Chapter 1: Introduction
Background
Post-operative pain is one of the consequences of surgeries and the fear of such pain is one of the main concerns of many patients who undergo surgery. This is a well-justified fear and post-operative pain has been accepted as a foreseeable part of post-surgery experienced by patients. However, even when unrelieved pain is reported, it may not result in corrective measures or many patients may not receive adequate postoperative pain relief because of staff failures to routinely assess pain and prescribed pain relief and physicians are not held accountable for poor analgesia. Another factor in inadequate pain relief is the fear of the possibility of the development of physical dependence, tolerance, addiction, and side effects which could prevent physicians from prescribing analgesic especially opioid ones.
According to Malek et al. (2017), immediately after an operation, the pain can be expected to be severe and may need controlling with strong parenteral opioids in combination with local anesthetic blocks and peripherally acting drugs. Normally, postoperative pain should decrease with time and the need for drugs to be given by injection should cease. There is then a step down to oral opioids and finally to non-steroidal anti-inflammatory drugs and acetaminophen on its own. As the experience of pain varies between patients and opioid effects vary between individuals, so the dosage of opioids need to be assessed for each individual in order to achieve adequate pain control. Analgesics or compounds with less pronounced dependency or tolerance should be used, if possible, and finally, analgesic therapy and the patient’s need for opioids should be evaluated frequently.
Research Objective
- To determine the strategies associated with the positive outcomes/Effects of using analgesics to control postoperative pain in adult patients?
- To investigate the effects of patients controlled analgesia among adult postoperative pain patients.
Research Questions
- What strategies are associated with the positive outcomes/Effects of using analgesics to control postoperative pain in adult patients?
- What are the effects of patients controlled analgesia among adult postoperative pain patients?
Chapter 2: a Literature review
Cardiac surgery has been associated with a significant amount of postoperative pain (Malek, Sevcik & Bejsovec, 2017). This has prompted the patients to participate in their own analgesia administration during their postoperative pain (Malek, Sevcik & Bejsovec, 2017). After a surgical procedure, patients can experience pain originating from rib retraction, median sternotomy or thoracotomy incisions, presence and removal of the chest drains, harvesting of vessels from the forearm or legs for grafting, and many more (Hooten, 2013). The severity of postoperative pain is determined by the surgical procedure used. For example, when a port-access coronary artery bypass (PACAB) which is a less invasive cardiac procedure is used, there is less tissue injury and less postoperative pain is experienced (Zubrzycki et al, 2018).
The common type of pain experienced after a surgical procedure is acute pain. According to Malek, Sevcik & Bejsovec (2017), post-operative pain is still not managed well in the 21st Century in more than half of the patients undergoing surgical procedures. The researchers used the case of the Czech Republic as evidence where 18% of the patients who underwent surgical procedures mentioned the pain to be a stressful experience after an operation. Moreover, the study further revealed that 36% of post-surgical complaints were as a result of pain. A review conducted by Maier in the management of postoperative pain in Germany gave common occurrences of postoperative pain among patients, specifically pain.
Patients Controlled Analgesics is extensively used in post-operative care. PCA has been found to be a more feasible option for clinician-driven titration and re-dosing. According to Bijur et al (2017), analgesics in 2011 were prescribed to approximately 97 million patients visiting the ED in the United States alone. However, the use of PCA requires a lot of time and may not be feasible in highly populated ED.
There is a growing concern of over-prescription of opioids in post-operative pain controlled analgesia, leading to addiction. According to Zhao et al (2019), 80% of patients who undergo a surgical procedure are given opioid analgesics to eliminate pain. Unfortunately, there is a great concern about the irrational use of opioids leading to dependence on the drugs and abuse (Zhao et al, 2019). This has contributed to a high mortality rate and burden to the economy (Zhao et al, 2019). In the United States alone, there are 33, 000 deaths per year as a result of opioid addiction, and as said above, the economy is burdened since the addicted persons will have to be treated (Zhao et al, 2019). From the year 2004 to 2012, 80% of patients who underwent a surgical procedure filled in the prescription of opioid analgesics (Bui et al, 2019). This is a concern because these rates have been increasing over time, and they were established inappropriate or excessive than the required dose (Bui et al, 2018). Statistics revealed by the United States in 2013 indicated that $78.5 billion was used to treat opioid addiction and overdose (Zhao et al 2019).
