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Abstract |
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 Top Abstract Literature ReviewConceptual FrameworkMethodsResultsDiscussionConclusionsReferencesREFERENCE |
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• Objective To determine types of analgesics administered for procedures, the prevalence and amounts of drugs given, and factors predictive of analgesic administration.
• Methods Pain was assessed before and immediately after procedures. Analgesic, sedative, and anesthetic agents administered within 1 hour before and/or during each procedure were noted.
• Results A total of 5957 adult patients at 164 national and 5 international sites participated. Pain intensity increased at the time of procedure for all procedures. More than 63% of patients received no analgesics. Less than 20% received opiates; mean total dose of opiate was 6.44 mg (SD, 8.96 mg). Only 10% of patients received combination therapy. Factors associated with the likelihood of receiving opiates were pain intensity before a procedure, femoral sheath removal, being white, and the duration of a procedure. Patients less likely to receive opiates had a medical diagnosis or were having tracheal suctioning. Only 14.5% of the variance in the amount of opiate administered was explained by factors entered into multiple regression models. Type of procedure was the only significant predictor of amount of opiate administered.
• Conclusions Most patients were not intentionally medicated even though pain intensity increased during their procedure. When used, analgesic amounts were low, and combination therapy was infrequent. Clinical trials are needed to evaluate optimal pain management for patients undergoing procedures.
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Literature Review |
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TopAbstractLiterature ReviewConceptual FrameworkMethodsResultsDiscussionConclusionsReferencesREFERENCE |
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Placement of central venous catheters is another frequently performed clinical procedure associated with pain and discomfort.5 Clinical guidelines recommend infiltration of subcutaneous tissues at the insertion site with local anesthetics such as 1% or 2% lidocaine. Yet, despite the frequency of placement of these catheters, no investigators have examined the effect of analgesic use on pain associated with the procedure.
Little has been reported on the painfulness of the removal of (non–chest tube) wound drains. In a study by Mimnaugh et al6 of pain associated with removal of Jackson-Pratt surgical wound drains, 11 of 31 patients received analgesic medications. Although no specific data on type or dosage of the medications were reported, Mimnaugh et al found no significant correlation between pain intensity scores and administration of pain medications.
Similarly, the pain associated with wound care and dressing changes in nonburn patients has not been studied widely. Although wound care specialists call attention to the need for proactive pain management for patients, studies of the pain associated with changing the dressings on nonburn wounds and interventions to prevent or treat pain associated with this commonly performed procedure are lacking.7
The pain and distress associated with endotracheal suctioning have been reported. Puntillo8 found that patients’ mean pain intensity during endotracheal suctioning was 4.9 (on a numeric rating scale of 0–10). Only 5 of 45 patients had received analgesics in the hour preceding the procedure; the mean dose was the equivalent of 1.6 mg of morphine. The correlation between pain intensity and amount of analgesics was small and nonsignificant.
Hallenberg et al9 explored patients’ perceptions of ventilator treatment postoperatively in 107 critically ill patients. In their study, 70 of the 107 patients received intravenous and/or epidural analgesics within the first 24 hours of intubation postoperatively, and 70% of the 70 were able to recall their experiences. Forty-four of the 107 patients also received rectally administered benzodiazepines (specific agent not reported), and 70% of the 44 were able to recall their experiences. Approximately 25% of the 107 patients reported discomfort associated with endotracheal suctioning, although the discomfort was not quantified.
Several authors10,11 described common analgesic practices associated with the removal of femoral sheaths. The effects of opiates (morphine or fentanyl) versus local anesthetics versus placebo were specifically evaluated in only one study.12 The use of opiates and/or local infiltration of lidocaine has been the primary analgesic intervention. Overall, the reported intensity of pain associated with the removal of femoral sheaths has been low, and the effects of opiates and local anesthetic injections before sheath removal have been mixed, depending on study design and on the medications studied and their doses.10–13 Apparently, however, analgesic therapies for this procedure provided good pain control in these studies, which had relatively small sample sizes.
In summary, previous studies on the effects of analgesic administration on patients’ perceptions of procedural pain are limited. Only a few studies involved the 6 procedures included in this report, and information on the analgesic requirements used to manage pain associated with the procedures generally was not included. In the studies that included analgesic use, the overall amounts of analgesics used were low, use was often reported as 24-hour usage, and the range of doses patients actually received for the procedure was not given.
