome after microsurgical subinguinal varicocelectomy in patients with varicocele associated infertility or scrotal pain. Materials and Methods A total of 224 men underwent 327 operations of microsurgical subinguinal varicocelectomy at a single university hospital because of infertility or painful scrotum. The diagnosis of varicocele was based on the findings of physical examination. The vast majority of the surgeries were performed on an outpatient basis. All patients underwent pre- and postoperative semen analysis or pain scale evaluation. Results For the 114 infertile patients who underwent varicocelectomy, significant improvements were noted between pre- and postoperative mean sperm count and total motile sperm count. Patients who received bilateral surgery had greater improvement than patients who received unilateral surgery. Repair of larger varicocele was associated with postoperative sperm count changes. Induction of spermatogenesis was observed in at least two of 11 patients with nonobstructive azoospermia. The overall semen improvement rate (improvement index, >0.5) was 70.2% and the 1-year spontaneous pregnancy rate was 33.3%. Of the 102 patients with painful scrotum, 66 patients (64.7%) reported complete resolution of pain, 30 patients (29.4%) had partial resolution, and no change was claimed in six patients (5.9%). For all patients, the pre-and postoperative mean verbal pain scale were 5.8 ±0.4 and 1.2 ± 0.4, respectively ( p Conclusion Microsurgical subinguinal varicocelectomy provides a minimally invasive and effective therapy to varicocele repair with significant improvements in semen quality and scrotal discomfort, and a low incidence of morbidity.

Experience with TVT-SECUR sling for stress urinary incontinence: a 141-case analysis

The objective of this study was to investigate complications, urinary incontinence symptoms, and overall satisfaction in patients undergoing the tension-free vaginal tape-SECUR (TVT-S) for stress urinary incontinence (SUI). We reviewed consecutive patients treated with TVT-S between April, 2006 and August, 2007, in a urogynecology practice. Outcomes assessed included complications, voiding function, change in SUI symptoms on the Medical Epidemiological and Social Aspects of Aging (MESA) questionnaire, and overall satisfaction. One hundred forty-one women (age, 54.1 +/- 12 years; BMI, 31.2 +/- 6.6 kg/m(2)) were treated for SUI with the TVT-S; 34 required concomitant procedures. There were no intra-operative complications. Immediate post-operative voiding function returned in all but one patient; none required sling release. Most patients (90%) reported no pain on a verbal pain scale. On follow-up, 117 patients denied SUI symptoms, 16 reported mild symptoms, and eight required additional treatment. The average MESA "stress" subscore decreased by 79% (13.0 +/- 7.8 points, p < 0.0001). Eighty-five percent felt "satisfied" with the procedure. TVT-S is a safe and effective treatment for SUI.

Bloc iliofascial et troubles cognitifs postopératoires chez la personne âgée

ObjectiveThe aim of this study was to assess the influence of a regional analgesia technique on the incidence of postoperative cognitive dysfunction (POCD) after hip surgery, in elderly patients. Patients and methodsPatients, aged over 65 years, were assigned in two groups according to the anaesthesia technique: group NKT (general anaesthesia with target concentration infusion of propofol and remifentanil, with a 0.1mg/kg-bolus of morphine at the end of surgery), group KT (preoperative iliaca compartment block with catheter and then general anaesthesia without bolus of morphine). Postoperative analgesia was similar in both groups: paracetamol, tramadol, and subcutaneous morphine if verbal pain scale equal or greater than 2 (0.1mg/kg). POCD was defined as a decrease in Mini Mental Status (MMSE) equal or greater than 2 points and was monitored during 2 days. Consumption of opioids, pain scores and side effects were recorded. ResultsSixty-five patients were included: 34 in NKT group and 31 in KT group. MMSE scores were higher in the KT group at day1 and day2 (p=0.01 and 0.0004, respectively). POCD was less frequent in group KT at day2 (6 % vs 41 % ; p=0.001) and pain scores were lower during the first 48hours (p=0.03). Remifentanil consumption was lower in KT group (0.43±0.18mg vs 0.61±0.25mg, p=0.002). Total amount of morphine, including the bolus in NKT group, was significantly lower in KT group (7 [5–17] mg vs 0 [0–5] mg, p<10−6). ConclusionPostoperative analgesia by iliaca compartment block with catheter seems to provide a decrease in the incidence of POCD after hip surgery in elderly patients. Study designProspective, observational study.

