Verbal Rating Scores For Pain Research Articles

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.

Silver-Coated Nylon Dressing Plus Active DC Microcurrent for Healing of Autogenous Skin Donor Sites

Burn wounds are a significant cause of morbidity and mortality, and improved outcomes are demonstrated with early closure of both primary burn wounds and skin donor sites. Thus, technology that decreases the healing time of burns and donor sites would be potentially lifesaving. We present the results of a single-center, prospective, double-blinded, randomized controlled trial to evaluate the efficacy of silver-coated dressing with active microcurrent in comparison to silver-coated dressing with sham microcurrent on wound-closure time for autogenous skin donor sites. Four hundred five patients were screened for treatment of their donor sites using a silver-coated nylon dressing with either sham or active microcurrent stimulation. Thirty patients were enrolled in the study and then randomized. Of these, 5 patients were removed from analysis due to protocol deviations. Differences in time-to-closure were analyzed using Kaplan-Meier analysis and the proportional hazard regression model. Subjective verbal pain rating scores (0-10; 0, no pain; 10, worst pain) were also recorded. All devices were blinded and programmed at an outside facility, so that every patient had either an active or sham device. The study was unblinded only after the final patient's donor site had healed. All patients achieved donor-site healing before postoperative day 20. The 14 patients in the active microcurrent group [mean, 10.8 (2.9) days; range, 7-15 days] experienced no difference in time to wound healing as compared to the remaining patients in the sham microcurrent group [mean, 11.1 (2.0) days; range, 8-14 days; P = 0.75]. There were no differences in pain from one group compared to the other. None of the donor sites exhibited clinical signs of infection. In a sample size of 25 burn patients, the addition of direct microcurrent to silver-nylon dressings did not decrease time to wound closure of skin donor sites, and it did not show a difference in reported pain levels.

Is Local Anesthetic Infiltration Prior to Intravenous Cannulation Beneficial to Patients?

Aims: Intravenous cannulation causes pain, anxiety and frustration in patients along with changes in hemodynamic parameters. Infiltration of local anesthetic lessens the pain of intravenous cannulation. This study was performed to compare cardiovascular responses and verbal rating pain scores in two groups with and without local anesthetic infiltration prior to venous cannulation. Methods: This was a randomized study conducted in 100 elective surgical patients, divided into two study groups with 50 patients in each: group A (Control) and group B (local anesthetic infiltration). Prior to venous cannulation in group B, 0.5 ml of 1% lidocaine was infiltrated at the procedure site at dorsum of the wrist. Patients in group A were cannulated directly without local anesthetic infiltration. The hemodynamic changes pre and post cannulation and verbal pain rating scores were recorded by blind observers in all patients. Results: Demographic values in two groups were similar. Increase in heart rate from baseline value was significant in control group (p &lt; 0.05). Post cannulation heart rate, systolic and diastolic blood pressure were significantly higher in group A compared to group B for the first three minutes (p &lt; 0.05). Amongst higher number of patients in group A, verbal rating pain score was significantly higher. Ninety-four percent of the patients in group B were pain free, comfortable and satisfied with the procedure. Conclusions: Intravenous cannulation can be made pain free with patient satisfaction and hemodynamic stability if carried out with prior local anesthetic infiltration. Nepal Journal of Obstetrics and Gynaecology / Vol 8 / No. 1 / Issue 15 / Jan- June, 2013 / 10-13 DOI: http://dx.doi.org/10.3126/njog.v8i1.8853

Low interscalene block provides reliable anesthesia for surgery at or about the elbow