There are several postoperative pain management interventions and strategies in use. A good example is an intervention that was initiated by the American Pain Society in collaboration with the American Society of Anesthesiologists (ASA). The postoperative pain management guidelines and procedures were commissioned by the two bodies purposively to encourage evidence-based, safer, and effective postoperative pain management in adults and children (Chou et al 2016). The procedures and guidelines captured the use of different pharmacological modalities, postoperative education, planning of postoperative pain management, the transition to outpatient care, and organizational procedures and policies. In 2012, a practice guideline containing procedure and processes was published by the ASA and later reviewed for approval by the American Society of Regional Anesthesia and Pain Medicine.
Understanding the use of analgesics to manage postoperative pain is very crucial in nursing practice, patient care, and management of health care organizations. When it comes to a patient’s outcome, Glowacki (2015) revealed that postoperative pain management done effectively improves early mobility and reduces the complications of ileus, myocardial infarction, and urinary retention. In addition, effective post-surgical pain management is associated with reduced pulmonary complications, reduced stress, earlier overall recovery, reduced rates of readmission, and improved quality of life. Just as earlier discussed, the healthcare system incurs losses associated with postoperative pain, nonetheless, adequate and earlier management of postoperative pain will ensure that financial resources that would otherwise be used to take care of the patients channeled to other economic sectors or improvement of the health care system. In 2013, the American Nurse Credential Center revealed that only 1672 of the registered nurses in the US had accredited pain management qualifications (Glowacki 2015). This, therefore, means that more nurses are needed in this field, hence, a suggestion by the Nurse Practitioner Healthcare Foundation which proposed the development of a standardized curriculum in pain management. This impacts nursing practice positively because they will have an increasing role to play in future postoperative pain management.
Some of the possible outcomes of using PCA may include; reduced postoperative complications, patients’ satisfaction, improved quality of life, prevention of pain development, and improved knowledge regarding pain management.
Acute Pain in Post-Surgery Patient
One of the most common symptoms before and after surgery or any medical intervention is acute pain. Weinrib et al. (2017) indicate that the presence of acute pain is sure evidence that the beholder has tissue insult that might be present due to injury, surgical operative procedure, disease, or childbirth that aims at preventing further damage. In the presence of acute pain, there is an unpleasant emotional and mental sensation that occurs in association with vegetative signs, psychological reactions, and behavior change (Noel et al. 2017). In essence, acute pain lasts several hours to days and barely a month but to makes the patient seek medical attention within minutes, hours, or a few days after its onset. Moreover, identifiable stimuli acute pain provokes acute pain and the pain disappears ones the injured tissue heals or the cause is removed. However, if it is ignored, acute pain can turn chronic, that is, the pain can be lasting more than months and the intensity might be similar or increasing intensity with time (Weinrib et al. 2017). Postoperative pain is a perfect example of acute pain and apparently, all surgical procedures lead to various levels of postoperative pain on the patient, which call for pain management. Weinrib et al. (2017) adds that as a concern, most patients undergoing surgical operation worry about postoperative pain and a number of studies including those conducted in nations with advanced health care systems reveal that even at the initial decade of the 21st century, close to one-third to half of the postoperative pain in patients had not been managed properly. The concern in pain poor management of postoperative pain depends on various factors that range from the intensity of the pain as the patient can reveal to healthcare provider facts.
Analgesia in Pain Management
Analgesia is drugs whose actions interfere with the pathophysiology of pain and ensures that pain is minimal on the patients. However, according to Hooten et al. (2013), the medical care provider should know the cause or origin of the pain, the sight of pain, aggravating, and relieving factors to the pain because this helps in knowing the divisions the pain affects in the patients. Moreover, pain assessment helps in grading and characterization of the pain, and its classification according to duration.