Avaliação da dor em histeroscopia ambulatorial: comparação entre duas técnicas

to compare the pain reported by patients submitted to hysteroscopy by the standard technique with carbon dioxide (CO2) and to vaginal hysteroscopy with physiological saline (0.9% NaCl). this was a prospective cohort study conducted at an ambulatory hysteroscopy service. A total of 117 patients with indication for the exam were included, being randomly assigned to one of the groups. All patients answered an epidemiological questionnaire and scored the pain expected before the exam and that felt after the end of the procedure on a verbal pain scale from 0 to 10. A speculum, traction of the cervix, insertion of a 30 masculine light source and a diagnostic shirt with a total diameter of 5 mm were used for the standard technique. The cavity was distended with CO2 under a pressure of 100 mmHg controlled with a hysteroflator, and a biopsy was obtained with a Novak curette. Vaginoscopy was performed without a touch by distention of the vagina with fluid, direct visualization of the cervix and introduction of the light source with two continuous-flow shirts, with an accessory channel with an oval profile, the whole set measuring 5 mm in diameter. The medium distention was 0.9% NaCl and the pressure used was that considered to be necessary for an adequate visualization of the canal and of the cavity with an external pneumatic pressurizer. The biopsy was obtained in a directed manner using an endoscopic clamp. The mean and standard deviation were calculated for the quantitative variables and the frequency was calculated for the qualitative variables. The Student's t-test was used to compare the means, and the chi-square or exact Fisher test was used (when n<5) for the categorical analysis using the SPSS 15.0 software. The study was designed for a 95% test power, with the level of significance set at p<0.05. the groups were similar regarding age, parity, previous uterine surgeries, menopausal status, and the need for a biopsy. In comparison to the group submitted to the standard technique, the vaginoscopy group involved a lower technical difficulty (5.1 versus 17.2%, p=0.03), a higher rate of exams considered to be satisfactory (98.3 versus 89.7%, p=0.04) and a lower pain index (4.8 versus 6.1; p=0.01), as the difference were more evident when patients who never had a previous normal delivery were compared (4.9 versus 7.1; p=0.0001). When the pain scale was stratified as mild (0-4), moderate (5-7) or intense (8-10), the vaginoscopy technique was found to be associated with a 52% reduction of the frequency of intense pain (p=0.005). vaginohysteroscopy was proved to be a less painful procedure than the technique based on the use of a speculum and CO2, regardless of age, menopause or parity, with more satisfactory results and lower technical difficulty.

Fast versus slow bandaid removal: a randomised trial

To determine whether slow or fast bandaid removal is less painful. A prospective, randomised, crossover trial was carried out at James Cook University, Townsville. Participants were healthy volunteers from Years 2 and 3 of the James Cook University medical school program. Medium-sized bandaids were applied bilaterally in three standard body locations and removed using slow and fast techniques. Pain scores were assessed using an 11-point verbal numeric pain scale. 65 participants were included in the study. The overall mean pain score for fast bandaid removal was 0.92 and for slow bandaid removal was 1.58. This represents a highly significant difference of 0.66 (P < 0.001). In young healthy volunteers, fast bandaid removal caused less pain than slow bandaid removal.

Intrathecal baclofen for postoperative analgesia after total knee arthroplasty

Study Objective To determine whether intrathecal baclofen is an effective adjunctive agent to decrease acute and chronic postoperative pain after total knee arthroplasty. Design Prospective, randomized, double-blind controlled trial. Setting Operating room and inpatient units of a university hospital. Patients 60 adult, ASA physical status I, II, and III patients presenting for total knee arthroplasty. Interventions Anesthesia was provided by spinal injection of 15 mg of 0.75% hyperbaric bupivacaine combined with either 100 mcg baclofen or saline. Sedation was provided with intravenous midazolam and propofol. Measurements Data were collected on adverse effects, opioid usage, and verbal pain scale (VPS) from 0 to 10. The study period was divided into six discrete time intervals that included the 1 st 72-hour postoperative period and a three-month post-discharge follow-up telephone call. Main Results The baclofen group used less morphine in the PACU than the control group (5 mg vs. 9.3 mg; P = 0.04). VPS were lower in the baclofen group than the treatment group, but significant differences could be demonstrated only in the time periods 48-72 hours and three months postoperatively. At three months, fewer patients in the baclofen group reported pain than the control group (8/27 vs. 19/29; P = 0.009). Regression analysis showed that the baclofen group was 4.5 times less likely to report pain at three months (95% CI: 1.5–16.6). Conclusions IT baclofen used as an adjuvant to spinal anesthesia for total knee arthroplasty allows for less postoperative opioid usage and less chronic pain at three months.

