AGREE Appraisal of Guidelines for Research and Evaluation

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1 Clinical Practice Guideline: Nursing Care of Postoperative Pain

2 AGREE Appraisal of Guidelines for Research and Evaluation

3 McCaffery McCaffery, & Beebe, 1989 Filos & Lehmann National Center for Health Statistics, %Apfelbaum, Chen, Mehta, & Gan, 2003 Filos & Lehmann % Dietric- Gallagher, Polomano, & Carrick, 1994 Dunwoody, Krenzischek, Pasero, Ratbmell, & Polomano, 2008 Chiang, Chen, & Huang, 2006Cantrill & Noyce 2001

4 Joint Commission on Accreditation of Healthcare Organizations ( ) ( ) ( ) AGREE

5 Apfelbaum, J. L., Chen, C., Mehta, S. S., & Gan, T. J. (2003). Postoperative pain exercise: Result from a national survey suggest postoperative pain continues to be undermanaged. Anesthesia and Analgesia, 97, Cantrill, J., & Noyce, P. (2001). Why is pain management suboptimal on surgical ward? Journal of Advanced Nursing, 33(6), Chiang, L. C., Chen, H. J., & Huang L. C. (2006) Student nurses knowledge, atitudes, and slfeficacy of cildren s pin mnagement: ealuation of an eucation pogram in Taiwan. Journal of Pain and Symptom Management, 32(1), Dietrick-Gallagher, M., Polomano, R., & Carrick, L. (1994). Pain as a quality management initiative. Journal of Nursing Care Quality, 9(1), Dunwoody, C. J., Krenzischek, D. A., Pasero, C., Rathmell, J. P., & Polomano, R. C. (2008).

6 Assessment, physiological monitoring, and consequences of inadequately treated acute pain. Journal of PeriAnesthesia Nursing, 9(1), S11-S21. Segerdahl, M. (2008). Procedural pain -- Time for its recognition and treatment! European Journal of Pain, 12(1), 1-2. Filos, K. S., & Lehmann, K. A. (1999). Current concepts and practice in postoperative pain management: Need for a change? European Surgical Research, 31, Joint Commission on Accreditation of Healthcare Organizations. (2001). Pain: Current understanding of assessment, management, and treatments. Retrieved May 1, 2008, from agement_and_treatment_jcaho.pdf McCaffery, M., & Beebe, A. (1989). Pain: clinical manual for nursing practice. St. Louis: CV Mosby Co. National Center for Halth Statistics. 2005) Inpatient procedures. Fast stats A to Z. Retrieved February 8, 2007.from Rupp, T., & Delaney, K. A. (2004). Inadequate analgesia in emergency medicine. Annals of Emergency Medicine, 43(4),

7 1++ 4 A B C D Cochrane Library Medline PubMed JCR Web Ebscohost MDConsultCEPS National Guideline Clearinghouse NGCCenter for Disease Control CDC Prevention Guidelines Database The National Institute for Clinical Excellence NICEGuidelines Advisory Committee GACNational Health and Medical Research Council New Zealand Guidelines Group Scottish Intercollegiate Guidelines Network (SIGN) MONASH University -The Centre for Clinical Effectiveness CCEG-I-N-- Guidelines International Network RNAO-Best Practice Guidelines NeLH guideline finder The AGREE Research Trust

8 12 3Cochrane Library National Guideline Clearinghouse NGCclinical guideline meta-analysis meta-synthesisprimary research meta-analysis systematic 1++ reviewsrandomized control trials, RCTs bias case-control study cohort study

9 A B C D target population 2. RCTs AGREE

10 10

11 B B C C % 98.7%descriptive words 1.3% Tung, Chen, Huang, Chiang, & Wu,

12 91%54% Carroll et al., 1999 Sloman, Rosen, Rom, & Shir, Rond, Wit, Dam, & Mulle, 2000 McCaffery, 1994 i n i t i a l assessment of pain JCAHO, 2001 JCAHO, 2001 multidimensional tool unidimensional tool 12

13 JCAHO, 2001 brief pain inventory McGill pain questionnaire2002 JCAHO, 2001 McGill pain questionnaire short-form McGill pain questionnairer Lee, 2001 unidimensional scales Visual Analogue Scale: VAS Numerical Rating Scale, NRSVerbal Descriptor Scale, VDS Face Rating ScaleVerbal Rating Scale, VRSTung et al., 2006 Williamson & Hoggart, 2005 Young, 1999VAS NRS VRS VAS Myles & Urquhar, 2005VAS NRS VRS NRS VRS Lee, 2001 Williamson & Hoggart, 2005 Face Rating Scale

