what is the best pain management practice for post-operative patients; patient controlled analgesia p.c.a. or convention

1. Fran Trujillo, R.N. Mary Woods, R.N. Edgar Paul, R.N. Jeff Jeter, L.P.N. OU College of Nursing

3. PICO P = Post-operative patients I = Patient Controlled Analgesia (P.C.A.) C = Conventional pain control (I.M.I.) O = Pain management

4. Various Parameters &Populations Studied Ages > / = 7 to 72 Surgeries Ethnicities & cultures International

5. Interventions Patient Controlled Analgesia (P.C.A.) Treatment for pain management Intramuscular (I.M.) injection Control group Comparison treatment for pain management

6. Variables of Interest Dependent Variable ~ Pain Independent Variable ~ Pain Control P.C.A. Conventional Pain Control (I.M.I.) There are other variables to consider as well: type of surgery, age, past pain experiences & preferences, culture & ethnicity, gender, disease process etc� There are other variables to consider as well: type of surgery, age, past pain experiences & preferences, culture & ethnicity, gender, disease process etc�

7. Burning Research Question What is the best pain management practice for post-operative patients; patient controlled analgesia (P.C.A.) or conventional opioid analgesia?

8. Literature Review Why is this a problem? Lack of clinical evidence to support a change in practice P.C.A. vs. I.M.I. Threats to validity Further research needed (Hudcova, 2008)

9. Literature Review Why is this a problem? Ineffective treatment of post-operative pain is documented Various attitudes, beliefs, and cultures issues regarding pain Pain symptoms are multi-faceted Pain is invisible; often not assessed Patient reluctance to report pain Professionals have knowledge deficits and misconceptions about pain issues (Yankova, 2008) (Bell, 2000)

10. Statistics P.C.A. weighted mean difference in pain intensity 8 points lower than control group 1st 24 hours 9 points lower than control group 25 to 48 hours 13 points lower than control group 49 to 72 hours (Hudcova, 2008)

11. Mean Pain Scores (Carter-Snell, 1997)

12. P.C.A. Patient Satisfaction Reported pain control significantly higher Ability to maintain near constant levels of analgesia No peaks and troughs as with I.M.I. Related to patient knowledge of P.C.A. & post-op experiences Patient teaching crucial in optimal pain control P.C.A. purpose & fear of addiction issues (Yankova, 2008)

13. Mean Satisfaction Scores (Carter-Snell, 1997)

14. Review of Literature What has been done to study the problem? Systematic Review Research studies

15. Pros Found in Systematic Review Patient preference for P.C.A. Length of Stay (L.O.S.) ~ 0.4 days shorter Clinically insignificant Evidence to support P.C.A. efficacy (Hudcova, 2008)

16. Pros Found in Studies Overwhelming evidence indicates P.C.A. provides superior analgesia resulting in less pain vs. I.M.I. Patient autonomy and control Self administering analgesia with P.C.A. Exact & higher dosage vs. I.M.I. No waiting for medication vs. I.M.I. (Carr, 1997) (Conner, 1995) (Carr, 1997) (Conner, 1995)

17. Pros Found in Studies Evidence suggests P.C.A. provides more analgesia vs. I.M.I. Some evidence suggests patients receiving I.M.I. report less pain (Carr, 1997) (Conner, 1995)

18. Cons Found in Systematic Review Clinical evidence does not support P.C.A. over conventional pain control (I.M.I.) P.C.A. patients may consume higher amounts of opioids (Hudcova, 2008)

19. Cons Found in Studies The cost of P.C.A. higher P.C.A. equipment Opioids used Differences in time cost insignificant between P.C.A. & I.M. groups Some patients receiving I.M. injections reluctant to ask for pain medication (Yankova, 2008) (Carr, 1997)

20. Cons Found in Studies Null hypothesis supported: P.C.A. vs. I.M I. Studies comparing P.C.A. vs. I.M.I. pain management provide inconclusive evidence supporting benefits of either method for post-operative patients. P.C.A provides inadequate pain relief after surgery Pain level higher at rest & with exertion with I.M. injections (Chang, 2004)

21. Cons Found in Studies Null hypothesis supported: P.C.A. vs. I.M.I. I.M.I. dosages lower Patient fear of I.M.I. Nurse�s belief about pain management Cost differences insignificant (Chang, 2004)