Implementing a Pain Management Program in a Long-Term Care Facility Using a Quality Improvement Approach

Pain constitutes a constant challenge facing staff and residents of skilled nursing facilities (SNF) and nursing homes (NH). Many SNF and NH have not adopted a uniform plan to assess and treat pain for their residents despite published literature that demonstrates that the implementation of scales improves detection and treatment of pain. The objective of this study was to analyze the baseline pain level in the institutionalized elderly, and then implement a standard pain scale for its assessment and evaluation, while simultaneously identifying challenges in adopting this standardized method. As part of a Quality Improvement Project (QI), a total of 40 patients were chosen at random in 2 of the major skilled care and dementia units at a Columbia area nursing home, 20 patients from each. A chart review was conducted to document the presence or absence of pain syndromes, pain medications used, and use of standardized tools for the evaluation of pain. Documentation regarding diagnosis of depression and behavioral problems were also noted as potential markers for the manifestation of pain. Verbal and nonverbal pain scales were introduced and approved by the medical and nursing staff. Training sessions for the administration of such tools were implemented. A baseline evaluation of pain level was obtained applying these newly adopted tools. One cycle using the PDSA (Plan-Do-Study and Act) model for QI was followed. Our evaluation showed that 84.2% (32/38) of our study population were females, and the mean age was 91.4 years. Fifty percent (19/38) of patients had mild to moderate pain. Because of nonstandardized approaches to analgesia, some regimens rendered clear potential for toxicity: ie, receiving more than 3 grams per day of acetaminophen. Most patients with cognitive deficits had lower levels of moderate pain (9.5% [2/21]) but higher levels of mild pain (33.3% [7/21]) when compared with patients with normal cognition or mild cognitive deficits (35.3% [6/17] and 17.6% [3/17], respectively). Nursing staff adopted successfully the chosen pain tools and gave positive feedback after the trial period, indicating that they were helpful tools to identify pain and treat it promptly. Active participation of nursing staff through the process of decision making, tailoring of the pain assessment scales, and feedback during the period of implementation of pain assessment tools was perceived to facilitate better results. New cycles of pain evaluation and improvement were scheduled. Pain evaluation and management is of paramount importance because of its high prevalence and demonstrated deleterious effects on both quality of life and long-term survival. Tools for verbal and nonverbal evaluation of pain are necessary in both NH and SCF. Also, regular cognitive and behavioral assessment may help evaluate pain by providing additional information to physicians, nurses, and other caregivers when treatment becomes more challenging and complex. The use of standard standing orders can easily help decrease the potential of toxicity related to the use of analgesics.

Inadequate pain relief with labor epidurals: a multivariate analysis of associated factors

Background Labor epidural analgesia providing inadequate pain relief may cause maternal dissatisfaction and may fail to produce effective anesthesia when topped up for operative delivery. This study looked at factors associated with inadequate labor epidural analgesia. Methods Data were prospectively collected from 275 parturients receiving labor epidural analgesia. Pain was assessed 30 min after epidural insertion using a verbal pain scale of 0 to 100. A score of 10 or more was considered to represent inadequate pain relief. Sixteen factors chosen by experienced obstetric anesthesiologists for their association with inadequate labor epidural analgesia were studied. Results Fifteen parturients were excluded. Forty-four of the remainder (16.9%) experienced inadequate pain relief. Multiparity, history of a previous failure of epidural analgesia, the use of air for loss of resistance, cervical dilatation >7 cm at insertion all had a statistically significant association with inadequate epidural analgesia (P < 0.05). Logistic regression showed that cervical dilatation >7 cm, a history of opioid tolerance, a previous failed epidural and insertion of the epidural by a trainee anesthesiologist increased the odds ratio for inadequate pain relief. Conclusions The final model correctly classified 93% of the epidurals that provided effective analgesia but classified only 9.3% of those providing inadequate pain relief. This information can be used to develop a predictive score and change practice resulting in fewer inadequate epidurals.