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Conceptual Framework |
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), introduced previously,14 provided a conceptual framework for the study of analgesic interventions for patients undergoing painful procedures. The model incorporates 3 primary dimensions: sensory-discriminative, motivational-affective, and cognitive. Briefly, the sensory-discriminative dimension, described by self-report, encompasses the intensity, location, and qualities of the pain experienced. The motivational-affective dimension incorporates the unpleasant emotions associated with pain and the aversion to and withdrawal from painful stimuli. A patient’s behavior, affect, and physiological response (eg, sympathetic activation) characterize this dimension. Finally, the cognitive dimension addresses the patient’s interpretation and meaning of the pain or the effectiveness of pain-relieving measures.
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Other pharmacological agents that may alter the perception of, or response to, pain include nonsteroidal anti-inflammatory agents, local anesthetics, and sedatives such as benzodiazepines. Nonsteroidal anti-inflammatory agents alter pain transmission by decreasing the inflammation associated with tissue injury. Local anesthetics also alter transmission of nociceptive impulses by blocking afferent sensory fibers. Although not primarily analgesic in their action, benzodiazepines may alter the perception of, and response to, pain. Benzodiazepines can act synergistically with opiates to reduce the perception of pain.
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Methods |
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Study Sites and Sample
Study sites were a convenience sample of hospitals that agreed to participate. Each site had a site coordinator who was a registered nurse with research experience and/or research support. The protection of human subjects in research was confirmed at each site. The study sample was a convenience sample obtained at participating institutions. Patients who were undergoing any of the study procedures and who met inclusion criteria were invited to participate. Patients were included in the study if they were awake, alert, and oriented and their medical condition was stable enough to allow them to respond to questions; were 4 years or older; could understand and communicate in English; were able to hear and see; and were experiencing the selected procedure as part of normal care. Patients were excluded from the study if they were receiving neuromuscular blocking medications or had a disease or injury that impaired sensory transmission proximal to the procedure site.
Instruments
A study packet was developed that included a comprehensive data collection tool.
The analgesic profile and other data collection tools were pretested at 7 hospital sites in 3 phases. In addition, the study packet and instructions were sent to an advisory group of more than 50 nurse experts from various clinical specialties for an assessment of completeness and usability. The materials were revised on the basis of these pretesting procedures.
Analgesic/Sedative Profile. One section of the tool, the Analgesic/Sedative Profile, was used to document analgesic and sedative agents administered within the 1-hour period preceding the procedure as well as during the procedure. The profile included a categorical checklist for the type of agent, route of administration, mode of administration, and total dose administered during the relevant time. The specific agents on the checklist included opiates, sedatives, nonsteroidal anti-inflammatory agents, and a few miscellaneous drugs (eg, acetaminophen, aspirin, and "other"). The instructions in this section read, "In completing the Analgesic/Sedative Profile, include information about only those analgesic or sedative agents that the patient received in the hour preceding the procedure or during the procedure."
In another section of the profile, respondents were asked to document the use of analgesic/sedative agents administered in conjunction with the procedure. That is, respondents were instructed to check categories of agents that had been administered specifically as a pre-medication. Five categories of agents could be selected: opiates, sedatives, nonsteroidal anti-inflammatory agents/other, local lidocaine injection, and topical cream containing a mixture of lidocaine and prilocaine (EMLA cream). Respondents could check a sixth option: "not applicable."
Measures of Pain Intensity and Pain Quality.
Pain intensity in patients 18 years and older (ie, the subjects of this report) was measured by using a 0 to 10 numeric rating scale, with higher numbers meaning greater pain intensity. Construct15,16 and concurrent15,17 validity of the numeric rating scale were previously established. Pain quality was assessed by using the word list of a modified McGill Pain Questionnaire–Short Form (MPQ-SF).18 The MPQ-SF contains 15 words that measure sensory (11 words) and affective (4 words) pain. The words awful, stinging, bad, dull, and numb were added to the MPQ-SF for this study to make the form a 20-item quality word list. The content validity of this modified version of the word list was determined during the pilot phases of the study. The Cronbach 
reliability coefficient for the modified MPQ-SF was .85.
Other Data
Additional procedure-related and demographic data that could influence the use of analgesics during a procedure were obtained from each patient’s chart. These data included the patient’s age, sex, diagnosis, presence of chronic pain, and chronic use of opiates.