14 2003 Ardery, Herr, Titler, Sorofman, & Schmitt, Ardery et al., * Visual Analogue Scale, VAS 1 0 n o p a i n unbearable pain * Verbal Rating Scale, VRS none, mild, moderate, severe * Numerical Rating Scale, NRS *Face Rating Scale, FRS

15 timing/ frequency 2-4 Carroll et al., Young, 1999 JCAHO,

16 JCAHO, 2001; Tung et al., 2006 flow record Carroll et al., 1999 Authors Article title Evidence level Ardery, Herr,Titler, Assessing and managing acute pain 2+ Sorofman, & Schmitt (2003) in older adults: A research base to guide practice Carroll et al. (1999) Pain assessment and management in critically ill postoperative and trauma patients: A multisite study 2+ 16

17 Pain: Current understanding of 1++ JCAHO (2001) assessment, management, and treatments. Pain measurement: Understanding 2+ Lee (2001) existing tools and their application in the emergency department McCaffery (1994) How reliable is your patient's pain 4 assessment The linearity of the visual analogue 2+ Myles & Urquhar (2005) scale in patients with severe acute pain A pain monitoring program for 2+ Rond, Wit, Dam, & Mulle (2000) nurses: effects on communication, assessment and documentation of patients' pain Sloman, Rosen, Rom, & Nurses' assessment of pain in surgical 2+ Shir (2005) patients. Tung, Chen, Huang, Assessment of pain intensity by 2+ Chiang, & Wu. (2006) nurses in the emergency department Williamson & Hoggart Pain: a review of three commonly 2++ (2005) used pain rating scales Young (1999) Acute pain management protocol (5) (2) (1)

18 Ardery, G., Herr, K. A., Titler, M. G., Sorofman, B. A., & Schmitt, M. B. (2003). Assessing and managing acute pain in older adults: A research base to guide practice. Journal of the Academy of Medical-Surgical Nurses, 12(1), Carroll, K. C., Atkins, P. J., Herold, G. R., Mlcek, C. A., Shively, M., Clopton, P., et al. (1999). Pain assessment and management in critically ill postoperative and trauma patients: A multisite study. American Journal of Critical Care, 8(2), Joint Commission on Accreditation of Healthcare Organizations. (2001). Pain: Current understanding of assessment, management, and treatments. Retrieved May 1, 2008, from agement_and_treatment_jcaho.pdf Lee, J. S. (2001). Pain measurement: Understanding existing tools and their application in the emergency department. Emergency Medicine, 13(3), McCaffery, M. (1994). How reliable is your patient's pain assessment? Nursing, 24(1), 19. Myles, P. S., & Urquhart, N. (2005). The linearity of the Visual Analogue Scale in patients with severe acute pain. Anaesthesia and Intensive Care, 33(1), Rond, M. E. J., Wit, R. W., Dam, F. S. A., & Muller, M. J. (2000). A pain monitoring program for nurses: Effects on communication, assessment and documentation of patients' pain. Journal of Pain & Symptom Management, 20(6), Sloman, R., Rosen, G., Rom, M., & Shir, Y. (2005). Nurses' assessment of pain in surgical patients. Journal of Advanced Nursing, 52(2), Tung, H.P., Chen, M. J., Huang, M. L., Chiang, H.S., & Wu, C.P. (2006). Assessment of pain intensity by nurses in the emergency department. Journal of Emergency Medicine, (Taiwan), 8(3), Williamson, A., & Hoggart, B. (2005). Pain: A review of three commonly used pain rating scales. Journal of Clinical Nursing, 14(7), Young, D.M. (1999). Acute pain management protocol. Journal of Gerontological Nursing, 25(6),

19 C C C Patient-controlled analgesia, PCA 3. NSAIDS Opioids patient-controlled analgesia, PCA 1. NSAID Opioids2000 Institute for Clinical System Improvement,

20 2. Opioids NSAID Institute for Clinical System Improvement, Opioids Krenzischek, Dunwoody, Polomano & Rathmell, PCA 10 12PCA Aminophenol mg po q4-6h 4000mg 10-15mg/kg po q4-6h Acetaminophen (salicylates) Aspirin mg po q4-6h 4000mg 10-15mg/kg po q4-6h Choline magnesium trisalicylate mg po q12h 3000mg --- Diflunisal 1000mg po 500mg q12h 1500mg