Patient-Controlled Analgesia
Patient-controlled analgesia (PCA) is a method used in pain management in which the patient decides when to get the dose of pain medication (Hübner et al. 2015). In most situations, PCA seems the best way to pay relief than involving another person such as a nurse who helps the patient in pain medication. In this type of pain management, the patient waits for the uncomfortable levels of pain and he/she presses a button on a computerized device that is attached to a central venous cannula that passes the analgesia from the computerized device that measures doses of the drug (Aloia et al. 2017). Currently, PCA is used in pan crises such as those encountered in pancreatitis and sickle cell crisis where excruciating pain needs management with opioid analgesia, but it is also used in postoperative acute pains. Additionally, PCA is also applicable in-home care of patients in hospice or those nursing moderate to severe pain due to cancer and those who cannot take per oral medications. Children young as 7 years old can be beneficiaries of the treatment using PCA if only they understand the instructions used in PCA and the principal idea (Aloia et al. 2017). However, the use of PCA is contraindicated and inapplicable in people who are disoriented, confused, or unconscious.
Effects of Patient-Controlled Analgesia
Benefits of Using Patient Controlled Analgesia in Postoperative Patients
The benefits are with the patient than with the medical provider because it gives positive results compared to other medical provider controlled analgesia. Foremost, the equipment allows the patient to take the lowest quantities of the analgesia that is effective in pain management as per the condition of the patient. The low doses prevent the patient from adverse effects of an overdose of the drug such as nausea, vomiting, and bowel disturbances amongst others (Martin R. Tramer & Bernhard Walder 1999). Additionally, the low dose prevents the patient from developing tolerance to high doses of the drug, which can result in another medical condition secondary to pain management with opioid drugs (Choiniere et al. 1998). Ideally, the aim of the administration of the drugs is to get the lowest dosage that can relieve pain and prevent the tolerance and adverse effects of the drug. Moreover, the patient gains wellness or becomes stable such that he/she can walk or move limbs, which allow them to start physiotherapeutic exercise and movement. Ability to move and exercise helps in preventing conditions associated with debilitation such as stasis of blood that can lead to venous thrombosis and later thromboembolism that predisposes the patient to other adverse conditions that are life-threatening (B. Walder et al. 2001). Such conditions include myocardial infarction secondary to thromboembolism in the coronary artery, stroke secondary to blockage vessels of the circle of Willis by an embolus, or deep venous thrombosis (B. Walder et al. 2001). In essence, myocardial infarction and stroke can result in death because myocardial infarction limits the amount of blood pumped from the heart to tissues, which leads to hypoxia and ischemia to tissues. Moreover, stroke can result in impaired function of the sympathetic system thus reducing the performance of the structures in the brain stem that control breathing and heart rate (Chelly et al. 2004). Thus, using patient-controlled analgesia reduces the chances of encountering adverse effects of analgesia related to using opioid drugs, tolerance to the drug, and improved condition of the patient that eliminates dangers that are associated with debilitation.
Also beneficial in patient-controlled analgesia is the ability of the patient to monitor his condition and only use the drug when it is necessary, which eliminates the regular input of a medical provider that sees the patient takes unnecessary levels of the analgesia that can cause adverse effects (Martin R. Tramer & Bernhard Walder 1999). Conversely, patient-controlled analgesia ensures that the patient is only getting very low amounts of the analgesic, which means that they cannot stimulate the nervous response that stimulates the chemoreceptor trigger zone, which is responsible for emesis (Martin R. Tramer & Bernhard Walder 1999).
However, medical providers also benefit from the efficiency of patient-controlled analgesia in a number of ways. The patent is in charge of the management of his/her pain, which means that follow up on the performance of the analgesia allows the practitioner to assess and grade the quality of pain more effectively (Varrassi et al. 1999). Additionally, the equipment ensures that the patient is getting low doses of the drug, which eliminates medical provider errors such as overdosage and delivery of high doses that might induce tolerance and adverse effects that worsens the quality of life of the patient (Chelly et al. 2004). While the medical care provider has an active involvement in the management of pain, the error associated with the delivery of dosage and adverse effects are eliminated, which gives the patient a better quality of life.