Procedure
Before the initiation of the selected procedure, a time 1 (baseline) pain assessment was done as follows. Pain intensity was assessed by using the 0 to 10 numeric rating scale. For patients who reported pain intensity equal to or greater than 1, pain quality was assessed by having a nurse read the word list from the data collection form to the patient. The patient indicated those words that described the pain that he or she was experiencing at that time.
At time 2, immediately after the procedure, pain intensity and quality were assessed in the same manner as at time 1. At time 2, the patient was asked to report the peak pain experienced during the procedure. At time 3, 10 minutes after the completion of the procedure, the patient was again asked to report his or her current pain intensity on the 0 to 10 numeric rating scale.
Data from the chart review were recorded by the site research associates, who returned all of the data collection forms to the appropriate site coordinator. Completed packets were returned to the national office of the American Association of Critical-Care Nurses for data entry and analysis.
Data Cleaning and Analysis
Before data analysis, the accuracy of data was evaluated through a review of descriptive statistics and a determination of logical congruence of findings with clinical practice. As a result, certain "decision rules" were followed for determining analgesic doses and duration of the procedures.
For analgesic doses, the following data were omitted from further analyses: all fentanyl scored in milligrams; all hydromorphone, meperidine, and oxycodone scored in micrograms; any morphine dose less than 0.5 mg; any hydromorphone dose less than 0.075 mg; any fentanyl dose less than 5 µg; and any meperidine dose less than 3.75 mg. The rationale for these decision rules was that those doses would not be within the range of normally administered doses. Then, all total opiate doses were converted to equivalent doses of morphine (Table 1).
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A number of descriptive and inferential statistical analyses were performed. Inferential analyses included the 
2 test, the Cramer V coefficient, 1-way analysis of variance, Pearson product-moment correlations, logistic regression, and multiple regression. The level of significance was established a priori at P<.05.
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Results |
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Number of Patients Receiving Medications Before a Procedure
Most patients did not receive analgesics, sedatives, or local anesthetic agents before and/or during their procedure (Table 2 and Figure 2). A total of 19.7% of patients received opiates before and/or during procedures. The highest percentage of patients who received opiates was for those undergoing femoral sheath removal (28.6%); the lowest percentage was for those having tracheal suctioning (3.7%). A total of 11.6% of patients received sedatives before and/or during procedures. Among patients undergoing placement of a central venous catheter, 31.1% received sedatives; less than 1% of patients having wound drains removed received sedatives.
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2 = 290.3; Cramer V coefficient = .05). Likewise, the difference among procedures in the percentage of patients who received sedatives and those who did not was significant (P<.001), but the associations were small (2 = 690.2; Cramer V coefficient = .12).
A total of 18.4% of patients received local anesthetics before and/or during procedures. A total of 89.5% of patients undergoing placement of a central venous catheter received local anesthetics, whereas 0% patients having removal of a wound drain received these agents. The difference among procedures in the percentage of patients who received local anesthetics before and/or during procedures and the percentage who did not was significant (P<.001). This association was moderate (2 = 1832; Cramer V coefficient = .31). Less than 4% of patients received nonsteroidal anti-inflammatory agents before and/or during procedures, and only 4 patients received a topical cream containing lidocaine and prilocaine before and/or during procedures.
A total of 36.4% of patients received some type of medication before and/or during procedures. Only 6.8% of patients undergoing placement of a central venous catheter received no medications. For other procedures, the percentages of patients who received no medications ranged from 41.6% for femoral sheath removal to 94.3% for tracheal suctioning. A total of 26.1% of the 5830 patients with available data received a single type of medication. For example, 70.3% of 192 patients undergoing placement of a central venous catheter received only local anesthetics before and/or during procedures. A total of 10.3% (n = 601 of 5830) received a combination of medications. For combination of medications, the highest percentage was for patients who received opiates and sedatives (n = 204 of 5830; 3.5%); among procedures, the highest percentage of patients who received both opiates and sedatives was 7.1% of 2528 patients who had removal of a femoral sheath. Although differences between the drug combination and procedure groups were significant (2 = 2529; P<.001), the percentage of explained variance was small (Cramer V2 = .09). When all types of medications for which records were kept (ie, opiates, sedatives, local anesthetic agents, and nonsteroidal anti-inflammatory agents) were considered, 20.6% of patients undergoing femoral sheath removal and 20.7% of patients having placement of a central venous catheter received some form of combination therapy. These percentages were well above the percentages for combination therapy for other procedures, all of which were less than 6%.
