Olsen, B.F. et al. Journal of Critical Care.Published online: 16 July 2016
Image shows artwork representing pain and disturbance
Purpose: To measure the impact of implementing a pain management algorithm in adult intensive care unit (ICU) patients able to express pain. No controlled study has previously evaluated the impact of a pain management algorithm both at rest and during procedures, including both patients able to self-report and express pain behavior, intubated and non-intubated patients, throughout their ICU stay.
Materials and methods: The algorithm instructed nurses to assess pain and guided in pain treatment, and was implemented in three units. A time period after implementing the algorithm (intervention group) was compared with a time period the previous year (control group) on the outcome variables pain assessments, duration of ventilation, length of ICU stay, length of hospital stay, use of analgesic and sedative medications, and the incidence of agitation events.
Results: Totally 650 patients were included. The number of pain assessments was higher in the intervention group compared with the control group. Additionally, duration of ventilation and length of ICU stay decreased significantly in the intervention group compared with the control group. This difference remained significant after adjusting for patient characteristics.
Conclusion: Several outcome variables were significantly improved after implementation of the algorithm compared with the control period.
Oliver, J.B. et al. Journal of Clinical Anesthesia, Volume 34. pp. 494-501
We conducted a preoperative survey of patients’ expectations of postoperative pain.
Patients are poorly informed of their risk for persistent postsurgical pain.
Patients expected more pain after surgery than they deemed acceptable.
Female patients and those in pain were more concerned about postoperative pain.
Study Objective: Acute postoperative pain may transition to persistent/chronic pain in up to 50% or more of patients after certain surgeries. Despite this concern, it is unclear that patients’ preprocedure understanding and expectations are aligned with these potential outcomes. This study was designed to evaluate the extent of this alignment and the potential impact on the quality of risk/benefit discussions before procedures.
Measurements: The survey items evaluated patients’ expectations of postoperative pain and how familiar patients were with the risk of persistent postsurgical pain based on their specific characteristics and procedure type.
Main Results: The overwhelming majority (80%) of patients were unaware of the risk of persistent postsurgical pain. Given the choice, most patients (65%) wanted to be informed of their risk, and 25% stated that it might even affect their decision to proceed with surgery.
Conclusions: There is great need for health care providers to discuss the significant risk of persistent postsurgical pain with patients in the preoperative setting. Patients need to be armed with realistic data to ensure high-quality discussions of risk/benefit, align expectations with outcomes, and potentially identify high-risk groups in which preoperative intervention can reduce the likelihood or severity of persistent postoperative pain syndromes.
Colloca, L. et al. Pain. 2016. 157(8) pp. 1590–1598
Abstract: Placebos are often used by clinicians, usually deceptively and with little rationale or evidence of benefit, making their use ethically problematic. In contrast with their typical current use, a provocative line of research suggests that placebos can be intentionally exploited to extend analgesic therapeutic effects. Is it possible to extend the effects of drug treatments by interspersing placebos?
We reviewed a database of placebo studies, searching for studies that indicate that placebos given after repeated administration of active treatments acquire medication-like effects. We found a total of 22 studies in both animals and humans hinting of evidence that placebos may work as a sort of dose extender of active painkillers.
Wherever effective in relieving clinical pain, such placebo use would offer several advantages. First, extending the effects of a painkiller through the use of placebos may reduce total drug intake and side effects. Second, dose-extending placebos may decrease patient dependence. Third, using placebos along with active medication, for part of the course of treatment, should limit dose escalation and lower costs. Provided that nondisclosure is preauthorized in the informed consent process and that robust evidence indicates therapeutic benefit comparable to that of standard full-dose therapeutic regimens, introducing dose-extending placebos into the clinical arsenal should be considered. This novel prospect of placebo use has the potential to change our general thinking about painkiller treatments, the typical regimens of painkiller applications, and the ways in which treatments are evaluated.
Kim, J. et al. Anesthesia & Analgesia. 2016. 123(2). pp. 436–444
Background: In this study, we examined the relationship between postoperative cognitive dysfunction (POCD) and intraoperative regional cerebral oxygen saturation (rSO2) in elderly patients undergoing spinal surgery.
Methods: We enrolled 87 patients older than 65 years. All patients were tested using a battery of cognitive function tests (Korean Mini-Mental State Examination and visuomotor test of Dynamic Lowenstein Occupational Therapy Cognitive Assessment–Geriatric Version) the day before their surgical operation and on the seventh postoperative day. Our threshold for defining POCD for a given patient was a Reliable Change Index score of <−1.96 occurring on 2 tests.