21 Magnesium salicylate 650mg po q4-6h 3000mg --- Salsalate 500mg po q4h 3000mg --- Sodium salicylate mg po q3-4h mg po q12h NSAIDs Sulindac 400mg Diclofenac potassium 50mg po q8h 150mg --- Etodolac mg po q6-8h 1200mg --- Fenoprofen calcium mg po q6h 3200mg --- Ibuprofen mg po q6-8h 2400mg 10mg/kg po q6-8h 2. Krenzischek et al., equianalgesic dose Morphine 30mg 10mg 1-10mg 10-30mg q 3-4 hr q 3-4 hr q 3-4 hr q 3-4 hr around the clock Hydromorphone 7.5mg 1.5mg 0.2-1mg 1-4mg Dilaudid q 3-4 hr q 3-4 hr q 3-4 hr q 3-4 hr Oxycodone 20mg NA NA 5-10mg Roxicodone q 3-4 hr q 3-4 hr mg/kg/ dose q 3-4 hr m g / k g / dose q 3-4 hr mg/kg/dose; q 3-4 hr mg/ kg/dose m g / k g / dose every4-6h m g / k g / dose every4-6h 21

22 equianalgesic dose Methadone 20mg 10mg 10mg 20mg 0.1mg/kg/dose 0.1mg/kg/dose Dolophine q 6-8 hr q 6-8 hr q 6-8 hr q 6-8 hr q 6-8 hr q 3-4 hr Levorphanol 4mg 2mg 2mg 4mg 0.02mg/kg 0.04mg/kg Levo- q 6-8 hr q 6-8 hr q 6-8 hr q 6-8 hr q 6-8 hr q 6-8 hr Dromoran Meperidine 300mg 100mg 100mg mg Demerol q2-3 hr q 3 hr q 3 hr q2-3 hr Codeine 130mg 75mg 60mg 30-60mg 0.5-1mg/kg q 3-4 hr q 3-4 hr q 2 hr q 3-4 hr q 3-4 hr Hydrocodone 30mg mg mg/kg Lorcet, Lortab, q 3-4 hr q 3-4 hr q 3-4 hr Vicodin Oxymorphone --- 1mg 1mg --- Numorphan q 3-4 hr q 2-3 hr - Nalbuphing mg 10mg mg/kg -- Nubain q 3-4 hr q 3-4 hr q 3-4 hr Butophanol --- 2mg 2mg Stadol q 3-4 hr q 3-4 hr Pentazocine 150mg 60mg 50mg Talwin q 3-4 hr q 3-4 hr q 4-6 hr Buprenorphine Buprenex mg q 6-8 hr.4mg q 6-8 hr mg/kg q 6-8 hr

23 NSAIDs NSAID 2000 Aspirin10 Aspirin Aspirin NSAIDs aspirin 2-3 NSAIDs2000 NSAIDs COX-2 reninangiotension Indomethacin IndocinNSAIDs Aspirin 2000NSAID 2000NSAID NSAID NSAIDNSAID2000 OpioidsGoodman, Gilman, Bruntun, Lazo, & Parker, 2006 Titration Pasero & McCaffery, 2002 end-tidal CO 2 Krenzischek et al., 2008 Opioids 23

24 OpioidsOddi Duocolax, Cascara, Senokot, 2007 Krenzischek et al., 2008 OpioidsMitra & Sinatra, 2004Opioids Krenzischek et al., 2008Opioids Swenson, Davis, & Johnson, 2005Opioids Institute for Clinical Systems Improvement, 2006; Porter & Jick, 1980 Opioids Krenzischek et al., 2008Opioids Opioids Goodman et al.,

25 PCA PCA PCA Pullen, 2003 Pullen, 2003 PCA PCA Pullen, Naser, Sinwan, & Wong, 2005 PCApiggybackedNaser et al., Wheatley, Schug, & Watson, 2001 obstructive sleep apnea syndromekrenzischek et al., 2008morphineNaloxone 2006 Naser et al.,

26 Authors Article title Evidence level Institute for Clinical Systems Improvement 2006 Krenzischek, D. A., Dunwoody, C. J., Polomano, R. C., & Rathmell, J. P PCA Assessment and management of acute 4 pain (5 th ed.) Pharmacotherapy for acute pain: 2+ Implications for practice. 26

27 Mitra, S., & Sinatra, R. S Naser, E., Sinwan, S., & Wong, H. B Pasero, C., & McCaffery, M Porter, J., & Jick, H Pullen, R. L Swenson, J. D., Davis, J. J., & Johnson, K. B Wheatley, R. G., Schug, S. A., Watson, D Perioperative management of acute 4 pain in the opioid-dependent patient. Nurse's knowledge on pain 2 management. Monitoring sedation 4 Addiction rare in patients treated with 4 narcotics [letter]. Managing I. V. patient-controlled 4 analgesia. Postoperative care of the chronic opioidconsuming patient. 4 Safety and efficacy of postoperative 2+ epidural analgesia (2) (6) PCA16(2) (1)