Amount of Opiates and Sedatives Administered Before and/or During Procedures
As noted earlier, most patients did not receive opiates and sedatives in the 1 hour before and/or during procedures. Table 3 gives the number and percentage of patients in each procedure group that received opiates by any route or mode before and/or during the procedure and the mean total doses administered (ie, total amount of opiates administered 1 hour before and/or during the procedure). Of the 586 patients (9.8%) who had an opiate dose noted, the amounts in morphine equivalents ranged from 0.5 to 167 mg (Figure 3). The mean amount administered was 6.44 mg (SD, 8.96 mg) in morphine equivalents; the mean amount in morphine equivalents across procedures ranged from 5.39 to 11.72 mg.
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The next analysis determined the relationship between presence of baseline pain (ie, pain at time 1) and administration of medications for pain before and/or during a procedure. For the 19.7% of patients who received opiates, those who had pain at time 1 were more likely to receive opiates before and/or during the procedure than those who did not have pain at time 1 (Figure 4). This finding was significant (P<.001). The correlation between actual pain intensity at time 1 and mean dose of opiate (in morphine equivalents) administered was small and nonsignificant (r = 0.02; P = .61). For the 11.6% of patients who received sedatives, those who did not have pain at time 1 were more likely to receive sedatives before and/or during the procedure than those who did have pain at time 1 (Figure 4). This finding was significant (P<.001). For the 18.4% of patients who received local anesthetics, those who did not have pain at time 1 were more likely to receive local anesthetics before and/or during the procedure than those who did have pain at time 1 (Figure 4). This finding was significant (P<.001).
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). An analysis was done to evaluate the relationship between pain intensity change scores and mean dose of opiate (in morphine equivalents) administered before and/or during the procedure to only those patients who had received some dose of an opiate (n = 586). However, the correlation between pain intensity change scores and mean dose of opiate administered remained low and nonsignificant (r = –0.05; P = .23).
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2 and t tests established that differences between patients who received opiates and patients who did not were not significant according to sex or the number of pain quality words chosen at time 1. The remaining 6 conceptual variables were entered into the logistic regression model because 2 and t tests indicated that these variables had significant relationships (P<.001) to whether patients did or did not receive opiates before and/or during a painful procedure. Logistic regression analysis requires the selection of a single reference group per each categorical variable against which to compare the other variables. Thus, for the procedure variable, placement of a central venous catheter was chosen as the reference group; for the ethnicity variable, other was the reference group; and for the diagnosis variable, other was the reference group.
Results from the logistic regression analysis are given in Table 5. Patients with greater pain intensity at time 1 or a longer procedure duration were significantly more likely than patients with lower pain intensity or shorter procedure duration to receive opiates before and/or during a painful procedure. Patients who experienced tracheal suctioning were significantly less likely to receive an opiate than those who had a central venous catheter inserted. Compared with patients having a central venous catheter inserted, patients who had a femoral sheath removed were more than twice as likely to receive opiates. The likelihood of receiving an opiate was not significantly greater or lesser for patients undergoing the other procedures than for patients who had a central venous catheter inserted.
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In order to further explore the issue of opiate administration for painful procedures, multiple regression analysis was used to examine factors that might influence the amount of opiates administered. The multiple regression model included only patients who had received an opiate and who had data for all of the entered variables (n = 550). The mean total dose administered 1 hour before and/or during the procedure was 6.42 mg (in morphine equivalents; SD, 9.13 mg), and the doses ranged from 0.5 mg to 167 mg (in morphine equivalents). Predictor variables entered into the model included age, ethnicity, diagnosis, pain intensity at time 1, specific type of procedure, and procedure duration (Table 6).
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Finally, an analysis was done to determine the mind-set of the practitioners regarding pharmacologically preparing patients before and during procedures. Thus, 2 questions were asked: (1) Did you premedicate the patient for this procedure? (2) Did you give the patient any of these agents during the procedure (ie, specifically for the procedure)? The results are presented in Table 7. A higher percentage of patients were reported to receive medications before the procedure than during the procedure. Although the percentage of patients who were given medication before a procedure was low, the 2 most frequently administered medications were opiates, which were administered 17.4% of the time before procedures, and lidocaine, which was administered 15.9% of the time. Less than 6% of patients received any type of medication during the procedure specifically for procedural pain. Thus, most practitioners did not appear to intentionally medicate patients for procedural pain.
