Morphine Fentanyl PainEffective Pain Relief In Post Operative Patients. Is Morphine or Fentanyl more effective in reducing pain in postoperative adult cardiac patients?
Pain is physiological mechanism and a means of the body alert the person about either currently present or impending damage to it. It can be defined as the “unpleasant sensory and emotional experience associated with actual or potential damage” (Gelinas, 2004). Consequently, the words discomfort has also been used interchangeably with pain in the past and can be defined as a “negativeaffective and/or physical state subject to variation in magnitudein response to internal or environmental conditions” (Gelinas, 2004).
Pain is a very important component in care of the surgical patients, both preoperative and post operative. Surgery itself afflicts large amounts of trauma on the patient. The pain that the patient has to incur afterwards adds his anxiety levels and stresses the body. Lack of or inadequate amounts of pain management by the staff, impacts the patients healing process. Their mobility and in the long terms their duration of hospital stay is also affected.
It is important that, for optimal patients health management and care, a means tool must be available to measure the patients pain assessment and relief requirement through pharmacological and non pharmacological means. Little research has been done to properly assess and document the prevalence of pain and its management protocols in post operative patients.
The pain scoring systems are available to attempt to quantify pain and manage it accordingly. These subjective ones include the categorical rating scales (CRS) in which patient rates pain from “No” to mild moderate or severe. Another one is the “Visual Analog score (VAS) where the individual scores are placed on a 10-cm line where the left anchor point is labeled “no pain” and the right anchor point is labeled “worst possible pain”. (Venkateswaran, P., 2006)
Since every patient has a varying threshold for pain, and requires varying levels of drugs, to over come the pain, it is better for there to be both a subjective indicator for pain as well as an objective one, that is to say, that the nurses an also assess how much pain the patient is in, by using a tool she is provided with.
Cardiac surgery is a major thoracic surgery and patients post operatively require lot analgesics to manage pain so that their morbidities associated with pain (like pain in breathing, walking etc) can be eliminated. Usually morphine is used for the purpose of pain relief but there are indications that Fentanyl can perform a similar relief without much of the side effects associated. There needs to be some focus into this theory.
This can be achieved by placing 2 similar populations of adult cardiac patients who have just undergone cardiothoracic surgery on morphine or Fentanyl. As is the standard procedure nowadays, quality indicators, both subjective and objective can be used. The VAS pain scoring card can be provided to the patients for them to record the different levels of pain that they feel. The nurses would be provided with indictors to record objective findings which can indicate pain.
“These can be physiological and behavioral indicators. The physiological indicators can be clustered into cardiovascular, respiratory and cerebral responses” (Gelinas, 2004). Pain associated responses would include tachypnea in respiratory, tachycardia and increased blood pressure in cardiac and raised ICP in cerebral responses. After assessment of the pain levels with the quality indicators, the pain management drugs will be administered and later the subjective and objective pain assessment will be repeated to see which drugs effects were greater and lasted longer.
A study conducted by Celine Gelinas on critically ill incubated patients, to find out what are the protocols and tools used to assess pain management are and if the patients were being given effective relief. He used subjective as well as objective tools. The results revealed that physicians placed no role in documenting pain in patients. Most of the reporting was done by nurses and the patients.
It was also noticed that nurse’s assessment of pain was much less than that reported by the patients themselves. The research concluded that the documentation overall about the pain and its management was incomplete in general with little attention being given. The research also noted that even after being notified about the pain, its effective management only took place 60 percent of the time. (Gelinas, 2004).
