Nurse Prescribing in Acute and Chronic Pain Management

This chapter contains sections titled: Introduction Acute pain Chronic pain Rationale for service development Evaluation use of audit and CPD Justifying the advanced nursing contribution to develop nurse prescribing in pain management Conclusions References

Post-Operative Pain Scores and Level of Regional Anesthesia Expertise: Using Clinical Outcomes to Assess Procedural Proficiency

Background and Objectives: Peripheral nerve blockade requires regional anesthesia skills that trainees learn in several formats. Technical proficiency has shifted from a quota to comprehensive procedural evaluation. Successful nerve blockade is the clinical endpoint validating proficiency but patient, technical and procedural factors influence this result. The purpose of this study was to determine if procedural expertise for sciatic nerve blockade influenced postoperative pain scores and opioid requirements and if patient factors, technique and repetition influenced this outcome. Method: Sciatic nerve blockade by nerve stimulation and ultrasound guidance and training level of the resident performing the procedure were recorded. Patient obesity, trauma, chronic pain, opioid use and preoperative pain scores were compared to post-procedure pain scores and opioid analgesic requirements. Results: 102 patients received sciatic nerve blockade from 47 trainees over a 36 month interval. A significant relation between training level and improved pain scores was not demonstrated but transition from nerve stimulation to ultrasound guidance lowered scores in all groups. Nerve blockade failure was frequent with chronic opioid use and trauma. Conclusion: Analgesic outcomes should be an integral part of assessment of proficiency in regional anesthesia techniques. Evaluating outcomes of procedures throughout training will longitudinally assess technical expertise.

Tumescent local anesthesia with ropivacaine in different concentrations in bitches undergoing mastectomy: plasma concentration and post-operative analgesia

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Antinociceptive activity of pre- versus post-operative intra-articular bupivacaine in goats undergoing stifle arthrotomy

OBJECTIVE: To evaluate the peri-operative analgesic efficacy of intra-articular bupivacaine administered before or after stifle arthrotomy. STUDY DESIGN: Prospective, randomized, blind, placebo-controlled experimental trial. ANIMALS: Thirty-nine healthy goats. METHODS: The goats were allocated randomly to one of three intra-articular treatment groups: group PRE (bupivacaine before and saline after surgery), group POST (saline before and bupivacaine after surgery) and group CON (saline before and after surgery). Anaesthesia was maintained with a constant end-tidal sevoflurane of 2.5%. Intra-operatively heart rate (HR), respiratory rate and mean arterial blood pressure (MAP) after critical surgical events (CSE) were recorded and compared with pre-incision values. Propofol requirements to maintain surgical anaesthesia were recorded. Flunixin was administered for 5 days. Post-operative pain assessment at 20 minutes, 2 hours, 4 hours after recovery and on day 2 and 3 included a multidimensional pain score (MPS), a lameness score and mechanical nociceptive threshold (MNT) testing. Rescue analgesia consisted of systemic opioids. Data were analysed using Kruskal-Wallis, Mann-Whitney, Friedman or chi-square tests as appropriate. RESULTS: Intra-operatively, group PRE had lower HR and MAP at several CSEs than groups POST/CON and required less propofol [0 mg kg(-1) (0-0 mg kg(-1))] than group POST/CON [0.3 mg kg(-1) (0-0.6 mg kg(-1))]. Post-operatively, group POST had significantly higher peri-articular MNTs than groups PRE and CON up to 4 hours after recovery. No treatment effect was detected for MPS, lameness scores and rescue analgesic consumption at any time point. CONCLUSIONS AND CLINICAL RELEVANCE: Pre-operative intra-articular bupivacaine provided notable intra-operative analgesia in goats undergoing stifle arthrotomy but did not reduce post-operative pain. Post-operative intra-articular bupivacaine provided a short lasting reduction of peri-articular hyperalgesia without affecting the requirements for systemic analgesia. Multimodal perioperative pain therapy is recommended to provide adequate analgesia for stifle arthrotomy in goats.

National audit of post-operative management in spinal surgery

Background: There is some evidence from a Cochrane review that rehabilitation following spinal surgery may be beneficial. Methods: We conducted a survey of current post-operative practice amongst spinal surgeons in the United Kingdom in 2002 to determine whether such interventions are being included routinely in the post-operative management of spinal patients. The survey included all surgeons who were members of either the British Association of Spinal Surgeons ( BASS) or the Society for Back Pain Research. Data on the characteristics of each surgeon and his or her current pattern of practice and post-operative care were collected via a reply-paid postal questionnaire. Results: Usable responses were provided by 57% of the 89 surgeons included in the survey. Most surgeons (79%) had a routine post-operative management regime, but only 35% had a written set of instructions that they gave to their patients concerning this. Over half (55%) of surgeons do not send their patients for any physiotherapy after discharge, with an average of less than two sessions of treatment organised by those that refer for physiotherapy at all. Restrictions on lifting, sitting and driving showed considerable inconsistency both between surgeons and also within the recommendations given by individual surgeons. Conclusion: Demonstrable inconsistencies within and between spinal surgeons in their approaches to post-operative management can be interpreted as evidence of continuing and significant uncertainty across the sub-speciality as to what does constitute best care in these areas of practice. Conducting further large, rigorous, randomised controlled trials would be the best method for obtaining definitive answers to these questions.