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Discussion |
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When the occurrence of any of these events is anticipated, nurses should preemptively treat patients with analgesics. Why so many patients in this study were not treated preemptively is unclear. Decreased levels of consciousness should not have been the reason, because the patients in our study were required to be alert enough to participate by answering questions and rating their pain.
When patients in this study did receive medications, the percentage who received them varied widely according to the type of procedure. That is, almost all patients having placement of a central venous catheter (93%) received some type of medication 1 hour before and/or during the procedure, whereas almost the same percentage of patients having tracheal suctioning (94.3%) received nothing.
This difference may be due to the context of each of these procedures. Placement of a central venous catheter requires planning, usually is done according to a standard procedure, and usually takes several minutes. Conversely, tracheal suctioning is often unplanned and is performed quickly. Thus, greater attention may be given to administration of an analgesic in preparation for placement of a central venous catheter than for tracheal suctioning. However, practitioners are encouraged to consider tracheal suctioning as a potential source of substantial pain; assessment and preparation of patients before the procedure is recommended. If suctioning is not emergent, time may be available to administer a short-acting analgesic. Nonpharmacological interventions could be considered for use in conjunction with analgesics.
Many different types of analgesics can be combined to prevent and/or control procedural pain. Yet only 1 of 10 of patients received combination therapy (ie, 2 or more different types of drugs) before and/or during their procedures. A combination regimen was used most often in patients who had femoral sheath removal, and this combination was most often opiates and sedatives; however, this group accounted for only 3.4% of all patients in the study.
Combination analgesic therapy for procedural pain has many potential advantages, particularly because of the different mechanisms of action of the various drug types. Opiates alleviate pain by blocking the activity of central opiate receptors, thus inhibiting transmission by pain fibers. Local anesthetic agents block pain transmission by interfering with nerve cell depolarization of peripheral pain fibers. Benzodiazepine sedatives can augment opiate therapy by providing anxiolysis, skeletal muscle relaxation, and, in higher doses, amnesia.20
Combination therapy can augment analgesic effect while preventing or minimizing side effects because lower doses of an individual agent that causes side effects can be used.21 In addition, when more than a single type of medication is used, the effects can be synergistic. Indeed, the patients in our study who were more likely to receive combination therapy, that is, patients undergoing removal of femoral sheaths and placement of central venous catheters, reported substantially less pain than did patients having other procedures. The findings on femoral sheath removal are consistent with those of previous studies10–13 and offer strong support for the use of a combination of drug types to enhance pain control and potentially minimize side effects for patients undergoing procedures.
We found differences in the amount of opiates (in morphine equivalents) administered according to type of procedure being performed, and type of procedure was a significant predictor in our multiple regression model. Patients having femoral sheaths removed received a mean dose of 5.39 mg of opiates, less than one half the mean dose of 11.72 mg given to patients having a central venous catheter inserted; this difference was significant. Patients having tracheal suctioning received the second largest total amount of opiates (10.26 mg) before and/or during their procedure.
Background conditions may account for the higher doses of opiates given to patients having a central venous catheter inserted or having tracheal suctioning. That is, serious and prolonged illnesses or injuries may be more likely in patients undergoing these 2 procedures than in patients undergoing the other studied procedures. This hypothesis requires further substantiation.
Even though patients having femoral sheaths removed received lower doses of opiates, as noted earlier, more of them received sedatives along with the opiates than did patients having a central venous catheter inserted. In addition, 89.5% of patients having a central venous catheter inserted had received local anesthetic agents, more than any other procedure group. Again, combination therapy should be considered an important prerequisite to effective pain management during procedures, because both removal of a femoral sheath and placement of a central venous catheter were associated with the least amount of pain.
Nevertheless, when the use of opiates for procedural pain is considered, a mean amount of 6.44 mg is extremely small, especially because of the high probability of pain associated with each of the procedures under study. No reliable recommendation for a mophine-equivalent dose for procedural pain is available, although a range of 1 to 10 mg intravenously has been suggested.1,22 However, these doses are only recommendations; the amount of opiate should be titrated according to the amount of pain expected from the procedure and according to the patient’s response and the duration of the procedure.
One factor that seemed to influence whether patients received opiates before and/or during a procedure was the pain they were experiencing before the procedure. Patients with pain at time 1 had a better chance of receiving opiates than those without pain. However, in contrast, patients were more likely to receive sedatives and local anesthetic agents if they had no pain before the procedure.