28 Agency for Health Care Policy and Research (AHCPR) (1992). Acute pain management: operative or medical procedures and trauma. AHCPR Publication No : Washington, DC, MA: Author. Goodman, L. S., Gilman, A., Brunton, L. L., Lazo, J. S., & Parker, K. L. (2006). Goodman & Gilman s the pharmacological basis of therapeutics (11th ed.). New York: McGraw-Hill. Institute for Clinical Systems Improvement. (2006). Assessment and management of acute pain (5th ed.). Retrieved March, 2006, from Accessed April 16, 2007 Krenzischek, D. A., Dunwoody, C. J., Polomano, R. C., & Rathmell, J. P. (2008). Pharmacotherapy for acute pain: Implications for practice. Pain Management Nursing, 9(1), Mitra, S., & Sinatra, R. S. (2004). Perioperative management of acute pain in the opioiddependent patient. Anesthesiology, 101(1), Naser, E., Sinwan, S., & Wong, H. B. (2005). Nurse s knowledge on pain management. Singapore Nursing Journal, 32(2), Pasero, C., & MaCaffery, M. (2002). Monotoring sedation. The American Journal of Nursing, 102 (2), Porter, J., & Jick, H. (1980). Addiction rare in patients treated with narcotics [letter]. New England Journal of Medicine, 302, 123. Pullen, R. L. (2003). Managing I. V. patient-controlled analgesia. Nursing, 33(7), 24. Swenson, J. D., Davis, J. J., & Johnson, K. B. (2005). Postoperative care of the chronic opioidconsuming patient. Anesthesiology Clinics of North America, 23(1), Wheatley, R. G., Schug, S. A., & Watson, D. (2001). Safety and efficacy of postoperative epidural analgesia. British Journal of Anaesthesia, 87(1),

29 C C

30 Imagery Hypnosis Biofeedback Good, Anderson, Ahn, Cong, & Stanton-Hicks, 2005; Kwekkeboom & Gretarsdottir, 2006; Schupp, Berbaum, Berbaum, & Lang, Johnson, Fuller, Endress, & Rice,

31 Good et al., 2005; Voss et al.,

32 30-60 Voss et al., 2004 Daake & Gueldner, 1989Madden et al., 1978 biofeedback electromyography; EMG electroencephalography; EEG galvanic skin response; GSR α β θ δ α 32

33 thermistor de Jong, Middelkoop, Faber, & van Loey,

34 Authors Article title Evidence level Daake et al de Jong et al Good et al Johnson et al Kwekkeboom & Gretarsdottir 2006 Lang et al Imagery instruction and the control of postsurgical pain. Non-pharmacological nursing interventions for procedural pain relief in adults with burns: A systemic literature review. Relaxation and music reduce pain following intestinal surgery. Altering patients responses to surgery: An extension and replication. Systematic review of relaxation interventions for pain. Adjunctive non-pharmacological analgesia for invasive medical procedures: A randomized trial

35 Levin et al. (1987 Madden et al. (1978 Schupp et al Voss et al N u r s i n g m a n a g e m e n t o f p o s t o p e r a t i v e p a i n : u s e o f relaxation techniques with female cholecystectomy patients. The effect of EMG biofeedback on postoperative pain following abdominal surgery. P a i n a n d a n x i e t y d u r i n g interventional radiologic procedures: Effect of patients' state anxiety at baseline and modulation by n o n p h a r m a c o l o g i c a n a l g e s i a adjuncts. Sedative music reduces anxiety and pain during chair rest after openheart surgery Breit & Van der Wall, 2004; Erdogan, Erdogan, Erbil, Karakaya, & Demircan, 2005; Usichenko et al., 2005 Cryotherapy 2005 transcutaneous electrical nerve stimulation; 35

36 TENS 2005 Erdogan et al., 2005 Breit & Van der Wall, Rakel & Frantz, Bjordal Johnson Ljunggreen TENS TENS 85Hz meperidine meperidine 2002 auricular acupuncture Barker et al., 2006; Usichenko et al., 2005 fentanyl Usichenko et al., Usichenko et al., 2005Barker

37 Authors Article title Evidence level meperidine Barker et al Out-of-hospital auricular acupressure in elder patients with hip fracture: A randomized 2+ double-blinded trial. Bjordal et al Transcutaneous electrical nerve stimulation (TENS) can reduce postoperative analgesic c o n s u m p t i o n. A m e t a - a n a l y s i s w i t h 1+ assessment of optimal treatment parameters for postoperative pain. Breit & Van der Wall Transcutaneous electrical nerve stimulation for postoperative pain relief after total knee arthroplasty. Rakel & Frantz 2003 Effectiveness of transcutaneous electrical nerve stimulation on postoperative pain with movement

