Patient-controlled analgesia compared to continuous infusion of local anesthetics

MN504: MN504 Scientific and Analytic Approaches to

Advanced Evidence-Based Practice Unit 4 Assignment Deija Badia, RN, BSN August 27, 2017

Clinical Question

Clinical Question: Is patient-controlled analgesia or continuous infusion of local anesthetics more effective to control pain after spinal fusion surgery?

The PICOT format is used to summarize questions in a form that will help explore effects of therapy through research (Riva, Malik, Burnie, Endicott, & Busse, 2012).

PICOT Format

PICOT question: In patients with spinal fusion surgery, how effective is patient-controlled analgesia compared to continuous infusion of local anesthetics for controlling pain post-operatively?

PICOT (populations/people/patient/problem, intervention, comparison, outcome, and time)

P- patients with spinal fusion surgery

I- the effectiveness of patient-controlled analgesia

C- to continuous infusion of local anesthetics

O- controlling pain

T- post-operatively

(Evidence Based Practice: PICO method, 2017).

Pain Management Methods

Patient-Controlled Analgesia (PCA)

A type of pain management that lets the patient decide when they will get a dose of pain medication.

With this type of pain treatment, an intravenous line is placed on the patient and a computerized pump is attached to the IV which allows the patient to release pain medicine, usually morphine or hydromorphone, by pressing a handheld button.

Risks of PCA:

Allergic reaction

Nausea or vomiting

Low blood pressure

Sleepiness

Constipation

Trouble breathing

(Patient-Controlled Analgesia Pumps, n.d.)

Pain Management Methods (Cont.)

Continuous Infusion of Local Anesthetics (CILA)

Consists of an elastomeric pump that holds local anesthetic.

Is connected by a valve to a small flexible catheter that acts as a soaker hose and allows continuous infusion of the medication to nearby tissues.

Example:

ON-Q Pain Relief System

Disadvantages:

the analgesic duration of most local anesthetics is relatively brief and might not provide significant long-term benefits with regard to pain relief.

(Kim, Ha, & Oh, 2016).

PubMed Database

A broad database created by the National Center for Biotechnology Information (NCBI) (Melnyk & Fineout-Overholt, 2015).

Completely free database (Melnyk & Fineout-Overholt, 2015).

Uses automatic term mapping (Melnyk & Fineout-Overholt, 2015).

Refines searches using filters (Melnyk & Fineout-Overholt, 2015).

Contains more citations compared to other databases (Melnyk & Fineout-Overholt, 2015).

Study Used for Research #1

Reynolds, R. A. K., Legakis, J. E., Tweedie, J., Chung, Y., Ren, E. J., BeVier, P. A., … Thomas, S. T. (2013). Postoperative Pain Management after Spinal Fusion Surgery: An Analysis of the Efficacy of Continuous Infusion of Local Anesthetics. Global Spine Journal, 3(1), 7–14. http://doi.org/10.1055/s-0033-1337119

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Study Used for Research #1 (Cont.)

Sample: patients with idiopathic scoliosis (IS) who underwent spinal fusion surgery.

Eligibility: (1) diagnosed with IS, (2) age 6 to 17, (3) elective spinal fusion surgery performed, (4) ability to use PCA, and (5) ability to self-report pain.

P value ≤ 0.05, two-tailed.

60% of patients treated with CILA would improve 2 or more units on the pain scale, in comparison with 40% patients treated according to the standard protocol.

With a proportional difference of 20% (40% versus 60%), the study will have power of 80.1% with a proposed sample size of 97 and 97 for the two groups.

Study Used for Research #2

Kim, S., Ha, K., & Oh, I. (2016). Preemptive multimodal analgesia for postoperative pain management after lumbar fusion surgery: a randomized controlled trial. European Spine Journal, 25(5), 1614. doi:10.1007/s00586-015-4216-3

Study Used for Research #2 (Cont.)

Sample: Patients who underwent posterior lumbar interbody fusion (PLIF) surgery for symptomatic lumbar 4–5 stenosis

Exclusion criteria: : (1) history of lumbar spine surgery, (2) smoking, (3) epidural or elective nerve-root blocks, (4) prior use of the investigated medications, (5) contraindication to morphine or any nonsteroidal anti-inflammatory drugs (NSAIDs), or (6) current use of anticoagulants or antiplatelet medication.

Sample Size: 80 patients

Group 1 (40 patients): preemptive multimodal analgesia treatment group

Group 2 (40 patients): control group that received only postoperative intravenous morphine

Measurement: Postoperative pain and functional levels were measured by the visual analog scale (VAS) and Oswestry Disability Index (ODI)

Mean ages at the time of surgery were 67.9 (7.6) years in group 1 and 66.3 (10.0) years in group 2 (P = 0.417).

Group 1 had significantly lower VAS and ODI scores at all time points than those of group 2, except the ODI on postoperative day 1.

Conclusion

After reviewing the given research articles, it can be determined that the continuous infusion of local anesthetics works better for pain management alongside other means of analgesics.

According to the research studies, pain levels are seen to decrease with the use of continuous infusion of local anesthetics compared to the use of patient controlled analgesia pumps.

References

Evidence Based Practice: PICO method. (2017). Purdue Libraries. Retrieved from http://guides.lib.purdue.edu/c.php?g=352904&p=2378098

Kim, S., Ha, K., & Oh, I. (2016). Preemptive multimodal analgesia for postoperative pain management after lumbar fusion surgery: a randomized controlled trial. European Spine Journal, 25(5), 1614. doi:10.1007/s00586-015-4216-3

Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-Based Practice in Nursing and Healthcare: A Guide to Best Practice. Philadelphia: Wolters Kluwer/Lippincott Williams et Wilkins.

References (Cont.)

Patient-Controlled Analgesia Pumps. (n.d.). Johns Hopkins Medicine. Retrieved from http://www.hopkinsmedicine.org/healthlibrary/conditions/orthopaedic_disorders/patient-controlled_analgesia_pumps_134,96/

Reynolds, R. A. K., Legakis, J. E., Tweedie, J., Chung, Y., Ren, E. J., BeVier, P. A., … Thomas, S. T. (2013). Postoperative Pain Management after Spinal Fusion Surgery: An Analysis of the Efficacy of Continuous Infusion of Local Anesthetics. Global Spine Journal, 3(1), 7–14. http://doi.org/10.1055/s-0033-1337119

Riva, J. J., Malik, K. M. P., Burnie, S. J., Endicott, A. R., & Busse, J. W. (2012). What is your research question? An introduction to the PICOT format for clinicians. The Journal of the Canadian Chiropractic Association, 56(3), 167–171.

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