These findings suggest that the use of sedatives and local anesthetics must have been planned specifically for the procedure. This planning is a positive step, because administration of sedatives and local anesthetics can make a procedure more comfortable whether a patient has pain before the procedure or not.
Procedural pain should be anticipated even for patients who do not have pain. Research indicates that a noxious barrage of the central nervous system can lead to the development of central sensitization.23 Central sensitization occurs when an increase in the excitability of a neuron can cause a response in a neural receptive field that previously was unresponsive. The increased excitability that accompanies central sensitization can produce an expansion of the area that will respond to a noxious stimulus, increase the magnitude and duration of a response, and reduce the threshold for a nociceptive response even in areas that previously had responded only to nonnoxious stimuli.23 Central sensitization can lead to persistent pain, that is, pain that continues for some time after a noxious event. Thus, no noxious stimulus should be considered benign, because the stimulus may affect the central nervous system in an adverse manner.
Central sensitization can be avoided by using preemptive analgesia. Preemptive antinociceptive treatment is an analgesic intervention provided before a noxious stimulus in order to "protect" the central nervous system. Local infiltrations of anesthetics, nerve blocks, intravenous or epidural opiates, nonsteroidal anti-inflammatory agents, and antagonists of receptors for N-methyl-D-aspartate such as ketamine have been used in studies of the effect of preemptive analgesia on postoperative pain, with equivocal results.24 No studies of the effect of preemptive analgesia on procedural pain are available, and experimental and clinical studies indicated that central sensitization and preemptive analgesic interventions are complex phenomena.24 However, sufficient evidence suggests that the use of more aggressive analgesic interventions before a procedure may protect the central nervous system and help avoid persistent pain.
The range of the mean total dose of opiates (in morphine equivalents) given 1 hour before and/or during a procedure was from 0.5 to 167 mg across the various procedures. However, pain intensity was higher at time 2, that is, at the time of the procedure, than at time 1. Yet, the positive change in pain intensity was not accompanied by an increase in opiate administration, because the correlations between the two were small and nonsignificant.
This finding lends further support to the suggestion that titration to effect did not occur during the procedures. Practitioners are encouraged to administer sufficient doses of analgesics before a procedure and to routinely assess the level of a patient’s pain during the procedure so that a sufficient amount of analgesic is administered. Even when baseline pain is taken into account, pain and the amount of opiates administered do not appear to be related.
In this study, we found certain factors that, when examined within the context of other factors, affected whether a patient received an opiate or not. What was learned from the logistic regression analysis was that patients with more baseline pain, those who underwent a longer procedure, those who had a femoral sheath removed, and/or those who were white had a statistically better chance than other patients of receiving an opiate for their procedure. Medical patients and/or patients having tracheal suctioning had a statistically lower chance of receiving opiates than did patients who had trauma or burns or were having one of the other procedures. The reasons for these findings are not clear, but some conjectures can be offered.
The presence of baseline pain may alert a practitioner to a patient’s need for analgesics during a procedure, especially a procedure that is expected to take a long time. The pain experienced by medical patients may not be as apparent to practitioners, or as expected, as the pain experienced by surgical patients; thus, practitioners might not think that an analgesic is required when medical patients are having procedures. Because tracheal suctioning is a rapid procedure performed on patients who are unable to speak, practitioners may not be aware of the pain involved and thus may not give the patients medication before the procedure. Future research is needed to test these clinically based assumptions.
The results of the multiple regression analysis of factors that could influence the dose of an opiate administered for a procedure provide a certain perspective to the issue of analgesic preparation for procedures. A patient’s age did not contribute significantly to the model, a finding that suggests that age was not a factor considered by practitioners in determining opiate doses. Few studies have been done of doses of analgesics required by elderly patients. Although age-related analgesic effects are extremely variable among elderly patients, changes in pharmacokinetics and pharmacodynamics could account for various adverse effects in this population.1 However, importantly, age does not have a unique influence on the experience of pain,25 and thus doses of analgesic should not be predicated on a patient’s age alone. Although formulas for determining postoperative doses according to age are available,26 no strong evidence suggests that age should be an important independent variable in administration of opiates to elderly patients during a procedure.
Baseline pain intensity, duration of the procedure, ethnicity, and patients’ diagnoses were also nonsignificant factors in the amount of analgesic administered. Pain intensity before a procedure may be a predictor of a patient’s response to procedural pain and thus should be a factor in making decisions about administration of an analgesic when procedural pain is likely. Again, doses of opiate given during a procedure can best be determined by regular pain assessments and assessment of the patient’s response to the drug.