The study employed a qualitative research method, specifically a literature review method. According to Rothstein & Borenstein (2006), a systematic review basically uses explicit methods to establish relevant studies or literature to the research question and then summarizes them. Generally, the aim of this literature search was to establish a solution to the research question using keywords to search the online databases for relevant literature. The purpose of this literature review was to come up with six relevant published research studies and then do a CASP to prove their credibility, and compare the themes of the six studies as the central part of the methodology that gives answer to the research question; What actions can nurses take to increase the effectiveness of analgesics to control postoperative pain in adult patients? According to Djikers (2017), CASP tool is very crucial because it focuses on assisting the researchers to decide whether the study will be helpful in answering the research question.
Data was collected by searching electronic databases, scanning reference lists of articles and consulting with experts in the field. No limits were applied for languages and foreign papers were translated. This search was applied to Medline (1966 – present), Pre-Medline electronic sources and also Cochrane and Database of Abstracts of Reviews of Effectiveness (DARE) databases were reviewed.
Search Strategy
The literature search was conducted in PubMed, Medline, Cochrane library, and CINAHL databases. The search involved keywords post-operation, pain, analgesics, post-cardiac surgery, and outcome. The databases were searched for relevant works of literature including Random Controlled Trials, Systematic Reviews, cross-sectional studies, and meta-analysis studies. Below is a Boolean search table that summarizes the search strategy that was used. Moreover, an advanced search was done to narrow down the results to fit in the inclusion criteria as discussed below. PubMed and Cochrane library gave a large number of articles, and therefore, an advanced search was conducted in the two databases to determine articles with free full texts and eliminate those with previews. A literature search in Medline combined the words patients, improved, and outcomes and use of “adults” eliminated literature that would be discussing children. A literature search in CINAHL was modified by using keywords “cardiac surgery”, “pain”. AND “analgesia to give articles that are more specific to post-cardiac operative patients.
| DATABASE | KEYWORDS USED |
| PubMed | Analgesia AND Postoperative |
| Medline | Patients AND Improved AND Outcome AND Adults |
| Cochrane Library | Analgesia AND Postoperative AND Outcome |
| CINAHL | Post-cardiac surgery AND Analgesia AND Patients. |
The strength of using the different search terms for the different databases search as in the table above was necessary to give a variety of published articles the study could select from.
Inclusion Criteria and Exclusion Criteria
The inclusion strategy was based on the year of article publication, language used and relevance to the research question. The first consideration was that all the articles were written in the English language. Secondly, the year of publication was a factor to consider and, articles published from 2009 up to date were included, and It was important to use articles not older than 10 years because they are not up to date. Using updated articles is important because they capture recent adjustments information, improvements and modifications in nursing practice. To determine the relevancy, the abstract of the identified articles was read and the relevant ones were included in the study.
Articles focusing on children’s patients were excluded. Moreover, reading of the abstracts was sententious to screen the most relevant articles that apply in this case. Once the articles were retrieved from the electronic databases, each article’s abstract was read to determine their relevance to the research question, irrelevant articles, reports, conference abstracts, and protocols were all excluded.
The table below shows the summary of the literature search from various databases
| Database | Key terms | Results | Selected based on the title | Selected based on abstract | Free literature could be accessed | Relevant Literature |
| PubMed | “Analgesia” AND “Postoperative” | 450 | 12 | 5 | 4 | 2 |
| Cochrane | “Analgesia” AND “Postoperative” AND “Outcome” | 375 | 10 | 6 | 3 | 2 |
| CINAHL | “Cardiac Surgery” AND “Pain” AND “Analgesia” | 250 | 7 | 4 | 3 | 1 |
| Medline | “Adult Patients” AND “Improved” AND “Outcome” | 125 | 7 | 2 | 2 | 1 |
As shown in the table above, the literature results were searched based on the relevancy of the title. For instance, PubMed had a large number of literature totaling to 450, 12 were selected based on the relevancy to the title. Once the abstracts were read, 5 articles were extracted. Out of these, only 4 could be freely accessed and only 2 found to be more relevant to the research question. Cochrane library gave the second largest number of articles totaling to 375, 10 were selected based on title 6 based on abstract, and only 3 could be accessed to get the 2 relevant literature. CINAHL database gave the least literature totaling to 250. Their titles were screened and 7 selected, out of these, only 2 had relevant abstracts. The accessible articles were 2 hence 1 relevant article that was used. Finally, out of 125 works of literature that were identified in Medline, only 7 were selected based on the title, 2 based on the abstract. These two were accessible but only 1 was relevant to the study.