Standardised antibacterial Manuka honey in the management of persistent post-operative corneal oedema: A case series

Background Corneal oedema is a common post-operative problem that delays or prevents visual recovery from ocular surgery. Honey is a supersaturated solution of sugars with an acidic pH, high osmolarity and low water content. These characteristics inhibit the growth of micro-organisms, reduce oedema and promote epithelialisation. This clinical case series describes the use of a regulatory approved Leptospermum species honey ophthalmic product, in the management of post-operative corneal oedema and bullous keratopathy. Methods A retrospective review of 18 consecutive cases (30 eyes) with corneal oedema persisting beyond one month after single or multiple ocular surgical procedures (phacoemulsification cataract surgery and additional procedures) treated with Optimel Antibacterial Manuka Eye Drops twice to three times daily as an adjunctive therapy to conventional topical management with corticosteroid, aqueous suppressants, hypertonic sodium chloride five per cent, eyelid hygiene and artificial tears. Visual acuity and central corneal thickness were measured before and at the conclusion of Optimel treatment. Results A temporary reduction in corneal epithelial oedema lasting up to several hours was observed after the initial Optimel instillation and was associated with a reduction in central corneal thickness, resolution of epithelial microcysts, collapse of epithelial bullae, improved corneal clarity, improved visualisation of the intraocular structures and improved visual acuity. Additionally, with chronic use, reduction in punctate epitheliopathy, reduction in central corneal thickness and improvement in visual acuity were achieved. Temporary stinging after Optimel instillation was experienced. No adverse infectious or inflammatory events occurred during treatment with Optimel. Conclusions Optimel was a safe and effective adjunctive therapeutic strategy in the management of persistent post-operative corneal oedema and warrants further investigation in clinical trials.

Alternative approach to the management of postoperative pain after pediatric surgical procedures

This paper reports two clinical cases in which the application of low-level laser therapy (LLLT) enhanced the postoperative symptoms after pediatric surgical procedures. Background: The uses of novel technologies allow more comfort to the patients and ensure a rapid procedure, and LLLT application has shown a positive effect in the prevention of discomfort after invasive procedures. Case description: Low-level laser therapy protocol was applied after surgical removal of supernumerary tooth and frenectomy resulting in less swallow and pain with no need of medication intake. Conclusion: The laser application was well accepted by both children and parents and showed a clinical efficiency in the follow-up examinations beyond the satisfactory quality of wound healing. Clinical significance: The LLLT approach is an excellent adjuvant therapy resource for delivery an optimal postoperative after surgical procedures in children.

Interventions for the management of mandibular fractures

BACKGROUND Fractures of the mandible (lower jaw) are a common occurrence and usually related to interpersonal violence or road traffic accidents. Mandibular fractures may be treated using open (surgical) and closed (non-surgical) techniques. Fracture sites are immobilized with intermaxillary fixation (IMF) or other external or internal devices (i.e. plates and screws) to allow bone healing. Various techniques have been used, however uncertainty exists with respect to the specific indications for each approach. OBJECTIVES The objective of this review is to provide reliable evidence of the effects of any interventions either open (surgical) or closed (non-surgical) that can be used in the management of mandibular fractures, excluding the condyles, in adult patients. SEARCH METHODS We searched the following electronic databases: the Cochrane Oral Health Group's Trials Register (to 28 February 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 1), MEDLINE via OVID (1950 to 28 February 2013), EMBASE via OVID (1980 to 28 February 2013), metaRegister of Controlled Trials (to 7 April 2013), ClinicalTrials.gov (to 7 April 2013) and the WHO International Clinical Trials Registry Platform (to 7 April 2013). The reference lists of all trials identified were checked for further studies. There were no restrictions regarding language or date of publication. SELECTION CRITERIA Randomised controlled trials evaluating the management of mandibular fractures without condylar involvement. Any studies that compared different treatment approaches were included. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed trial quality and extracted data. Results were to be expressed as random-effects models using mean differences for continuous outcomes and risk ratios for dichotomous outcomes with 95% confidence intervals. Heterogeneity was to be investigated to include both clinical and methodological factors. MAIN RESULTS Twelve studies, assessed as high (six) and unclear (six) risk of bias, comprising 689 participants (830 fractures), were included. Interventions examined different plate materials and morphology; use of one or two lag screws; microplate versus miniplate; early and delayed mobilization; eyelet wires versus Rapid IMF™ and the management of angle fractures with intraoral access alone or combined with a transbuccal approach. Patient-oriented outcomes were largely ignored and post-operative pain scores were inadequately reported. Unfortunately, only one or two trials with small sample sizes were conducted for each comparison and outcome. Our results and conclusions should therefore be interpreted with caution. We were able to pool the results for two comparisons assessing one outcome. Pooled data from two studies comparing two miniplates versus one miniplate revealed no significant difference in the risk of post-operative infection of surgical site (risk ratio (RR) 1.32, 95% CI 0.41 to 4.22, P = 0.64, I(2) = 0%). Similarly, no difference in post-operative infection between the use of two 3-dimensional (3D) and standard (2D) miniplates was determined (RR 1.26, 95% CI 0.19 to 8.13, P = 0.81, I(2) = 27%). The included studies involved a small number of participants with a low number of events. AUTHORS' CONCLUSIONS This review illustrates that there is currently inadequate evidence to support the effectiveness of a single approach in the management of mandibular fractures without condylar involvement. The lack of high quality evidence may be explained by clinical diversity, variability in assessment tools used and difficulty in grading outcomes with existing measurement tools. Until high level evidence is available, treatment decisions should continue to be based on the clinician's prior experience and the individual circumstances.