The reasons the duration of a procedure did not significantly influence the amount of opiates administered are unclear, even though duration influenced whether patients would receive any opiates. A reasonable assumption is that practitioners would have more opportunities to assess a patient’s response during a longer procedure and so intervene accordingly. Perhaps longer procedures are not automatically more painful ones. For example, patients having chest tube removal, a rapid procedure, experience a substantial amount of pain associated with the procedure.27,28 Thus, the need for opiates and the duration of a procedure may have a linear pattern, and the extent of noxious injury rather than the duration of a procedure may be a more important predictor of pain. If a patient is undergoing an extended, seemingly painless procedure, administration of sedatives rather than opiates might be a more effective option for ensuring the patient’s psychological comfort.
Our findings on ethnicity are intriguing. Although it seemed to influence whether a patient would receive an opiate, ethnicity did not influence the amount of opiate administered during a procedure. We know of no study on the influence of ethnicity on procedural pain. Some studies29,30 on postoperative pain indicated that white patients received significantly more total postoperative opiates than did patients who were members of ethnic minority groups. McDonald29 suggests that these differences may be due, in part, to differences in pain expression, reluctance of some nonwhites to receive opiate analgesics, or a tendency to give less credibility to complaints of patients in nonwhite ethnic groups.
Little science is available to provide a physiological rationale for using lower doses of opiates in non-whites. In a small study of 8 Chinese and 8 white healthy men, Zhou et al31 found that compared with the Chinese subjects, the white subjects had lower morphine clearance, more depressed respiratory response to carbon dioxide, greater reduction in blood pressure, and less nausea after intravenous injections of 0.15 mg/kg of morphine. Although the results of Zhou et al cannot be generalized to a larger population of ethnically diverse patients, the findings suggest that more caution is needed in administering opiates to white patients than in administering these drugs to Chinese patients. However, until and unless research indicates otherwise, ethnicity should not be considered an independent factor in decisions on the administration of opiates.
The results of the multiple regression analysis provide some insight on factors that influence the doses of opiates used during painful procedures. However, the following characteristics of our study must be considered: (1) this analysis was based on the data of only 10% of the patients in the study, that is, on only a small group who had received any opiates at all, and (2) the combination of factors examined explained only 7.3% to 14.5% of the variance. Thus, the analysis offers only limited insight into factors that influence decisions on the doses of opiates used. Future research is needed to determine the contribution of other factors to decisions about doses of opiates.
Finally, the findings on practitioners’ administration of analgesics specifically to prevent or treat procedural pain deserve consideration. Less than 18% of patients received any of the medications before the procedure for the purposes of premedication. Less than 6% of patients received any of the medications during the procedure to treat procedure-related pain. These findings suggest that the minority of patients who received medications were probably receiving the drugs for other reasons. This situation is not a problem if a patient experiences little to no procedural pain; it is a problem if practitioners are not focusing on controlling procedure-related pain. Practitioners are advised to be proactive and systematic in their approach to administration of analgesics for patients who are undergoing procedures and should remember the previously described benefits of preemptive analgesia.
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Conclusions |
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Although our results provide new and significant insights into analgesic practices for procedural pain, clinical trials are warranted to test the efficacy of specific analgesic interventions. Such studies most likely will provide guidance to clinicians dedicated to the promoting the comfort of patients who undergo diagnostic-and treatment-related procedures.
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ACKNOWLEDGMENTS |
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When critically appraising the AJCC journal club article that you have just read, consider the questions and discussion points listed below.
| These journal club discussion points can also be found online at www.ajcconline.org. Click on Journal Club. Also included on the Web site are "Guidelines for Critiquing Research," a helpful list of common questions used to guide a research critique, and "Glossary of Research Terms," a list of commonly used terms and their definitions.
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  C. Gelinas, M. Fortier, C. Viens, L. Fillion, and K. Puntillo Pain Assessment and Management in Critically Ill Intubated Patients: a Retrospective Study Am. J. Crit. Care., March 1, 2004; 13(2): 126 - 136. [Abstract] [Full Text] [PDF]
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K. Puntillo Pain Assessment and Management in the Critically Ill: Wizardry or Science? Am. J. Crit. Care., July 1, 2003; 12(4): 310 - 316. [Abstract] [Full Text] [PDF]
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