38 Erdogan et al Usichenko et al Usichenko et al Prospective, randomized, placebo-controlled study of the effect of TENS on postthoracotomy pain and pulmonary function. Auricular acupuncture for pain relief after total hip arthroplasty: A randomized controlled study. Auricular acupuncture reduces intraoperative fentanyl requirement during hip arthroplasty: randomized double-blinded study EndorphinsAcupuncture Acupressure 2. Imagery 3. Biofeedback 4. Patient education 5. Relaxation methods 6. Transcutaneous electrical nerve stimulation; TENS 38

39 level of evidence grades of recommendation A A, B, D 3 5 A, B, D A, B, D A, B, D 39

40 A, B, D 5 15 A, B, C,D 2002 meperidine 13(1) (3) (2) (1) 5-23 Barker, R., Kober, A., Hoerauf, K., Latzke, D., Adel, S., Kain, Z. N., et al. (2006). Out-of-hospital auricular acupressure in elder patients with hip fracture: A randomized double-blinded trial. Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine, 13(1), Bjordal, J., Johnson, M. I., & Ljunggreen, A. E. (2003). Transcutaneous electrical nerve stimulation (TENS) can reduce postoperative analgesic consumption. A meta-analysis with assessment of optimal treatment parameters for postoperative pain. European Journal of Pain, 7, Breit, R., & van der Wall, H. (2004). Transcutaneous electrical nerve stimulation for postoperative pain relief after total knee arthroplasty. Journal of Arthroplasty, 19(1), Daake, D. R., & Gueldner, S. H. (1989). Imagery instruction and the control of postsurgical pain. Applied Nursing Research, 2, de Jong, A. E., Middelkoop, E., Faber, A. W., & van Loey, N. E. (2007). Non-pharmacological nursing interventions for procedural pain relief in adults with burns: A systemic literature 40

41 review. Burns, 33, Erdogan, M., Erdogan, A., Erbil, N., Karakaya, H. K., & Demircan, A. (2005). Prospective, randomized, placebo-controlled study of the effect of TENS on post-thoracotomy pain and pulmonary function. World Journal of Surgery, 29(12), Good, M., Anderson, G. C., Ahn, S., Cong, X., & Stanton-Hicks, M. (2005). Relaxation and music reduce pain following intestinal surgery. Research in Nursing & Health, 28, Johnson, J., Fuller, S., Endress, P., & Rice, V. (1978). Altering patients responses to surgery: An extension and replication. Research in Nursing and Health, 1, Kwekkeboom, K. L., & Gretarsdottir, E. (2006). Systematic review of relaxation interventions for pain. Journal of Nursing Scholarship, 38(3), Lang, E. V., Benotsch, E. G., Fick, L. J., Lutgendorf,S., Berbaum, M. L., Berbaum, K. S., et al. (2000). Adjunctive non-pharmacological analgesia for invasive medical procedures: A randomized trial. The Lancet, 355, Madden, C., Singer, G., Peck, C., & Nayman, J. (1978). The effect of EMG biofeedback on postoperative pain following abdominal surgery. Anaesthesia and Intensive Care, 6, Rakel, B., & Frantz, R. (2003). Effectiveness of transcutaneous electrical nerve stimulation on postoperative pain with movement. Journal of Pain, 4(8), Schupp, C. J., Berbaum, K., Berbaum, M., & Lang, E. V. (2005). Pain and anxiety during interventional radiologic procedures: Effect of patient s state anxiety at baseline and modulation by nonpharmacologic analgesia adjuncts. Journal of Vascular and Interventional Radiology, 16(12), Usichenko, T. I., Dinse, M., Hermsen, M., Witstruck, T., Pavlovic, D., & Lehmann, C. (2005). Auricular acupuncture for pain relief after total hip arthroplasty: A randomized controlled study. Pain, 114, Usichenko, T. I., Dinse, M., Lysenyuk, V. P., Wendt, M., Pavlovic, D., & Lehmann, C. (2006). Auricular acupuncture reduces intraoperative fentanyl requirement during hip arthroplasty: A randomized double-blinded study. Acupuncture & Electro-Therapeutics Research, 31, Voss, J. A., Good, M., Yates, B., Baun, M. M., Thompson, A., & Hertzog, M. (2004). Sedative music reduces anxiety and pain during chair rest after open-heart surgery. Pain, 112,

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