Oral ibuprofen for acute postoperative pain

In this short communication we wanted to find out what is the analgesic effect of single dose oral Ibuprofen for adults with postoperative pain? Ibuprofen at 200mg and 400mg are effective in producing at least 50% pain relief in patients with moderate to severe postoperative pain (at least 30mm on a VAS). They are safe to use without common adverse effects. The use of Ibuprofen 200mg or 400mg should be considered as standard practice or protocol for pain relief in post-operative settings. Clinicians should consider a range of factors before prescribing or administering Ibuprofen for acute post-operative pain, including but not limited to, the duration of pain relief with Ibuprofen of different doses, Ibuprofen formulation, cost and patient preference.

Oxycodone or oxycodone plus paracetamol for acute postoperative pain in adults

In this short communication we wanted to find out what is the analgesic effect of single dose oral oxycodone, with or without the addition of paracetamol, for adults with postoperative pain? Oxycodone at doses of 5mg and above is an effective analgesia for patients with moderate to severe postoperative pain. The efficacy of oxycodone is increased with the addition of paracetamol. The use of oxycodone 10mg plus paracetamol 625mg can be considered for use in the pain relief protocol in post-operative settings. Clinicians should consider a range of factors before prescribing or administering oxycodone for acute post-operative pain, including but not limited to, individual patient clinical profile, adverse effects, cost and patient preference.

An intervention study to improve pain management by nurses : normative beliefs and perceived control

Based on a predictive model of nurses' intentions regarding pain management, an intervention was developed to improve nurses' pain management. The intervention involved a series of workshops with cohorts of nurses working in acute care wards to address the important antecedents to their intentions: normative beliefs and perceived control. Pre- and post-intervention measures demonstrate the effectiveness of the intervention. The effectiveness of this intervention in improving the management of patients' pain is compared with a patient education program group and a control group. The findings provide support for further developing interventions based on the theory of planned behavior.

Oropharyngeal dysphagia in an elderly post-operative hip fracture population : a prospective cohort study

Background: normal ageing processes impact on oropharyngeal swallowing function placing older adults at risk of developing oropharyngeal dysphagia (OD). Anecdotal clinical experience has observed that older patients recovering from hip fracture surgery commonly develop OD post-operatively. Objective: to document the presence of OD following hip fracture surgery, and the factors associated with OD. Methods: one hundred and eighty-one patients with a mean age of 83 years (range: 65–103) admitted to a specialised orthogeriatric unit were assessed for OD post-surgery for hip fracture. Pre-admission, intra-operative and post-operative factors were examined to determine their relationship with the presence of OD. Results: OD was found to be present post-operatively in 34% (n = 61) of the current population. Multivariate logistic regression analyses revealed the presence of pre-existing neurological and respiratory medical co-morbidities, presence of post-operative delirium, age and living in a residential aged care facility prior to hospital admission to be associated with the post-operative OD. Conclusion: these results highlight that OD is present in a large number of the older hip fracture population. Early identification of OD has important implications for the provision of timely dysphagia management that may prevent secondary complications and potentially reduce the hospital length of stay.

Advocacy in pain management: the role of the anaesthetic nurse specialist

Peri-operative nursing practice is constantly changing and demanding specialist knowledge, skills and expertise to embrace these changes. All patients in need of anaesthesia are entitled to the same high quality peri-operative care and therefore those assisting the anaesthetist must be competent and effective practitioners. With this in mind the authors shall give a reflective account highlighting the role of Anaesthetic Nurse Specialist (ANS) in promoting leadership within the peri-operative environment and how it can be nurtured and facilitated to achieve professional autonomy and promote patient advocacy.