Study Objective To determine whether interscalene brachial plexus block (ISB) provides adequate anesthesia for surgery on or about the elbow. Study Design Case series. Setting Operating room of an academic teaching hospital. Patients 78 patients scheduled for elective elbow surgery. Interventions All patients received an ISB using a low approach technique. A stimulating needle was inserted in the interscalene groove two cm above the clavicle. A volume of 35-45 mL of mepivacaine 1.5% or ropivacaine 0.5% was administered after obtaining a motor response of any component of the brachial plexus with a current intensity of 0.2-0.4 mA (0.1 msec). Measurements Block success rate, defined as the ability to complete surgery without use of intraoperative opioids or general anesthesia, was assessed. Verbal rating scores for pain (0 = no pain, 10 = worst pain imaginable) were obtained in the recovery room. Main Results Low ISB resulted in successful surgical anesthesia in 75 (96%) of the study patients. Verbal rating scores were low (0-2) for all patients postoperatively. Conclusions The low interscalene block can be used to provide surgical anesthesia in the majority of patients having surgery on or about the elbow.

Combination of opioid agonist and agonist–antagonist: patient-controlled analgesia requirement and adverse events among different-ratio morphine and nalbuphine admixtures for postoperative pain

BackgroundNalbuphine, a mixed agonist–antagonist opioid, has a potential to attenuate the mu-opioid effects and to enhance the kappa-opioid effects. However, when morphine and nalbuphine are mixed together, the clinical interactions in different combining ratios on analgesic effect and adverse events are unknown. MethodsThis randomized, double-blind controlled study investigated five different combining ratios of morphine and nalbuphine in 311 patients undergoing gynaecologic operations. The concentrations [morphine (mg ml−1)]/[nalbuphine (mg ml−1)] were 1/0 in Group 1, 0.75/0.25 (ratio 1:3) in Group 2, 0.5/0.5 (ratio 1:1) in Group 3, 0.25/0.75 (ratio 3:1) in Group 4, and 0/1 in Group 5. Patient-controlled analgesia (PCA) requirement, postoperative pain, and adverse events were evaluated throughout the postoperative 24 h period. ResultsTwenty-four hour PCA requirements were similar among the five groups. Verbal rating scores for pain were statistically higher in Groups 2 and 4 than in Group 3. The incidences of pruritus were higher in Group 1 (15.6%) than in Group 2 (6.2%), Group 3 (3.4%), Group 4 (1.6%), and Group 5 (0%). The incidences and severity of dizziness, nausea, and vomiting were not significantly different. ConclusionsThe interaction between morphine and nalbuphine in PCA admixture on analgesia is additive. Combinations of morphine and nalbuphine in PCA can decrease the incidence of pruritus, and the antipruritus effect is ratio-dependent. This may provide a novel combination strategy of opioid agonist and agonist–antagonist for postoperative pain management after gynaecologic surgery.

Dropped Head Deformity due to Cervical Myopathy

Case series. Report long-term outcomes, complications, and surgical technique of cervical myopathy (CM) patients treated with posterior instrumented, cervico-thoracic (C-T) fusions. CM is a rare, progressive, debilitating condition where weakness of neck extensor muscles results in a dropped head deformity (DHD), or severe flexible, cervico-thoracic kyphosis. Treatment algorithms are currently based on small case reports and only 1 patient's short-term surgical outcome. Re-examination at follow-up, chart review, and radiographic analysis was carried out for all CM patients with DHD treated by the senior author. Additional outcome measures included Odom criteria, verbal rating scores for pain, and patient satisfaction ratings. Patients with less than 2-years follow-up, previous cervical spine surgery or intrinsic, structural spinal deformities were excluded. Nine CM patients met the study inclusion criteria with average follow-up of 6 years (range, 2-17 years) and average age 67 years. Four primary and 5 secondary myopathies after radiotherapy underwent deformity correction and posterior arthrodesis with instrumentation from the second cervical level to the upper thoracic spine. Patient presentation, deformity correction, and surgical techniques are described. All pain ratings improved, satisfaction was excellent in 7 and fair in 2 patients, and Odom scores were good to excellent in 7 and fair in 2 patients. Shoulder weakness remained equivalent or improved after surgery and all ambulated independently, though 1 continued to use a walker. Eleven postoperative complications are described. Surgical correction with posterior, instrumented C-T spinal fusion is associated with high patient satisfaction rates in CM patients with DHD. Complications are frequent but do not diminish long-term outcomes. New rod and screw instrumentation with bone morphogenic protein may improve arthrodesis and correction.