In and interventional study conducted by Francoise Bardiau in 2003, the quality indicators e.g. VAS were introduced in the surgical and anesthesia department. After a survey of assessment of knowledge of nurses, VAS to assess pain was the nurses worked to improve pain management. After further surveys, it was noted that initiation of programs to setting of quality indicators improves the overall pain management system. (Bardiau, F., M, 2003)
Idvall E tested a 5 point scale to measure the effects of quality indicator maintain pain relief measurements. “The results suggest initial support for the new instrument as a measure of strategic and clinical quality indicators in postoperative pain management, but it must be further refined, tested and evaluated”. (Idvall E 2002)
A multidisciplinary program development was introduced based on evidence based medicine to focus on construction of proper management protocols to implement clinician as well as patient based pain relief programs “The results suggest that addressing pain management through a variety of strategies targeted at the level of the institution, the clinician, and the patient may lead to desired changes in practice and better outcomes for patients.” Bedard, D (2006). A survey conducted on post operative cardiac ICU patients, about their pain experiences revealed that despite the pain management regimes in place nowadays, the pain frequencies, and intensities were the same as they were more than a decade ago.
Pain management is a vital component of patient care. Quality of pain management can only be assessed through proper indicators. These can be multimodal. The patient populations on which these indicators can be applied are preoperative and postoperative patients. Post operative cardiac patients under nursing care can benefit well from implementation of quality indicators such as VAS. In the nursing profession subjective scoring by the patients themselves enables the nurses to manage the pain properly.
This will lead to quicker recovery by the patients and earlier discharge. In the long term this means leads financial implications on the patients due to reduced hospital stay. Also nursing work load gets reduced as the patient tern over is increased. The healthcare cost gets reduced. A Post operative pain management (POP) project was conducted in 2003. A nationwide survey was done to see the implementation of quality improvement projects in the field of pain management, it was noted that more than 70% of the hospitals were reportedly satisfied with the implementations and the outcomes of the quality improvement programs.
Based on the analysis, it is noted that on the positive side, proper implementations of the quality indicators and improvement programs in the healthcare system and especially in the ICU and surgical wards, the patients stay can become quite comfortable. The stay can be reduced and the cost of healthcare to the system, the insurance companies, and the patient themselves can be reduced. In the other hand we can clearly see that by using the indicators we in effect are placing more workload on the nurses.
If the subjective VAS and the objective physiological changes in the patient has to be monitored regularly just to assess the pain levels, a lot of quality time will be wasted. This time could have been used to tend to more critical patients. Now the question arises if it is worth the effect to implement the QI programs.
The answer would lie in Force field analysis and the Lewin’s theory. If the benefits out way the set backs, we can implement the system. The idealistic thing would be that we assess the pain management needs of each department of the health care system and implement the QIs in the ones in which the implementation benefits out way the costs.
Bardiau, F., M., Taviaux, N., F., Albert, A., Boogaerts, J., G., Stadler, M, (2003), An Intervention Study to Enhance Postoperative Pain Management. Anesthesia and Analgesia. Retrieved on February 26th, 2008, from http://www.anesthesia-analgesia.org/cgi/content/abstract/96/1/179
Bedard, D (2006). The pain experience of post surgical patients following the implementation of an evidence-based approach. Pain management nursing. Retrieved onFebruary 26th, 2008, from http://www.find-health-articles.com/rec_pub_16931414-pain-experience-post-surgical-patients-following-implementation.htm
Gelinas C, Fortier,M., Viens, C., Fillion, L., Puntillo, K., (2004). , Pain Assessment and Management in Critically Ill Intubated Patients: a Retrospective Study. American Journal of critical care. Retrieved on February 26th, 2008, from http://ajcc.aacnjournals.org/cgi/content/full/13/2/126
Idvall E., Hamrin E., Unosson M. (2002). Development of an instrument to measure strategic and clinical quality indicators in postoperative pain management. Journal of Advanced Nursing. . Retrieved on February 26th, 2008, from http://www.ingentaconnect.com/content/bsc/jan/2002/00000037/00000006/art02130;jsessionid=2n189mrighst7.alice?format=print
Venkateswaran, R., Prasad K. N., (2006). Management of postoperative pain, Indian journal of anesthesia. Retrieved on February 26th, 2008,