Below is a PRISMA flow diagram that shows the number of identified studies, excluded studies, and included studies (Liberati et al, 2009).
PRISMA 2009 Flow Diagram
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Ethical Implications
Ethical considerations during systematic reviews are of great importance. According to Vergnes et al (2010), there is adequate evidence showing that the methodology used in conducting the literature search does not prevent unethical studies inclusion. Vergnes (2010) further adds that it is ironic that the inclusion of unethical studies is made easy and even supported by the need to provide more information. All data was anonymized locally and input into a preformed encrypted spreadsheet to be given to the study leads. No identifiable patient data are to leave the respective trust and all published data will be anonymized with respect to the patient and the trust. Individual trust data or consultant names were also not be published in an identifiable manner. To ensure ethical acceptability, credibility, and reliability of this thematic analysis, the research was conducted by taking into consideration the ethical guidelines included in the works of literature. Furthermore, the guidelines for the responsible systematic reviews and conduct incorporating legislation and self-regulation were applied by ensuring only articles that had adequate ethical consideration of their participants were used.
Chapter 4: Results
The table below is a summary of the result articles retrieved from the electronic databases, with a focus on the aim of the studies, type of study, main findings and conclusion, and strengths and limitations of the articles.
| Author/Date | Aim of the Study | Type of Study | Main findings/Conclusion | Strengths & Limitations |
| Yong & Coulthard (2010) | To determine whether there is a difference between the protective analgesia groups compared with conventional analgesia groups with the aim of improving postoperative pain experience | RCT | Patients in the protective analgesia group experienced severe pain as compared to the patients in the conventional group. | The study used an adequate sample size of 122 that gave a reasonable result worth using as a literature source. However, the research only used ibuprofen for protective analgesia and conventional analgesia hence the result may not be conclusive. |
| Vitile et al (2019) | To establish pain management practices and describe patient satisfaction measurements for intensive care patients after cardiac surgery with a sternotomy approach at a hospital in the University of Riga, Latvia. | Cross-Sectional | After 24 hours from surgery, patients’ pain management satisfaction was high, despite the fact that the nurses’ knowledge was average, and this further classified communication and attitude as two main factors affecting patients’ satisfaction. | The sample size of 72 used was small hence cannot be used to generalize the effect on the general population. Therefore, more research is needed. |
| Nachiyunde & Lam (2018) | To determine the efficacy of different modes of analgesia in postoperative pain management and early mobilization in postoperative cardiac surgical patients. | Systematic Review | The use of combined techniques including PCA with Opioids and local anesthetic subcutaneous infusions are the best pain management strategies, especially in post-cardiac surgery. This will assist in avoiding vomiting and excessive nausea. | The inclusion and exclusion criteria used is so strict hence there were a limited number of literature used for analysis |
| Van Dijk et al (2010) | To describe the knowledge of the patients and nurses and beliefs concerning pain management. In addition, the researchers wanted to establish the effects education has on patients and nurses’ beliefs on postoperative pain. | RCT | The study revealed outstanding results, for instance, the intervention group that consisted of patients who were actively involved in their postoperative pain control posted an increase in their level of knowledge | The article used an adequate sample size on the nurses; hence the results can be considered valid. However, there are many postoperative patients experiencing pain. |
| Shah, Wong & Wong (2015) | To determine patient satisfaction and positive outcomes in pain management after an ambulatory surgery | Systematic Review | A combination of multimodal analgesia and local anesthetics technique will assist to improve the quality of pain relief. However, the study was not able to prove whether the patients treated through this technique gets satisfied since patient satisfaction is a complex concept entailing cognitive, social, and cultural issues. | The study only used two databases, that is MEDLINE and Embase to retrieve their literature, therefore, the researchers had limited options to get relevant information to answer the research question. |