Postoperative Epidural Morphine for Postpartum Tubal Ligation Analgesia

Women undergoing postoperative postpartum tubal ligation (PPTL) often experience considerable pain. We hypothesized that epidural morphine, as part of a multi-modal analgesic regimen, would decrease postoperative pain and the need for systemic analgesia after PPTL. In a double-blinded study, patients were randomized to receive epidural saline or morphine 2 mg, 3 mg, or 4 mg after epidural anesthesia for PPTL. Postoperatively, ibuprofen 600 mg was administered every 6 h and patients could request acetaminophen 325 mg/hydrocodone 10 mg. The primary outcome variable was time to first request for supplemental analgesia. Verbal rating scores for pain and the incidence and severity of side effects were recorded for 24 h. Morphine group subjects requested supplemental analgesia later and received fewer doses compared with the saline group subjects. Peak cramping and incisional verbal rating scores for pain and the area under the verbal rating scores for pain x time curve for cramping pain were less after epidural morphine compared with saline, but there were no differences among morphine groups. Nausea, vomiting, and pruritus occurred more often in all morphine groups and subjects who received morphine 4 mg required treatment for these side effects more frequently than the saline or morphine 2 mg groups. In conclusion, epidural morphine 2 mg as part of a multi-modal analgesic regimen improved analgesia and decreased the need for supplemental analgesics after PPTL. The need to treat side effects with morphine 2 mg was not increased compared to a regimen of oral acetaminophen/opioid/nonsteroidal antiinflammatory analgesics.

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.

Opioid-sparing Effects of a Low-dose Infusion of Naloxone in Patient-administered Morphine Sulfate

A naloxone infusion is effective in reducing epidural and intrathecal opioid-related side effects. The use of naloxone infusion concomitant with intravenous morphine patient-controlled analgesia (PCA) has not been evaluated, probably because of an expected direct antagonism of the systemic opioid effect. The authors compared the incidence of morphine-related side effects and the quality of analgesia from two small doses of naloxone infusion. Sixty patients classified as American Society of Anesthesiologists physical status 1, 2, or 3 who were scheduled for total abdominal hysterectomies were enrolled in the study. Patients received a standardized general anesthetic. In the postanesthetic care unit, patients received morphine as a PCA. They were randomized to receive either 0.25 microg x kg(-1) x h(-1) naloxone (low dose), 1 microg x kg(-1) x h(-1) (high dose), or saline (placebo) as a continuous infusion. Verbal rating scores for pain, nausea, vomiting, and pruritus; sedation scores; requests for antiemetic; and morphine use were recorded for 24 h. Blood pressure, respiratory rate, and oxyhemoglobin saturation were also monitored. Sixty patients completed the study. Both naloxone doses were equally effective in reducing the incidence of nausea, vomiting, and pruritus compared with placebo (P < 0.05 by the chi-squared test). There was no difference in the verbal rating scores for pain between the groups. The cumulative morphine use was the lowest in the low-dose group (42.3 +/- 24.1 mg; means +/- SD) compared with the placebo (59.1 +/- 27.4 mg) and high-dose groups (64.7 +/- 33.0 mg) at 24 h (P < 0.05 by analysis of variance). There was no incidence of respiratory depression (<8 breaths/min) and no difference in sedation scores, antiemetic use, respiratory rate, and hemodynamic parameters among the groups. Naloxone is effective in preventing PCA opioid-related side effects. Naloxone infusion at 0.25 microg x kg(-1) x h(-1) not only attenuates these side effects but appears to reduce postoperative (beyond 4-8 h) opioid requirements. This dosing regimen can be prepared with 400 microg naloxone in 1,000 ml crystalloid given in 24 h to a patient weighing 70 kg.