Results: POCD was detected in 20 patients (23%) at the seventh postoperative day. Between-patient baseline characteristics, surgical data, and baseline cognitive function were similar for both those who developed POCD and those who did not. A univariate analysis that included age, female sex, education level, presence of diabetes, and duration of intraoperative decline in rSO2 to a level of <60% of baseline revealed that only diabetes and duration of rSO2 <60% (odds ratio, 1.01; 95% confidence interval [CI], 1.005–1.010) were found to be risk factors for POCD. After multivariate logistic regression analysis of these 2 variables, only the duration of rSO2 <60% (odds ratio, 1.006; 95% CI, 1.00–1.01, P = 0.014) remained as an independent risk factor for POCD. The area under the receiver operation characteristic of the duration of rSO2 <60% was 0.70 (95% CI, 0.57–0.82; P = 0.008). The optimal cutoff value was 157 minutes with a sensitivity of 75% and specificity of 72%.
Conclusions: This study showed that the duration of decline in rSO2 <60% during lumbar spinal surgery was correlated with the development of POCD at the seventh postoperative day in elderly patients.
Wisman-Zwarter, N. et al. European Journal of Anaesthesiology. August 2016. 33 (8) pp. 559–567
Background: True competency-based medical education should produce graduates meeting fixed standards of competence. Current postgraduate programmes are usually based on a pre-determined length of time in training making them poorly suited for an individual approach. The concept of entrustable professional activities (EPAs) enables a more flexible, personalised and less time-dependent approach to training programmes. An EPA is a unit of professional practice, to be entrusted to a trainee to execute without supervision once they demonstrate sufficient competence. As EPAs relate competencies to clinical practice, they structure training and assessment more logically according to the way clinicians actually work. A first step in building an EPA-based curriculum is to identify the core EPAs of the profession.
Objectives: The aim of this study was to identify EPAs for postgraduate training in anaesthesiology and to provide an example of how an existing curriculum can be transformed into an EPA-based curriculum.
Design: A modified Delphi method was used as a consensus approach applying three Delphi rounds.
Setting: Postgraduate specialty training in anaesthesiology in the Netherlands.
Participants: All programme directors in anaesthesiology in the Netherlands except for a single programme director who was involved as a researcher in this study and could not participate.
Main Outcome Measures: Agreement among participants on a list of EPAs. Agreement was specified as a consensus rate of more than 80%.
Results: In this study, 27 programme directors (69% overall response rate) reached consensus on a set of 45 EPAs that describe a curriculum in anaesthesiology for the Netherlands.
Conclusions: This study is a first step toward a more contemporary curriculum in competency-based postgraduate anaesthesiology training.
Al-Hakim, L. et al. European Journal of Anaesthesiology. August 2016.33 (8). pp. 581–587
Background: Work disruption in operating rooms hinders flow of patients and increases chances of error. Previous studies have largely considered the types of disruption occurring in operating rooms, but have not analysed systematically the objective impact of disruption.
Objective: The objective was to evaluate the impact of disruption on time efficiency in preoperative anaesthetic work in the operating room and to link disruption to failures in co-ordination of care.
Design: Prospective, cross-sectional and observational study.
Setting: Disruptions were evaluated in operating rooms of five hospitals across three countries: Australia (one community hospital, one teaching hospital); Thailand (two community hospitals); China (one teaching hospital).
Participants: The preoperative phase of anaesthesia induction/patient positioning of 64 surgical patients across specialities was prospectively evaluated (Australia = 33; Thailand = 12; China = 10). Further, interviews were carried out with 16 consultant anaesthetists and surgeons and 13 senior operating room nurses involved in the care of these patients.
Main Outcome Measures: Disruptions were identified by trained observers in real time during the preoperative phase; four types of care co-ordination problems were identified from the interviews with senior anaesthetists, surgeons and nurses, and linked to the disruptions. Descriptive analyses of time efficiency were performed.
Results: Complete data were available from 55 cases. Good inter-observer agreement was obtained across measurements (range 74 to 92%). An average of three disruptions per case during the preoperative phase, were observed (range 2 to 9). ‘Disruption types’: disruptive staff activities were associated with most timewasting (median = 1 min per case, range 0 min 0 s to 4 min 45 s per case). ‘Care co-ordination problems’: co-ordination lapses within the operating room team, and between them and the preoperative team were associated with most timewasting (median = 1 min per case, range 0 min 0 s to 5 min 0 s per case).
Conclusions: The study quantifies time inefficiencies affecting anaesthetic work during the preoperative phase. Work disruption wastes time and is preventable.