| Mitsiou & Mitsiou (2013) | To establish the satisfaction of patients with their postoperative pain management using strategies such as analgesics while identifying the characteristics of their pain and exploring any possible gaps in post-operative pain management in Armed Forces’ Hospitals in Anthems. | Survey | The findings of this survey established that 90.7% of patients were generally satisfied with how their post-surgical pain was being managed. On the other hand, 53.3% of the patients were fully satisfied with their post-surgical pain management. Generally, the study demonstrated that all patients who underwent major surgery were satisfied with their pain management owing to the fact that they were involved in their pain management | The patients’ expectations about their post-operative pain level and pain relief were not investigated. The previous patients’ pain experience was not investigated and this might have affected their pain assessment. Again, this study is valid because a sample of 150 patient respondents was used and this gives the general view of the entire population of postoperative pain patients. The study contributed to answering the research question owing to the fact that one of the factors that contribute to improved outcomes of postoperative patients is that they are involved in their analgesics use. |
Critical appraisal is a process used to determine the strengths and weaknesses of research in a systematic way. According to Young & Solomon (2009), the most sententious aspect of the critical appraisal process is the evaluation of validity, appropriateness, and relevance of the study design and the research question. Moreover, the methodological design used in the study should be carefully evaluated. Therefore, a Critical Appraisal Skills Program (CASP) tool was used to evaluate the validity and relevance of the systematic review articles. CASP suggests ten checklist questions that can help in critically appraising a research study. In this case, the Critical Appraisal of the six articles was conducted based on three questions, that is; do the studies answer and focus on a valid research question? Do the studies use an adequate sample size? Do the studies have valid results?
All the articles focused on valid research questions with specific research designs to answer the research questions. To begin with, Yong & Coulthard (2010) focused on a valid research question of whether there is a difference between the protective analgesia groups compared with conventional analgesia groups with the aim of improving postoperative pain experience. This research question is almost similar to what Nachiyunde & Lam (2018) were addressed, which was to determine the efficacy of different modes of analgesia in postoperative pain. Similarly, Shah, Wong & Wong (2015) and Mitsiou & Mitsiou (2013) also addressed similar research questions that focused on determining patients’ satisfaction with their postoperative pain management.
Among the six articles presented above, only Yong & Coulthard (2010) and Van Dijk (2019) adopted Random Controlled trial designs, whereas Nachiyunde & Lam (2018) and Shah, Wong & Wong (2015) used systematic reviews. On the other hand, the article by Vitile et al (2019) and Mitsiou & Mitsiou (2013) employed cross-sectional studies and survey designs respectively. When it comes to the sample size, the article by Yong & Coulthard (2010) clearly addressed a focused issue; for example, it focused on a sample of 122 postoperative patients’ population, and a protective and a conventional analgesia intervention given. However, the sample size used was by Vilite et al (2019) is 72 which is quite small considering a large number of patients experiencing postoperative pain in the general population. Van Dijk et al (2010) and Mitsiou & Mitsiou also used an adequate sample size that gave the hypothesized findings, whereas Shah, Wong & Wong (2015) limited their review in only two databases, that is; MEDLINE and EMBASE.
Finally, based on the question of the validity of the findings of the articles, the findings of Yong & Coulthard (2010) can be considered valid because of the adequate sample size used to give the findings that Patients in the protective analgesia group experienced severe pain as compared to the patients in the conventional group. However, the research only used ibuprofen for protective analgesia. Similarly, Van Dijk et al (2010) and Mitsiou & Mitsiou (2013) produced vali results that can be applied in the general population owing to the adequate sample size used and the design. On the other hand, the findings by the article Vilite et al (2019) may not be valid due to the small sample size of 72 which is quite small considering a large number of patients experiencing postoperative pain in the general population hence the findings may not be valid.
Analysis
| Theme 1 | Theme 2 | Theme 3 | Theme 4 | |
| Patients’ Satisfaction and Improved quality of life. | Characteristics of Postoperative pain | Patient-Controlled analgesia and opioids. | Nurses and Patient’s knowledge regarding pain management | |
| Article 1 | √ | √ | √ | |
| Article 2 | √ | √ | ||
| Article 3 | √ | √ | ||
| Article 4 | √ | √ | ||
| Article 5 | √ | √ | ||
| Article 6 | √ | √ | √ | √ |