22. Hudcova vs. Bronwyn Comparisons in findings P.C.A. patients consume higher amounts of opioids P.C.A. favored Threats to validity (Hudcova, 2008) (Bronwyn, 2005)

24. Hudcova vs. Chang Comparisons in findings P.C.A. favored but inconclusive P.C.A. patients had shorter L.O.S. Threats to validity (Hudcova, 2008) (Chang, 2004)

25. Hudcova vs. Carter-Snell Comparisons in findings P.C.A. favored Clinical evidence does not support P.C.A. over conventional pain control (I.M.I.) Threats to validity (Hudcova, 2008) (Carter-Snell, 1997)

26. Hudcova vs. Yankova Comparisons in findings Inconclusive to rate P.C.A. over conventional pain control (I.M.I.) Threats to validity (Hudcova, 2008) (Yankova, 2008)

27. Results of Studies P.C.A. favored over Conventional (I.M.I.) Pain Management Favored intervention for pain management Patient satisfaction higher r/t lesser pain Superior method of analgesia administration Clinical statistics insignificant in terms of changing practice to PCA only. PCA favored but inconclusive. Either method inconclusive. Clinical statistics insignificant in terms of length of stay.Clinical statistics insignificant in terms of changing practice to PCA only. PCA favored but inconclusive. Either method inconclusive. Clinical statistics insignificant in terms of length of stay.

28. Results of Studies P.C.A. favored over Conventional (I.M.I.) Pain Management Immediate access to higher & exact dosages Pain ratings lower Shorter length of stay in hospital Patient education facilitated P.C.A. operation Clinical statistics insignificant in terms of changing practice to PCA only. PCA favored but inconclusive. Either method inconclusive. Clinical statistics insignificant in terms of length of stay.Clinical statistics insignificant in terms of changing practice to PCA only. PCA favored but inconclusive. Either method inconclusive. Clinical statistics insignificant in terms of length of stay.

29. Pain Phenomena��..More Variables & Is pain experienced differently in other cultures/environments? Do men experience pain differently than women? Do various types of surgery yield varying degrees of pain? How do past experiences affect pain manifestations? Do certain pain medications work better than others?

30. Patient Interventions Effective pre-operative teaching on pain control method Consider pain control experiences & preferences Assess Pain Rate pain Administer analgesic as needed

31. Patient Interventions Monitor pain control effectiveness Monitor Vital Signs Re-assess pain Rate pain Music, touch, massage, relaxation, & imagery Evaluate pain control method

32. Rationales Pain is subjective Pain causes physiological & mental instability Opioid analgesics may cause adverse side effects Pain must be assessed and re-assessed for effective control Pain must be evaluated for effective patient outcomes

33. Suggestions for Further Study Nurses play key role in pain management Continuing education is pivotal Clinical practice is a constantly changing environment Patient and care provider education positively influences pain management (Johnston, 1993)

34. Suggestions for Further Study Compare & contrast various opioids per Patient history Dosage Surgical procedure Disease process

35. References Bronwyn, E. (2005). Differences in postoperative opioid consumption in patients prescribed patient-controlled analgesia (PCA) versus intramuscular injection. American Society for Pain Management Nursing. 6 (4),137-144. Carter-Snell, C., Fothergill-Bourbonnais, F., Durocher-Hendriks, S. (1997). Patient controlled analgesia and intramuscular injections: a comparison of patient pain experiences and postoperative outcomes. Journal of Advanced Nursing 25(4),681-690). Chang, A.M., Ip, W.Y., Cheung, T.H. (2004). Patient-controlled analgesia (PCA) versus conventional intramuscular injection (I.M): a cost effective analysis. Journal of Advanced Nursing, 46(5), 531-541. Hudcova, J., McNicol, E.D., Quah, C.S., Lau, J., Carr, D.B. (2008). Patient controlled analgesia versus conventional opioid analgesia for postoperative pain (review). The Cochrane Collaboration Issue (4), 1-73. Yankova, Z. (2008). Patients� knowledge of patient controlled analgesia (PCA) and their experiences of postoperative pain relief: a review of the impact of structured preoperative education. Journal of Advanced Perioperative Care, 3(3), 91-99.